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									                Community Health
                    Assessment
                 and Intervention
                 Planning Training
                        Presented by the
                  Missouri Department of Health
                       and Senior Services


                      Bureau of Health Informatics
                  Center for Local Public Health Services



                              Andrew Hunter
                               Becca Mickels
                               Janet Wilson
                                John Gulick
                             Aileen McMurrer




                                                   Summer 2009
                                               Regional Trainings


[Type a quote
Table of Contents
DHSS Resources ....................................................................................................................................... 1
    DHSS Home Page ....................................................................................................................................... 1
    Data, Surveillance Systems & Statistical Reports ....................................................................................... 2
    Community Health Assessment and Intervention Planning Tools ............................................................. 3

Community Data Profiles ......................................................................................................................... 5
    Overview .................................................................................................................................................... 5
    County-level Studies ................................................................................................................................. 10
    Child Health Profile .................................................................................................................................. 15
       Documentation ................................................................................................................................... 15
       Statistics .............................................................................................................................................. 16
    Stroke Profile............................................................................................................................................ 25
    Hospital Revenues Profile ........................................................................................................................ 31
    Data from External Organizations ........................................................................................................... 35
      Social and Economic Indicators Profile ............................................................................................... 35
      Alcohol and Drug Abuse Problems Profile .......................................................................................... 37
    Citations ................................................................................................................................................... 38
    Profiles Exercises ...................................................................................................................................... 39

MICA (Missouri Information for Community Assessment) ..................................................................... 41
    Overview .................................................................................................................................................. 41
    Population MICA ...................................................................................................................................... 43
    Birth MICA................................................................................................................................................ 48
       Drill-Down Variables ........................................................................................................................... 51
       Confidence Intervals ........................................................................................................................... 53
       Drill-Down Indicators .......................................................................................................................... 54
    Death MICA .............................................................................................................................................. 56
      Age-Adjusted Rates ............................................................................................................................. 58
      Drill-Down Variables ........................................................................................................................... 59
      Maps ................................................................................................................................................... 60
      Map for more specific causes within selected cause .......................................................................... 66
    Hospital Discharges, Charges and Days of Care MICA ............................................................................. 67
      Zip Code Tables ................................................................................................................................... 70
    Cancer Registry MICA .............................................................................................................................. 72
    Procedures MICA...................................................................................................................................... 75
    WIC (Women, Infants, and Children) MICA .............................................................................................. 76
    Local WIC Provider MICA ......................................................................................................................... 78
    TANF (Temporary Assistance for Needy Families) MICA .......................................................................... 82
    Citations ................................................................................................................................................... 85
    MICA Exercises ......................................................................................................................................... 86
Priorities MICA ....................................................................................................................................... 89
    Overview .................................................................................................................................................. 89
    Creating the List of Priorities ................................................................................................................... 90
    Additional Information about how the Priorities Formula Works ........................................................... 96
    Interpreting the List of Priorities (Rank) ................................................................................................... 97
    Other Facts to Consider ........................................................................................................................... 97
    Criteria Data Sources ............................................................................................................................... 97
       Amenability to Change ........................................................................................................................ 97
       Community Support ............................................................................................................................ 98
       Death Trend Statistically Significant ................................................................................................... 98
       Disability Burden ................................................................................................................................. 98
       Hospital Days of Care .......................................................................................................................... 98
       Number of Deaths ............................................................................................................................... 99
       Number of Deaths Under Age 65 ........................................................................................................ 99
       Number of Hospitalizations and ER Visits ........................................................................................... 99
       Racial Disparity for ER Visits ................................................................................................................ 99
       Racial Disparity for Deaths .................................................................................................................. 99
       Prevalence/Incidence.......................................................................................................................... 99
       Prevalence/Incidence Trend ............................................................................................................. 100
       Data Sources ..................................................................................................................................... 100

Works Cited ......................................................................................................................................... 100

Index .................................................................................................................................................... 101
DHSS Resources

DHSS Home Page
An easy way to locate the community health assessment and intervention planning tools
is to access the Data, Surveillance Systems & Statistical Reports link from the DHSS
home page.

http://www.dhss.mo.gov/




                                         ~1~
Data, Surveillance Systems & Statistical Reports
The first section of this web page contains the community health assessment and
intervention planning tools: Community Data Profiles, MICA (Missouri Information for
Community Assessment), Priorities MICA, and Intervention MICA. Other data
resources are also listed on this page.

http://www.dhss.mo.gov/DataAndStatisticalReports/index.html




                                        ~2~
Community Health Assessment and Intervention Planning Tools

Community Data Profiles are available for various subject areas. Each Community
Data Profile table provides data on 15-30 indicators for the county/city selected.
Information provided includes data years, number of events, county/city rate, statistical
significance (compared to the state), quintile ranking, state rate, links to additional
graphing functions, and multiple downloading options.

MICA (Missouri Information for Community Assessment) data sets provide
information on health conditions and associated topics. Users can choose from among
the many conditions, generate data tables by year of occurrence, age, gender, race, and
county or zip code of residence, and obtain age-adjusted rates. MICA also allows users
to download tables into other applications in order to produce charts or graphs. Data for
the MICAs are extracted and summarized from files maintained by the Missouri
Department of Health and Senior Services. Frequencies are then pre-computed for each
combination of the variables. This provides two major advantages: the response time to
create and return a table is usually less than five seconds, and no individual record can be
accessed. Confidentiality rules have been developed to protect the privacy of individuals.

Priorities MICA provides a structured process for determining the priority health needs
of a community. This tool allows a user to select diseases or risk factors for prioritization
and then choose criteria to be used to determine the priority health needs among those
diseases or risk factors. Users can rate the level of community support for each
disease/risk factor and the importance of each criterion. Priorities can be determined for
the state of Missouri, individual counties, or selected cities/areas. A total weight is given
to each disease/risk factor based on the user’s choices, and the diseases/risk factors are
then presented as a ranked list.

Intervention MICA is an interactive, evidence-based planning tool. It provides links to
information and resources which can be used to design, implement, and evaluate
interventions that improve the health of a community. Intervention MICA includes seven
steps: Partnerships, Assessment, Readiness & Preparation, Capacity, Intervention,
Evaluation, and Momentum.

Together these four tools can assist health professionals with the process of continuous
community health improvements.



PLEASE NOTE: DHSS is in the process of making major changes to the department’s
website, and the Bureau of Health Informatics is currently upgrading the community
health assessment and intervention planning tools. While many of these changes will
occur behind the scenes, in the coming months some alterations will be made to the
material presented here. The exact screen captures presented in this handbook may not
be available in the future.



                                            ~3~
Community Data Profiles
Overview

We will first look at the Community Data Profiles, located at
http://www.dhss.mo.gov/CommunityDataProfiles/. Each Profile consists of a table
containing 15-30 indicators related to the chosen topic. These tables include information
such as the number of events, the county/city rate, statistical significance compared to the
state, quintile ranking, and the state rate for each indicator. Profiles can be viewed for the
state as a whole, each of Missouri’s 115 counties, Eastern Jackson County (which
excludes Kansas City and Independence), and the cities of Independence, Joplin, and
Kansas City. Regional data is available for the County-level Studies and the Diabetes
and Heart Disease Profiles.




                                            ~5~
Note the additional links available in the blue bar on the left. The Definitions link
provides information about some of the types of data available in the Profiles. These
types of data will be described later in this handbook, as will the MICA data tools, which
can be accessed from the next link.

The Publications link leads to the Vital Statistics Annual Reports. Provisional data on
some topics is also available here, usually before final data is uploaded to the Profiles or
MICAs. These provisional data reports show how birth, death, marriage, dissolution, and
other related data for a particular month and cumulative twelve-month period compare to
data from the same time periods in previous years. Provisional data have not been
completely reviewed or adjusted and do not include data that is reported late to Vital
Records. All provisional data are subject to change.




                                           ~6~
The final link, Contact Us, provides the mailing address, phone number, and email
address of the Bureau of Health Informatics, which maintains the Profiles and MICA
tools.




                                        ~7~
                                        Community Data Profiles – Topic Overview
                      Vital    BRFSS/     Vital                                                                      Non-
                     Records   Survey    Records   Hospital/   Population                                           DHSS
     Profile          Births    Data     Deaths      ER        Estimates    STDs   WIC           Other              Website
    2003-2007
County-Level Study
  Comparisons
                                                                                        No Health Coverage

2007 County-Level
      Study                                                                             No Health Coverage
                                                                                         Traffic Crashes –
                                                                                         Impaired Driver,
                                                                                         School Attendance,
                                                                                         Employment,
                                                                                         Vocational
 Alcohol and Drug
 Abuse Problems                                                                     Rehabilitation, Juvenile
                                                                                         Court Referrals, Police
                                                                                                                     
                                                                                         Reports, Criminal
                                                                                         Justice, Substance
                                                                                         Abuse Programs,
                                                                                         Primary Drug Problems
  Assault Injury                                    
                                                                                         Lead Testing, Divorces
   Child Health                                                                     Involving Children,
                                                                                         Probable Cause Child
                                                                                         Abuse/Neglect
 Chronic Disease                                    
 Death – Leading
     Causes                                                                
     Delivery                                                                         Delivery Types,
                                                                                         Abortions
     Diabetes                                     
 Emergency Room                                      
  Heart Disease                                                                       Hospital Utilization
                         Vital    BRFSS/    Vital                                                                      Non-
                        Records   Survey   Records   Hospital/   Population                                           DHSS
      Profile            Births    Data    Deaths      ER        Estimates    STDs   WIC            Other             Website
                                                                                           Balance Sheet,
 Hospital Revenues                                                                        Operating Margin,
                                                                                           Markup
 Hospitalization –
    Inpatient                                          
     Hospitals                                                                            Utilization, Facilities,
                                                                                           Staffing
   Infant Health                                                                       Infants on Medicaid
    Medicaid                                                                               Medicaid Recipients by
   Participation                                                                           Race and Age
  Minority Health                                                          
                                                                                           Fertility Rates,
   Preconception/
  Family Planning                                                                        Abortions, Unintended
                                                                                           Deliveries
      Prenatal                                                                           Prenatal Medicaid,
                                                                                           Food Stamps
                                                                                           Household Types,
                                                                                           Population by Place
                                                                                           Category, Disability,
                                                                                           Housing, Employment,
Social and Economic
     Indicators                                                                         Income,
                                                                                           Agriculture/Farming,
                                                                                                                       
                                                                                           Work/Commuting
                                                                                           Patterns, Education,
                                                                                           Poverty
Self-Inflicted Injury                                 
       Stroke                                                                           Hospital Utilization

Unintentional Injury                                  
 Women’s Health                                       
County-level Studies

The County-level Study was conducted in Missouri in 2002-2003 and again in 2007-
2008. Just over 50,000 Missouri adults (ages 18 and over) were interviewed in the 2007
study. Approximately 15,000 were interviewed in the 2003 study. Because of the lower
number of respondents in 2003, data from two or three smaller counties were combined.

The studies utilized the Centers for Disease Control and Prevention (CDC) Adult
Tobacco Survey (ATS) and selected questions from the Behavioral Risk Factor
Surveillance System (BRFSS). Data from the ATS may be found in the Secondhand
Smoke, Tobacco Use, and Tobacco Cessation Profiles. BRFSS data on various
diseases, health conditions, and preventive practices may be found in the Health and
Preventive Practices Profiles. The 2003-2007 County-level Study Comparison
Profiles compare results from the 2003 and 2007 studies by combining the 2007 data into
the same county groupings used in the 2003 study.

To view a Profile, highlight it, then select the desired geographic area and click on the
submit button.




                                           ~ 10 ~
The 2007 County-level Study Health and Preventive Practices Profile for the State of
Missouri appears below. To review a complete description of the 2007 study, click on
the hyperlinked title County-level Study 2007.

The data presented on the default page of the Profile are weighted percents. Age-adjusted
percents may be selected through the hyperlink at the top of the page. (These types of
statistics will be further explained later in this handbook.)

Tabs at the top of each table of State of Missouri data segment the indicators by
demographics. The definition of an indicator may be viewed by selecting its hyperlinked
label. Download features include the ability to download state, regional and county data
for an indicator to an Excel table, a PDF document, and a map. The entire Profile may be
downloaded to a PDF document and printed using one of the Print Profile links that
appear at the top and bottom of the screen. A map of the indicator No health-care
coverage is displayed on the next page.




                                         ~ 11 ~
The data tables presented with the map may be hidden so that only the map is printed. To
hide the data table, click the minimize button next to the Data Table heading.




                                         ~ 12 ~
To select a different region or county for a Profile, click on the Select a different
geographical area link. A drop-down box will appear and the desired geography can be
selected from the list.




                                        ~ 13 ~
Below is the Health & Preventive Practices Profile for Adair County. On each county
Profile, the percent for each indicator is compared to the region and state data to
determine if there is a statistically significant difference. If there is no significant
difference, “N/S” is shown. If the county percent is statistically significantly higher, “H”
is shown. If the county percent is statistically significantly lower, “L” is shown.
Statistically significant differences will be explained in more detail later in this
handbook.




PLEASE NOTE: The Bureau of Health Informatics is in the process of upgrading the
community health assessment and intervention planning tools. All Profiles will
eventually be converted to the format used by the County-level Studies. As of the
publication date of this handbook, most Profiles still use the format illustrated on the next
page.




                                           ~ 14 ~
Child Health Profile

The Child Health Profile contains a variety of indicators related to the health of
individuals ages 1-19 years. The next examples will be taken from the Child Health
Profile for Pemiscot County.

A portion of this Profile appears below.




Documentation

Throughout the Profiles, many labels are linked to additional information about the data.
Simply click on any hyperlinked label to view a definition and/or source information.
For example, the following description is linked to the indicator WIC Participation:
Ages 12 to 59 Months – Inclusive:

WIC Participation Ages 12-59 Months

Unduplicated count of resident children ages 1 through 4 participating in WIC and
the percent this number is of all resident children ages 1 through 4 using noted year
population estimates. WIC participation acquired from the WIC Certification data set.

Additional information can also be found in the footnotes. The footnotes to the Child
Health Profile contain the following explanation of WIC Participation rates:

WIC Participation rates are per 1,000 resident children ages 1 through 4 using
population estimates for noted year.




                                           ~ 15 ~
Statistics

Several statistical measures are used to describe each indicator.




Number of Events is also commonly referred to as Frequency. In the indicator above
(WIC Participation of children ages 12 to 59 months), the number of events, or
frequency, for Pemiscot County in 2007 was 743.

The Rate is the number of events (numerator) divided by the population at risk
(denominator) multiplied by a constant. The rate allows comparisons to be made among
different counties that have different populations. In the Pemiscot County example, we
have already determined that the number of events, or frequency, is 743. The population
at risk would be all Pemiscot County children ages 12 to 59 months (1 to 4 years).
Looking at the Population Estimates section of the Profile, we determine that this
population consists of 1,222 individuals.




The appropriate constant to use depends on the rarity of the event. The constant is used
to convert the decimal that results from dividing the frequency by the population into a
more usable number. It will always be a multiple of 10, such as 1,000 or 100,000. A
constant should be chosen that will convert the rate into a number greater than or equal to
1. The following table provides examples of the appropriate constant to use in different
situations.




                                           ~ 16 ~
  Frequency ÷        Constant to          Rate        Indicator             Source
   Population           Use
      .081              100                8.1        Low Birth Weight Infant Health
                                                      (<2,500 grams)    Profile, State
                                                                        Rate, 2002-
                                                                        2006
     .0092              1,000              9.2        Asthma ER Visits Child Health
                                                      for Children      Profile, State
                                                      Under 18          Rate, 2006
     .00060             10,000             6.0        Neural Tube       Infant Health
                                                      Defect Births     Profile, State
                                                                        Rate, 2001-
                                                                        2005
    .000037            100,000             3.7        Cancer Deaths for Child Health
                                                      Children 15-19    Profile, State
                                                                        Rate, 1997-
                                                                        2007

The resulting rate of WIC Participation by Pemiscot County children ages 12 to 59
months is:
                Number of Events ÷ Population at Risk x Constant = Rate
                          743 ÷ 1,222 = .6080 * 1000 = 608.0

When using rates, it is very important to specify the constant so that others can determine
the prevalence of the indicator. In the example above, the rate of WIC Participation by
Pemiscot County Children Ages 12 to 59 Months is 608.0 per 1,000 resident children
ages 1 through 4.

The State Rate is also provided in the sixth column of data for comparison.

The Significantly Different column indicates whether the differences between the
county rates and the corresponding state rates were probably the result of chance factors.
    “H” – 95% confidence that the county rate is statistically higher than the state rate
    “L” – 95% confidence that the county rate is statistically lower than the state rate
    “N/S” – cannot state with confidence that the difference between the county rate
       and the state rate is not due to random variations. The difference is not
       statistically significant.

In this example, we can be 95% confident that Pemiscot County’s rate of WIC
Participation for children ages 12 to 59 months is statistically higher than the state rate.
There is a statistically significant difference between the county rate and the state rate.

Ranking Quintiles provide a general idea of how a particular county ranks on an
indicator compared to the rest of the counties in Missouri. A quintile is one-fifth of a
ranked list. The 115 counties of Missouri (including St. Louis City) are ordered by rate

                                            ~ 17 ~
from lowest to highest. They are then divided into five quintiles, with 23 counties in each
quintile (115 ÷ 5 = 23). In cases where the numbers of events are small, a county may
fall into the highest or lowest quintile on the basis of a few events, even if the underlying
true rate is not particularly high or low. Quintiles are not shown if more than half of the
counties have fewer than 20 events.

                               Quintile        Ranks
                                  1       1-23 Highest rates
                                  2      24-46
                                  3      47-69
                                  4      70-92
                                  5     93-115 Lowest rates

Pemiscot County has a quintile ranking of 1, indicating that it ranks among the top 23
counties in Missouri for rate of WIC Participation by children ages 12 to 59 months.

Trend Lines graphically show the rate of occurrence of a disease or risk factor over time.
They also illustrate the direction and acceleration of changes in that rate. If the rate of an
indicator is increasing over time (i.e., has an upward-sloping trend line) it may be
considered more urgent than indicators for which the rate is decreasing (i.e., have a
downward-sloping trend line). Indicators which have trend lines with steep upward
slopes may be considered more urgent than those with trend lines which are also
increasing but have more gradual slopes.

As with rates themselves, there is random variation in the trend lines of rates, so that a
line that slopes upward may not represent a statistically significant increase, particularly
if it is based on small numbers. For that reason, we run significance tests to determine
whether or not we can be at least 95 percent confident that what appears to be an increase
or decrease is real, not just the result of random fluctuation. The results of these
significance tests are explained in the Trend Analysis, which appears below the trend
line chart.

Three-year moving averages are also used on the trend lines to smooth random
variations that may occur in a particular year. Please note that trends are available only if
each three-year period of the moving average has an average of 20 or more events.

In the trend line chart on the next page, we can see that the rate of WIC Participation for
Pemiscot County children ages 1-4 has declined since 2000-2002. The trend analysis
informs us that this decline is statistically significant. (As explained earlier, the
difference between the county and state rates for the year 2007 is also significant.)




                                           ~ 18 ~
To download the three-year moving averages table, simply click the download link at the
bottom of the screen. A File Download box will appear. Selecting Open will
immediately open the table in an Excel workbook. Selecting Save will allow the Excel
file to be saved first, with the option of opening the file once the save is complete.




                                        ~ 19 ~
Please note that the trend line chart does not download into Excel, only the data table.
Once the data is downloaded, Excel’s Line Chart tools can be used to recreate and
customize the trend line.




                                           ~ 20 ~
The Advanced Graphics feature allows for comparisons of the rates of different counties
or of multiple indicators for the originally selected county.


To compare multiple counties: Press and hold down the CTRL key while using the
mouse to click up to seven county names in the drop-down list. (CTRL, SHIFT, and
arrow keys may be used to select counties that are listed consecutively.) The state rate
will also be shown for comparison. To continue our example, let’s compare Pemiscot’s
rate to those of its two neighboring counties, Dunklin and New Madrid. Select all three
counties from the list, then click the Submit button.




                                          ~ 21 ~
We can now see that Pemiscot’s rate is higher than New Madrid’s but lower than
Dunklin’s. All three counties have rates that are significantly higher than the state rate.
Pemiscot and Dunkin are both ranked in the highest quintile, while New Madrid is ranked
in the second-highest quintile.

The table can be downloaded into Excel by using the Download link at the bottom of the
screen. The graphics do not download, only the data table. This option allows the data to
be manipulated and formatted to the user’s specifications in another software program,
such as Excel. The Column Chart tool in Excel can be used to recreate the graphics, if
necessary.

To compare multiple indicators: On the county/indicator selection screen, press and
hold down the CTRL key while using the mouse to click up to eight indicators in the
drop-down list. Only two indicators are available in the WIC section for Pemiscot
County. Select those indicators, then click on the Submit button below the indicator
selection box. We can see that only a fraction of WIC Participants ages 1 to 4 are
overweight. The table can be downloaded using the link at the bottom of the screen.
Again, the chart itself will not download but can be recreated in Excel.




                                          ~ 22 ~
The Download County Data option, which is found in the last column of the Child
Health Profile, allows the user to download into Excel the set of frequencies for all
counties for the selected indicator.




Download options allow the entire Profile or the Three-Year Moving Average Rates for
all Indicators to be downloaded into Excel using the links at the bottom of the screen.




                                          ~ 23 ~
By Race Profiles are available for the state of Missouri and the following counties/cities
which have large African-American populations: Boone, Greene, Jackson, Kansas City,
Mississippi, New Madrid, Pemiscot, St. Charles, St. Louis, St. Louis City, and Scott.
Simply select the By Race link at the top of the Profile to view this data.




The resulting Profile by Race is partially shown below. To return to the overall
population data, simply select All Residents.




                                          ~ 24 ~
Stroke Profile

One of the newest additions to the Community Data Profiles is the Stroke Profile. The
Stroke Profile contains information on risk factors, prevalence, mortality,
hospitalizations, ER visits, and hospital utilization indicators for strokes.


In the following examples we will look at the Stroke Profile for Atchison County.




                                         ~ 25 ~
The first section of the Stroke Profile contains data about the risk factors for stroke and
stroke prevalence. These data were collected from the Behavioral Risk Factor
Surveillance System (BRFSS). The BRFSS is a cross-sectional telephone survey that
generates United States and state-specific information about health risk behaviors,
clinical preventive services, disease prevalence, health care access, and other health-
related issues. More information about the BRFSS is available at the following web
address: http://cntysvr1.lphamo.org/pubdocs/brfss/index.php.




Selecting any of the hyperlinked risk factors displays documentation about that risk
factor. For example, selecting Physical inactivity displays the following information:

       Physical inactivity

       Persons who reported outside their regular jobs, they did not participate in any
       physical activities or exercises such as running, calisthenics, golf, gardening or
       walking for exercise during the past month, also called no leisure time physical
       activity during the past month.

The BRFSS section of the Stroke Profile differs from the Child Health Profile in that it
uses Weighted Counts and Weighted Percents rather than unadjusted, or crude,

                                           ~ 26 ~
numbers of events and rates. These weighted counts and percents allow us to better
generalize the survey results to the overall population. “Population weights in the
BRFSS make adjustments for the following factors: (1) The probability of selection for a
given phone number; (2) The probability of reaching a household (adjusting for the
number of telephones per household); (3) The probability of reaching an adult in the
household (adjusting for the number of adults per household) and (4) The demographic
distribution of the sample (poststratification)” (Goldberg et al.).

The rates shown in this section are the rates for a region of the state, not for
individual counties, as the data are not statistically stable below the regional level.
To view the counties included in the region, select the region link at the top of the Profile.




The second section of the Stroke Profile is more similar to the Child Health Profile.
However, the rates used in this section are age-adjusted. Age-Adjusted Rates allow us
to make fairer comparisons among groups with different age distributions. For example, a
county having a higher percentage of elderly people may have a higher rate of death or
hospitalization than a county with a younger population, merely because, in general, an
elderly population is more likely to die or be hospitalized. Age adjustment can make
different counties more comparable.




A "standard" population distribution is used to adjust death and hospitalization rates. The
age-adjusted rates are rates that would have existed if the population under study had
been distributed by age the same way as in the "standard" population. The footnotes to
the Profile reveal that the standard population used in this case was the U.S. 2000

                                           ~ 27 ~
standard population. This is the standard population recommended by the National
Center for Health Statistics.




If you compare rates from different sources, it is very important that you
use the same standard population on both sides of your comparison. It is
not legitimate to compare adjusted rates which use different standard
populations.




                                        ~ 28 ~
Additional documentation regarding age-adjusted rates can be found by selecting the
hyperlinked Age-Adjusted Rate heading.




                                         ~ 29 ~
The third section of the Stroke Profile contains Hospital Utilization Data. These data
show the total charges and total days of care for the different types of strokes, as well as
other data specific to particular types of strokes.




As with the Child Health Profile, either the entire Stroke Profile or the Three-Year
Moving Average Rates can be downloaded using the links at the bottom of the screen.




Data by Race are also available for counties/cities with large enough African-American
populations.




                                           ~ 30 ~
Hospital Revenues Profile

Most of the Profiles contain features similar to those already covered. However, a few of
the Profiles are quite different. One of these is the Hospital Revenues Profile.




In this Profile, hospital financial and utilization data are available for individual hospitals
within each county.




The financial data includes the Balance Sheet, the Statement of Revenues and Expenses,
and Other Financial Statistics, such as the Operating Margin and Total Markup.




                                            ~ 31 ~
~ 32 ~
Several of the data categories are hyperlinked to additional documentation about those
categories. Simply select one of the hyperlinked categories, such as Total Operating
Revenue, to view the documentation.




The last section of the table contains Selected Utilization Statistics, such as the number of
Licensed Beds and Average Length of Stay.




                                           ~ 33 ~
A printer-friendly version of the table is accessible through a link at the top of the Profile.




Other links in the same area of the Profile allow the table to be downloaded or another
county to be selected.




                                            ~ 34 ~
Data from External Organizations

Two Profiles contain data provided by organizations other than the Department of Health
and Senior Services.


Social and Economic Indicators Profile

The Social and Economic Indicators Profile contains data provided by the University of
Missouri Extension Office of Social and Economic Data Analysis (OSEDA).




                                         ~ 35 ~
Each county table contains a variety of data about population, employment, income,
agriculture/farming, education, children and families, and health status. A portion of the
table for Taney County appears below.




Below the table, footnotes are provided, as well as links to a narrative profile of the data
and sources of the data.




                                           ~ 36 ~
Alcohol and Drug Abuse Problems Profile

The Alcohol and Drug Abuse Problems Profile contains data provided by the Missouri
Department of Mental Health.




A portion of the Profile for Howard County appears below.




                                        ~ 37 ~
Citations

When using information from the Community Data Profiles in reports or presentations,
please cite the source using the following format.


      Within the document or presentation:

              The 2007 WIC Participation rate for Pemiscot County children ages 12-59
              months was 608.0 per 1,000 residents. This rate was statistically
              significantly higher than the state rate of 299.6 per 1,000 residents.
              Pemiscot County was ranked in the highest quintile for this indicator
              (MODHSS, Child Health Profile).


      References page:

              MODHSS (Missouri Department of Health and Senior Services).
                   Community Data Profiles. In Child Health Profile. Retrieved May
                   6th, 2009, from
                   http://www.dhss.mo.gov/ASPsChildHealth/Main.php?cnty=929.




                                        ~ 38 ~
Profiles Exercises

1. You are researching diabetes in Ray County and need to find out how the number of
   ER visits due to this condition has changed over the past few years. Use the Profiles
   to find this information.
   a. Which Profile did you use?
        _____________________________________________
   b. What feature did you use to determine how the number of ER visits has changed
        over time?
        __________________________________________________________________
   c. Has the number of cases in Ray County increased, decreased, or remained the
        same since 1996? ___________________ Is this a statistically significant
        change? _____________
   d. Has the number of cases in the State of Missouri increased, decreased, or
        remained the same since 1996? _________________ Is this a statistically
        significant change? ______
   e. During what years was the Ray County rate higher than the state rate?
        _______________
   f. This feature only allowed you to compare Ray County and the state. How could
        you create trend lines for multiple counties?
        __________________________________________________________________
        __________________________________________________________________

2. You are writing a report on births to mothers ages 15 to 17 years who are residents of
   Stone County. Use the Profiles to create a chart that can be included in your report.
   The chart should compare Stone County’s rate to the rates of its surrounding counties
   (Barry, Christian, Lawrence, and Taney).
   a. Which Profile did you use?
      _________________________________________________
   b. What feature did you use to create the chart? _____________________________
   c. Which counties have rates that are statistically significantly higher than the state
      rate?
      __________________________________________________________________
   d. Which counties have rates that are statistically significantly lower than the state
      rate?
      __________________________________________________________________
   e. Which counties have rates that are not statistically significantly different than the
      state rate?
      __________________________________________________________________
   f. Do any of the counties have unstable rates?
      ____________________________________
   g. Into which ranking quintile does Stone County fall? ______ What does this tell
      us about Stone County’s rate compared to the other 114 counties in Missouri?
      __________________________________________________________________
      __________________________________________________________________


                                          ~ 39 ~
3. A coalition in your county is interested in working on either tobacco use or obesity
   among adults. You have been asked to begin compiling information to help the group
   decide on which topic they should focus their time and resources. Use the 2007
   County-level Study Profiles to obtain the answers to the following questions:
   a. What is the crude weighted percent of obesity among adults in your county?
      ___________ What is the crude weighted percent of current cigarette smoking?
      ___________
   b. Is there a significant difference when comparing the age-adjusted prevalence of
      obesity in your county to the region? ___________ To the state? ___________
   c. Is there a significant difference when comparing the age-adjusted prevalence of
      current cigarette smoking in your county to the region? _________ To the state?
      _________
   d. In what quintile ranking does the age-adjusted prevalence of obesity for your
      county fall? ___________ In what quintile ranking does current cigarette
      smoking in your county fall? ___________ Where did you find this information?
      __________________________________________________________________
   e. What related data from the 2007 County-level Study might you also consider
      when completing the assessment of the obesity problem in your county?
      __________________________________________________________________
      __________________________________________________________________
      What related data might you want to consider regarding the tobacco use problem?
      __________________________________________________________________
      __________________________________________________________________




                                        ~ 40 ~
MICA (Missouri Information for Community Assessment)

Overview

The MICA tools allow users to create and download customized tables based on selected
variables. To access the MICAs, we could return to the DHSS home page and select the
Data, Surveillance Systems & Statistical Reports link, or we can use the MICA link
that is available in the left bar of the Community Data Profiles website.




                                        ~ 41 ~
Selecting this link takes us to the MICA website at
http://www.dhss.mo.gov/MICA/index.html.




The blue bar on the left side of this screen provides many of the same links that are
available on the Community Data Profiles screens. Links to Priorities MICA and
Intervention MICA are available here as well.




                                          ~ 42 ~
Population MICA

One of the simplest MICAs to use is the Population MICA. A brief description of the
data is presented on the Population MICA website. Additional information about this
specific MICA is available through the Definitions and Documentation links in the left
bar.




Population MICA has only one option available: Table only - Statewide, County(ies)
and/or City(ies) 1990-2007. Selecting this option will allow us to begin building a
Population table.




                                        ~ 43 ~
Submitting the default query shown above returns the following table.




County was selected as the row variable in Step One. State of Missouri was then
selected as the state/county/city of interest for this row variable in Step Five. Year was
selected as the column variable in Step Two. The year 2007 was selected in Step Four as
the year of interest for this column variable. No ranges were selected in Step Three, and
Frequencies only was selected in Step Six. The resulting table thus shows only the total
population of Missouri for 2007.




                                          ~ 44 ~
Suppose we want to determine how many children under the age of 15 lived in Butler
County and each of its surrounding counties of Ripley, Carter, Wayne, Stoddard, and
Dunklin during each year between 2004 and 2007. To perform this query, we would
make the following selections:

Step 1: Select a row variable. Choose Counties/Cities so that the individual counties
will be listed on rows in the table. If the No Sort function is selected, the counties/cities
will be listed in alphabetical order, as they appear in the selection list. (Any selected
cities would be listed after the counties.) If the Sort function is selected, the areas will be
listed in descending order by rate.

Step 2: Select a column variable. Choose Year so that each year will be listed in a
separate column in the table.

Step 3: If you want to choose a particular range (example: Ages 25-44) do not select that
variable above, choose it in the pull-down box below. Since we are only interested in
residents under the age of 15, we must select Under 15 from the Age drop-down list.

Step 4: Select year(s) of interest. 2004, 2005, 2006, 2007

Step 5: Select county(ies) or city(ies) of interest. Scroll down the county list and select
Butler. Then, while holding down the CTRL key, select the remaining counties of
Carter, Dunklin, Ripley, Stoddard, and Wayne. (Holding down the CTRL key allows
the selection of multiple counties.)

Step 6: Frequencies or Frequencies with Percents. We are only interested in the number
of children, so Frequencies only should be selected.

Once the query is submitted, the following table is produced.




                                            ~ 45 ~
If we decide that we would prefer the Years to appear as row variables and the
Counties/Cities to appear as column variables, we can simply select the Rotate option
rather than modify our original query.




                                         ~ 46 ~
MICA tables have a Download option, similar to that available in the Community Data
Profiles. The tables download into Excel, allowing them to be imported into reports or
presentations.




                                         ~ 47 ~
Birth MICA

For our next examples, let’s look at the Birth MICA, which contains data concerning
births of Missouri residents.




Some MICAs contain additional options such as maps and zip code tables, which will be
discussed later in this handbook. Also note the Related Links option in the left bar.
This link provides other sources of information about the MICA topic currently being
viewed. Some of these sources may be other MICAs or Profiles, while some may be
sources outside of DHSS.




                                        ~ 48 ~
For now, let’s go back to the main Birth MICA page and look at the county-based table
option (Table only - Statewide, County(ies) and/or City(ies) 1990-2007).




                                        ~ 49 ~
The county table query screen in the Birth MICA is very similar to the query screen in
the Population MICA. However, the Birth MICA contains an additional step, Step Six,
Select an indicator variable. This step allows users to create tables based on specific
maternal and child health indicators. Some of the other steps contain additional variables
that pertain to Birth.

Suppose we want to find the cumulative number and rate of preterm births in Dent
County for the years 2001 through 2007. We would like to see this information by race
and also by the trimester in which the mother first received prenatal care. To perform
this query, we would select the following options:

Step 1: Select a row variable. Race
Step 2: Select a column variable. Prenatal Care
Step 3: Select a range (Optional). No selection.
Step 4: Select year(s) of interest. 2001, 2002, 2003, 2004, 2005, 2006, 2007
Step 5: Select county(ies) or city(ies) of interest. Dent
Step 6: Select an indicator variable. Gestation: Preterm (less than 37 completed
weeks)
Step 7: Output Type. Since we want to see rates, we need to select Frequencies and
Percents, No Confidence Intervals.


The following table is produced once the query is submitted.




                                          ~ 50 ~
Drill-Down Variables

Note that the only races shown in the table on the previous page are White and
Black/African-American. If we were interested in the data for some other racial group,
we would need to select the All Races drill-down hyperlink in order to produce the
following table showing all racial categories.




For this particular query, the small numbers available for races other than White and
Black/African-American have triggered a confidentiality rule. These rules are in place
to protect individuals from being identified in cases where only a small number of
observations occur. More information on confidentiality rules is available through the
Definitions link.

(Note that Hispanic is not listed as a Race. Hispanic data is listed under the variable
Ethnicity. Rates by Ethnicity are not available for individual counties.)




                                           ~ 51 ~
Drill-down hyperlinks are available for some other variables as well. The following
example shows a drill-down hyperlink on the age variable in Population MICA.




Selecting the Under 15 hyperlink produces the following table.




                                         ~ 52 ~
Confidence Intervals

Another feature available in many of the MICAs is the ability to Select confidence
intervals for rates. Confidence intervals are ranges of rates in which the true rate would
fall a specified percentage of the time “if repeated sampling of the population were
performed” (Goldberg et al.). Both 95% and 99% confidence intervals are available.
Let’s go back and select the 95% confidence interval for our query about preterm births
in Dent County. The resulting table is very wide, so it has been rotated below for easier
viewing.




The first confidence interval listed is for White residents with No Prenatal Care who had
a preterm birth sometime between 2001 and 2007. The confidence interval is 30.0 to
90.3. We can be certain that 95% of the time, the true rate for this population will fall
within this interval. However, this interval is very wide, which decreases the likelihood
that the true rate is actually the 66.7 rate shown. In other cases, such as All White
residents, the confidence interval (9.9 to 13.4) is much narrower, so the true rate is more
likely to be the rate shown (11.5).




                                           ~ 53 ~
Drill-Down Indicators

In the previous examples, we chose Preterm births as our indicator. This indicator was
fairly easy to find in the list of selected indicators. Some indicators, however, may not be
as easy to locate. For example, suppose we want to determine the number and rate of
very low birth weight (VLBW) infants delivered in Kansas City in 2007 who were not
born in level 3 hospitals. We would choose the following criteria:

Step 1: Select a row variable. Indicator

Step 2: Select a column variable. Year

Step 3: Select a range (Optional). No selection.

Step 4: Select year(s) of interest. 2007

Step 5: Select county(ies) or city(ies) of interest. Kansas City (Choose Kansas City in
the Cities box. If a county or State of Missouri is highlighted in the Statewide/County
box, hold down the CTRL key and click on that selection to deselect it.)

Step 6: Select an indicator variable. After scrolling through the list, we do not find the
exact indicator we are seeking (VLBW infants not delivered in a level 3 hospital). We
do, however, find an indicator that seems to be related to our area of interest, Birth
Place: Very Low Birth Weight Births Delivered in a Level 3 Facility. We can make
this selection to see if it contains the data we need.

Step 7: Output Type. Since we want to see rates, we need to select Frequencies and
Percents, No Confidence Intervals.




                                           ~ 54 ~
Once the query is submitted, the following table is displayed:




The table provides the number of VLBW Births Delivered in a Level 3 Facility and also
the total number of Kansas City live births for 2007. Although this data may be helpful,
it is not exactly what we need because we are still unable to calculate the number of
VLBW births that were not delivered in a Level 3 facility. However, if we click on the
hyperlinked indicator, we can view additional data.




This additional data contains the needed information, the number of VLBW Births Not
Delivered in a Level 3 Facility. Additional data is available for many selected indicators
throughout the MICA system.

                                          ~ 55 ~
Death MICA

One of the most frequently used MICAs is the Death MICA. The Death MICA provides
data on deaths of Missouri residents.




                                     ~ 56 ~
The Table only option provides a query screen that is similar to those used in the
Population and Birth MICAs. However, note that an additional selection box has been
added in Step Seven.




                                        ~ 57 ~
Age-Adjusted Rates

The MICAs that we have viewed thus far have presented only crude, or unadjusted, rates.
The Death MICA includes the option to Select a standard population for age
adjustment. As described earlier, a "standard" population distribution is used to adjust
death and hospitalization rates. Age-adjusted rates are the rates that would have existed if
the population under study had the same age distribution as the "standard" population.
The U.S. 2000 standard population is recommended by the National Center for Health
Statistics and is used as the default setting in MICA. The 1940 and 1970 U.S. standard
populations are also available, as are the Crude Rates.

Again, if you compare rates from different sources, it is very important that you use the
same standard population on both sides of your comparison. It is not legitimate to
compare adjusted rates which use different standard populations. Additional
documentation regarding age-adjusted rates can be found in the Definitions section of the
MICA home page.




                                           ~ 58 ~
Drill-Down Variables

Step Six of the Death MICA lists only the major causes of death. As with the Birth
MICA, it is necessary to use drill-down hyperlinks to view specific indicators within the
major categories. For example, in the following table, default options were used for all
steps except Step Six, in which Other infections and parasites was selected as the cause
of death. The resulting table shows only the overall total, not the number of deaths from
specific infections and parasites.




Selecting the drill-down hyperlink on Other infections and parasites displays these
specific causes of death.




                                         ~ 59 ~
Maps

The Map option within MICA is useful because it provides a graphical view of the
prevalence of a condition throughout the state.

The map option is located on the introductory page as shown below.




                                        ~ 60 ~
For example, we could map our previous general query about 2007 deaths from Other
infections and parasites.




For this query, no map was generated due to the small number of occurrences. (In some
cases, the table data may also be suppressed due to small numbers or confidentiality


                                        ~ 61 ~
rules.) Let’s select another cause of death, Cancer. The resulting map and a portion of
the data table appear below.




                                         ~ 62 ~
Because we selected Frequencies and rates, rates were used to generate the map on the
previous page. If Frequencies only had been selected, frequencies would have been
represented instead.




                                        ~ 63 ~
The default setting in Step Four divides the counties using quintiles. Other settings
allow the mapped data to be displayed based on quartile rankings, as shown below.
Quartiles are calculated in the same manner as quintiles, except that the counties are
divided into four groups instead of five.

The decision to use either quintiles or quartiles often depends on the ranking method that
is used in other data to which the MICA data will be compared. One advantage of using
quintiles is that the central grouping (the middle one-fifth of the data) can be considered
the average group.




                                          ~ 64 ~
The Higher/Lower than State setting generates a map which shows whether each
county’s rate is statistically significantly different from the state rate. Other settings in
Step Four allow the user to select a color scheme and county labels.




                                            ~ 65 ~
Map for more specific causes within selected cause

Suppose we want to map a specific type of cancer instead of cancer in general. We need
to go back to the query screen and select Map for more specific causes within selected
cause in Step Three. When this query is submitted, a list of specific types of cancers is
generated.




Once a selection is made from this list and the query is submitted, the information for the
specific type of cancer chosen will be displayed. A partial view of the skin cancer data
appears below:




                                          ~ 66 ~
Hospital Discharges, Charges and Days of Care MICA

The Hospital Discharges, Charges and Days of Care MICA can provide insight into the
prevalence of certain health problems in Missouri.




                                       ~ 67 ~
When using the county data table option, users can select the specific area of interest
(discharges, charges, or days of care) on the query screen.




                                           ~ 68 ~
As with most MICAs, drill-down topics are available for some of the indicator variables
in Step Six. For example, the Mental disorders indicator drills down to several more
specific diagnoses.




                                         ~ 69 ~
Zip Code Tables

Some MICAs include zip code table options on the introductory page. These options
allow users to generate tables based on zip codes rather than counties/cities. The Any
Zip option requires the user to enter specific zip codes in Step Four of the query screen.
If multiple zip codes are entered, they must be separated by spaces.




Separate zip code tables are available for the Kansas City, Springfield, and St. Louis
areas. Each of these query screens provides a list of zip codes from which the user can
make selections. A map showing zip code locations is also included for reference. The
Springfield query screen is displayed on the next page.



                                          ~ 70 ~
~ 71 ~
Cancer Registry MICA

The Cancer Registry MICA provides cancer incidence data for Missouri residents. It
operates somewhat differently from the other MICAs.




Three table options are available. The first option, State, BRFSS, Region and/or
County MICA for seven (7) major sites and all sites combined provides data for three-
year periods. The only variables that can be queried are sex, stage, geographic location,
and seven major cancer sites. Counties and BRFSS regions are available but cities are
not. In the following table, State/Region/County was chosen as the row variable.
Northwest Region was selected as the area of interest in Step Five.




                                         ~ 72 ~
If a BRFSS region is chosen, users have the option of drilling down on the hyperlinked
region name to view the counties included in that region.




In this example, the Invasive stage (the default setting) was chosen in Step 3. Drilling
down on the hyperlinked term Invasive at the top of the table produces the following list
of more specific categories of invasive cancer:




A table can then be generated for any of these categories. The Distant table is shown
here.




                                          ~ 73 ~
The second option, State and/or BRFSS Region MICA for seven (7) major sites and
all sites combined, adds the variables age, race, and cancer grade to the query screen, as
well as the ability to select single years. However, individual counties are not available
for queries, only the state or BRFSS regions. Drill-down hyperlinks are not available for
regions in this option.

The third option, State and/or BRFSS Region MICA for nineteen (19) major cancer
sites and all sites combined, operates much like the second option. However, additional
cancer sites have been added. The cancer sites are also categorized differently and have
more drill-down options. For example, if the incidence of invasive leukemias in the State
of Missouri for the year 2006 is needed, the following table can be generated by selecting
the Invasive stage in Step Three and Leukemias in Step Six.




As in the example from the first option, a drill-down hyperlink is available for the
invasive state. However, another drill-down hyperlink is available for leukemias, which
produces the following list of types of leukemias.




Drilling down on the first type generates another table that provides the incidence of
invasive lymphocytic leukemia in the State of Missouri during the year 2006.




                                          ~ 74 ~
Procedures MICA

The Emergency Room, Inpatient Hospitalization, and Hospital Discharges, Charges and
Days of Care MICAs provide data on diagnoses but not on treatments provided. The
Procedures MICA, on the other hand, provides information on specific procedures
performed.




As with other MICAs, drill-down hyperlinks are available for most indicators so that data
about specific types of procedures can be displayed. For example, a drill-down hyperlink
on Operations on the ear links to a table showing specific types of ear procedures
performed.




                                         ~ 75 ~
WIC (Women, Infants, and Children) MICA

The WIC MICA actually contains five separate MICA data sets: Prenatal, Postpartum,
Prenatal/Postpartum, Infant, and Child. Each data set contains maternal and child health
indicators pertaining to that particular WIC population.




                                         ~ 76 ~
An explanation of each data set as well as links to county data tables or maps can be
viewed by selecting any of the hyperlinked data set titles or the All hyperlink.




                                          ~ 77 ~
Local WIC Provider MICA

A Local WIC Provider MICA (LWP MICA) is available on the Local WIC Provider
website. The web address for this tool is http://www.dhss.mo.gov/LocalWICProviders/.
This site can also be accessed by returning to the DHSS home page and selecting Topics
A-Z.




On the Topics A-Z website, select the letter W from the alphabet at the top or scroll
down to the bottom of the list to select WIC Local WIC Provider.




                                          ~ 78 ~
On the Local WIC Providers website, choose Data & Statistical Reports in the left bar.




                                        ~ 79 ~
From the list of Data and Statistical Reports, select the second Missouri Information for
Community Assessment (MICA) option.




The LWP MICA is password protected due to confidentiality concerns. User names and
passwords have been distributed to local WIC provider staff. Questions about LWP
MICA access should be directed to the state WIC office.




                                         ~ 80 ~
The LWP MICA includes all of the WIC data sets (Prenatal, Postpartum,
Prenatal/Postpartum, Infant, and Child) and all of the data available in the WIC MICA.
However, the LWP MICA also provides data about individual WIC providers.




                                         ~ 81 ~
TANF (Temporary Assistance for Needy Families) MICA

The TANF MICA contains data about the number of Missouri residents receiving
welfare assistance. Tables are available for four types of residents: families, adults,
children, and persons.




The TANF MICA Family query screen is shown on the next page. Note that Step Six
requires the user to select the month(s) of interest and that data are from the last day of
each month. The TANF MICA is updated monthly.




                                            ~ 82 ~
A query is available for family service area as well as state/county. The table for Family
Services Area 1 is shown below.




                                          ~ 83 ~
The drill-down hyperlink on the family service area label displays the counties included
in that service area.




                                         ~ 84 ~
Citations

When using information from MICA in reports or presentations, please cite the source
using the following format.


      Within the document or presentation:

       Fourteen of the very low birth weight (VLBW) births occurring in Kansas City in
       2007 did not take place in a Level 3 Facility. Therefore, the rate of VLBW births
       not occurring in a Level 3 Facility was 14.5 per 100 VLBW births (MODHSS, Birth
       MICA).


      References page:

       MODHSS (Missouri Department of Health and Senior Services). MICA. In Birth
            MICA. Retrieved May 6th, 2009, from
            http://www.dhss.mo.gov/BirthMICA/index.html.




                                         ~ 85 ~
MICA Exercises

  1. A co-worker shows you the following table and asks if you could help recreate it
     for the most current year of data available. What criteria should be used to create
     the updated table?




         a.   MICA: ____________________________________________________
         b.   Step One: Row variable __________________, Sort function ________
         c.   Step Two: Column variable _______________________________
         d.   Step Three: Race _______________, Ethnicity ________________,
              Sex ________, Age _____________, Patient Type __________________,
              Intention __________, Disposition _________________
         e.   Step Four: Year of Interest _______________________
         f.   Step Five: Statewide/County/Cities
              ____________________________________________________________
              ____________________________________________________________
              ____________________________________________________________
              __________________
         g.   Step Six: Mechanism _________________, Location ________________
         h.   Step Seven: Statistics to be displayed _________________, Standard
              population _______________, Confidence intervals _________________




                                        ~ 86 ~
2. You are asked to research asthma prevalence among different demographic
   groups in Missouri. Use either the Inpatient Hospitalization or Emergency Room
   MICA to perform your analysis on the most current year of data available.
      a. How did you find asthma?
          _______________________________________
      b. Look at sex first. Which sex has a higher rate of asthma? _____________
      c. Now add age to your analysis. Which age-sex group has the highest rate
          of asthma? ________________________________________________
          Does this surprise you based on your response to b.? _________
      d. You decide to look more closely at the group listed in c. and add race to
          your analysis. What race has the highest rate of asthma for the age-sex
          group you listed in c.? ____________________________________
      e. Add the counties for which rates by race are available (Boone, Greene,
          Jackson, Kansas City, Mississippi, New Madrid, Pemiscot, St. Charles, St.
          Louis, St. Louis City, and Scott). Which area has the highest rate of
          asthma for the race-age-sex group you listed in d.?
          ________________________________________




                                    ~ 87 ~
Priorities MICA

Overview

Priorities MICA is a tool that allows the user to prioritize or rank diseases or risk factors.
It gives the user an objective method of ranking health concerns for a geographic area
(city, county, or state). Priorities MICA can be used by agencies to determine funding
allocation or by communities or counties as part of the assessment process.

Priorities MICA can be accessed by selecting the third link in the list under Community
Health Assessment and Intervention Planning on the Data, Surveillance Systems &
Statistical Reports website. Links are also available in the blue bar and in the list of
MICAs on the MICA home page.




                                            ~ 89 ~
Creating the List of Priorities

The opening page of Priorities MICA requires you to make some initial choices. It also
provides locations of additional information to assist in making those choices.




The first choice (Step #1) is found in the middle of the screen. You must determine
whether to prioritize diseases or risk factors. Only one option can be chosen; they
cannot be ranked together. The system was designed to separate diseases from risk
factors because the same criteria for prioritizing diseases could not also be used to
prioritize risk factors. For example, there are no death data for the risk factors "high
cholesterol" or "mother underweight," and there are no incidence or prevalence data for
some diseases.

Before making a choice, you may wish to view the lists of diseases and risk factors that
are available for ranking. These can be found by clicking the boxes in the upper left
section of the screen (circled in red above).




                                          ~ 90 ~
The diseases and risk factors selected for inclusion in this application were based on the
Department of Health and Senior Services (DHSS) strategic plan, Healthy People 2010
objectives, and available data.

The chart below lists the diseases available for ranking in Priorities MICA:




The set of risk factors available for ranking in Priorities MICA includes:




                                          ~ 91 ~
Step #2, found at the bottom of the opening page and circled in red above, asks you to
determine the demographics of the population you want to use for computing priorities.
You may choose All Races, Whites, or African-Americans. Likewise, Both Sexes,
Males, or Females may be chosen. If you are interested in only a particular age group,
several options are available, including Infants/Children, Adolescents, Adults, or
Seniors, in addition to All Ages. After making these selections the user should click the
Go to Next Page button.




                                          ~ 92 ~
Step #3 appears at the top of the next page (shown below) and allows you to determine
what diseases to include in your Priorities analysis. The default option includes all 42
diseases in the rankings. If you deselect the Select All Diseases box located at the top of
the screen, you can then select the individual diseases that you wish to include in your
analysis.




Near the bottom of the screen is Step #4. In this step you will select the criteria to use for
determining Priorities. There are 10 criteria options available. The default option
includes all criteria. By deselecting the All Criteria box, you can choose individual
criteria to include when conducting the Priorities ranking. The definition and source
material for each criterion can be found by clicking on the individual criteria hyperlinks.




                                           ~ 93 ~
After the Next Page button is clicked, the final selection screen appears. Step #5 asks
that you rate the level of community support for each disease/risk factor. At first glance,
the number of decisions required in this step can appear overwhelming; however, the
default level is set to #2 for all choices. You are free to vary from the default listing but
you do not have to make any changes in order to compute priorities. Choosing #1, Active
Community Opposition, will subtract points from that indicator when computing
priorities. Likewise, rating any indicator as a 3 or 4 (at least Some Interest in the
Community) will add points for the indicator when computing priorities.




Step #6 is found near the bottom of the same page and asks you to rate the level of
importance of the criteria that you selected in Step #4. The default for all criteria is
average.




                                            ~ 94 ~
At the bottom of this page is the final choice (Step #7). Here you must choose for which
geography you will run the priorities analysis. You may choose the state of Missouri or
any of the 115 counties or 3 cities (Kansas City, Independence, or Joplin) listed. Eastern
Jackson County is also available as an option. You may choose only one geographic
area. You cannot choose multiple areas.




After making your geographic choice, press the Compute Priorities button at the bottom
of the screen. In this example we chose to prioritize all diseases, for all races, ages, and
genders, for Kansas City. A portion of the priorities output generated from these
selections is shown below.




The top 14 diseases are listed by rank in the table. The Total Weight column on the right
side of the page contains the value calculated using the formula developed by DHSS.
The choices you made in the seven steps leading up to the Computing of Priorities

                                           ~ 95 ~
affected the total weighted score. You are able and encouraged to repeat the seven steps,
making different choices to see how the rankings change based on the input you provide.

Clicking on the word Rank (circled in red in the table on the previous page) will take you
to another table that shows the values and weights of the criteria for each disease/risk
factor. A portion of this table is shown below.




You can see that the number of deaths due to diabetes for 1996-2006 was 1,333 and that
this indicator received a weight of 37. In comparison, Heart Disease had 11,296 deaths
and received a weight of 42. Because only 42 disease conditions were analyzed, this
means that Heart Disease was the #1 leading cause of death for Kansas City. Diabetes
had a weight of 37, meaning that it was the #6 leading cause of death. However,
Diabetes was ranked as the #1 Priority overall due to the criteria and weights selected by
the user.

Additional Information about how the Priorities Formula Works

The Priorities MICA lists each of the diseases/risk factors in priority order based upon the
criteria that are selected. For each criterion selected, the diseases/risk factors are ordered
in magnitude and given a ranking from 1 to n (n=the number selected) with 1 being the
disease with the highest magnitude. For example, for the criterion "number of deaths" the
disease that has the highest number of deaths receives the highest ranking while the
disease that has the lowest number of deaths receives the lowest ranking.

The ranking for each criterion is multiplied by the level of importance weight assigned by
the user. If the level of importance for the criterion is high, the ranking for a disease/risk
factor is multiplied by two. If the level of importance for the criterion is average, the
ranking for a disease/risk factor is multiplied by one. If the level of importance for the
criterion is low, the ranking for a disease/risk factor is multiplied by one-half. The

                                           ~ 96 ~
ranking times the level of importance weight gives the weighted ranking for each
disease/risk factor.

The weighted rankings for each disease/risk factor are summed across all criteria to
obtain a total score for each disease/risk factor. The total scores for the diseases/risk
factors are then ranked. The disease/risk factor having the highest total score is shown as
the highest priority disease/risk factor.

Interpreting the List of Priorities (Rank)

The final total score for each disease/risk factor does not have any inherent mathematical
value. The scores cannot be tested for statistical significance. The scores only provide a
general sense of the rank ordering of diseases/risk factors. One should not over-interpret
the rankings. For example, if two diseases have different but close scores, one should not
place a high value on the relative rankings. In this case the diseases should be considered
of similar importance. It is best to arbitrarily categorize the ranked diseases/risk factors
into groups of high, medium, and low priority and plan accordingly.

Other Facts to Consider

The Priorities MICA is only a tool. It should be used along with other information that is
available in a community. There may be other important diseases/risk factors in a
community that are not part of Priorities MICA. The fact that a disease/risk factor is not
included in Priorities MICA does not mean that a community should ignore that
disease/risk factor.

If Priorities MICA is used as part of a community needs assessment process, it is
recommended that the community planning committee include Priorities MICA as part of
a group process. The committee can decide which diseases/risk factors will be selected
for prioritization. Next, committee members can decide as a group which criteria will be
used for prioritization. If "community support" is selected as one of the criteria, then the
planning committee can determine through a group process the level of community
support that exists for each of the selected diseases/risk factors. Finally, the committee
can rate the level of importance of each criterion. Upon completion of this group process,
the committee can review the results. It may want to change some of the criteria or
weigh the criteria differently to determine how those changes would alter the final list of
priorities.

Criteria Data Sources
Amenability to Change

This criterion measures the scientific knowledge about known community interventions
that have been shown to prevent or reduce a given disease, as opposed to known
successful clinical interventions.



                                           ~ 97 ~
   1. Interventions not evaluated in the literature for outcomes or published evaluations
      show inconsistent or negative results.
   2. Published evaluations of outcomes of interventions show positive results.
   3. Interventions recommended by a federal agency on a federal agency best practice
      list.
   4. Interventions recommended by Community Preventive Services Task Force
      (CPSTF).

Community Support

This is a subjective measure (determined by the user) of the current level of support in the
community for addressing the disease/risk factor. The highest level of community support
for each disease is given a score of 4 and the lowest level of support (i.e., active
opposition) is given a score of 1.

   1.   Active community opposition
   2.   No groups/persons showing interest
   3.   Some interest groups/persons showing interest but not organized
   4.   Community coalition organized or support by elected official(s) or private
        business

Death Trend Statistically Significant

This is a measure of the urgency of the disease. If the number of deaths is increasing over
time, a disease is more urgent than one for which the death rate is decreasing. The
measure used is the coefficient of the slope of the regression line for the time period. If
the regression coefficient is not significantly different from 0 (the regression line is
parallel to the x axis), then the trend is not significantly increasing or decreasing. All
diseases that have a non-significant slope coefficient are set at 0 since it is not meaningful
to rank diseases where the slope coefficients are statistically the same.

Disability Burden

The disability burden for each disease is measured by the number of years lived with
disability taken from Revised Global Burden of Disease 2002 Estimates. Estimates are
gathered from reports for WHO subregions for 2002 as reported in the World Health
Report 2004. Tables are taken from GBD 2002: YLDs ('000) by age, sex, and cause for
the year 2000 Region 3: AMRO A. Numbers are divided by an additional 1000.

Hospital Days of Care

Hospital days of care is another measure of the severity of a disease and its potential
impact on financial resources due to the cost of hospital care and time unavailable to
perform normal duties. The hospital days of care data are obtained from the patient
abstract system (PAS).


                                           ~ 98 ~
Number of Deaths

The number of deaths is a measure of the severity of the disease.

Number of Deaths Under Age 65

This is another measure of the severity of a disease.

Number of Hospitalizations and ER Visits

The number of hospitalizations and emergency room (ER) visits is used to measure the
magnitude of the disease. For most diseases, data are not available on incidence or
prevalence; therefore, hospitalization and ER data are used instead. Further
documentation of the hospital discharge data and ER data are available. The data come
from acute care hospitals and hospitals operated by the Department of Mental Health.

Racial Disparity for ER Visits

Because racial disparity data are not routinely available on the incidence or prevalence of
diseases, ER visits are used as a proxy to determine racial disparities. ER data were
selected over hospital discharge data because there may be barriers for inpatient care due
to the lack of insurance. These barriers are not as much of a factor for care in an
emergency room. The primary minority population in Missouri is African-American;
therefore, the measure is computed as the ratio of the African-American age-adjusted ER
visit rate for a specific disease divided by the White age-adjusted ER visit rate for the
same disease.

Racial Disparity for Deaths

This is a second measure of racial disparity. The measure is computed as the ratio of the
African-American age-adjusted death rate for a specific disease divided by the White
age-adjusted death rate for the same disease.

Prevalence/Incidence

Prevalence is the number of people who have a condition at a specific point in time.
Incidence is the number of new people who get the condition during a specified time
period. The Behavioral Risk Factor Surveillance System (BRFSS) is used to obtain the
prevalence of high cholesterol, obesity, smoking, high blood pressure, no cervical cancer
screening, no exercise, no health insurance for ER visits and no mammography.
Incidence data is drawn from birth certificate data for low birth weight, mother
overweight, prenatal care inadequate, very low birth weight not delivered in level III
center, mother underweight, out-of-wedlock births, repeated births under age 18, smoking
during pregnancy, and very low birth weight. Other data files include pregnancy,
abortion, and child abuse/neglect from the Department of Social Services, Division of


                                           ~ 99 ~
Family Services for teenage pregnancy under age 18, abortions, and child abuse and
neglect.

Prevalence/Incidence Trend

This is a measure of the urgency of the risk factor. If the prevalence/incidence of a
particular risk factor is increasing over time, it is a more urgent risk factor than one for
which the prevalence/incidence is decreasing. The measure used is the coefficient of the
slope of the regression line for the time period. If the regression coefficient is not
significantly different from 0 (the regression line is parallel to the x axis), then the trend
is not significantly increasing or decreasing. All risk factors that have a non-significant
slope coefficient are set at 0 since it is not meaningful to rank risk factors where the slope
coefficients are statistically the same.

Data Sources

The data sources are Death Certificates, Emergency Room Visits, Hospital Discharges,
Behavioral Risk Factor Surveillance System (BRFSS), Birth Certificates, Abortions,
Pregnancies, and Child Abuse/Neglect. We only used data sources that are available for
all diseases or risk factors. For example, cancer registry data and communicable disease
reports were not used because there are no comparable incidence data for other diseases.
BRFSS questions were only used if they were asked on the county 2001 BRFSS survey.



Works Cited

Goldberg, Carmelle, et al. BRFSS Data Systems Course Glossary. Retrieved May 18,
      2009, from the Centers for Disease Control and Prevention:
      http://apps.nccd.cdc.gov/brfssdatasystems/glossary.asp




                                           ~ 100 ~
Index


Advanced Graphics, 21                                 Local WIC Provider MICA. See LWP
Age-Adjusted Rates, 27                                  MICA
Alcohol and Drug Abuse Problems                       LWP MICA, 78, 80, 81
   Profile, 37                                        Map, 60, 66
Behavioral Risk Factor Surveillance                   Number of Events, 16, 17
   System. See BRFSS                                  Office of Social and Economic Data
Birth MICA, 48, 50, 59, 85                              Analysis. See OSEDA
BRFSS, 26, 72, 74, 100                                OSEDA, 35
Bureau of Health Informatics, 3, 7, 14                Population MICA, 43, 50
Cancer Registry MICA, 72                              Priorities MICA, 2, 3, 42, 89, 90, 91, 96,
Charges, 30, 68                                         97
Child Health Profile, 15, 23, 26, 27, 30,             Procedures MICA, 75
   38                                                 Publications, 6
Citations, 38, 85                                     Quartile, 64
Confidence Intervals, 53                              Quintile, 3, 5, 17, 18, 39, 40
Confidentiality, 51, 61                               Race, 24, 30, 50, 51, 86
Constant, 16, 17                                      Rate, 16, 17, 29
Contact Us, 7                                         Related Links, 48
Data, Surveillance Systems & Statistical              Rotate, 46
   Reports, 1, 2, 41                                  Significantly Different, 17
Days of Care, 30, 68                                  Small Numbers, 18, 51, 61
Death MICA, 56, 58, 59                                Social and Economic Indicators Profile,
Definitions, 6, 43, 51, 58                              35
Diabetes, 39                                          Specific Causes within Selected Cause,
Documentation, 15, 43                                   66
Download, 19, 23, 47                                  Standard Population, 27, 28, 58
Drill-Down, 51, 52, 59, 69, 74, 75, 84                Statistically Significant, 17, 18, 39
Emergency Room MICA, 87                               Stroke Profile, 25, 26, 27, 30
Ethnicity, 51, 86                                     TANF, 82
Financial Data, 31                                    Temporary Assistance for Needy
Footnotes, 15, 27, 36                                   Families. See TANF
Frequency, 16, 17                                     Three-Year Moving Averages, 18
Healthy People 2010 Objectives, 91                    Trend Analysis, 18
Higher/Lower than State, 65                           Trend Lines, 18
Hispanic, 51                                          Utilization Statistics, 33
Hospital Discharges, Charges and Days                 Vital Statistics Annual Reports, 6
   of Care MICA, 67                                   Weighted Counts, 26
Hospital Revenues Profile, 31                         Weighted Percents, 26
Hospital Utilization Data, 30                         Weighted Rankings, 97
Inpatient Hospitalization, 75, 87                     WIC MICA, 76
Intervention MICA, 42                                 Zip Code Options, 70


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