Schloman, Barbara. (August 31, 2001). Using health statistics: A Nightingale legacy www.nursingworld.org/ojin/infocol/info_6.htm

The Role of Health Statistics?

No more forceful example of the value of using health statistics to understand and improve health conditions exists than displayed by Florence Nightingale. The recent book by Dossey (1999), Florence Nightingale: Mystic, Visionary, Healer, relates the dramatic tale of Nightingale’s use of statistics to understand the causes of deaths in the Crimean War and of her advocacy to standardize the collection of medical data within the army and in civilian hospitals. For her, the use of health statistics was a major tool to improve health and influence public opinion.

Imagine Nightingale’s reaction to today’s increasing availability of health data. The Federal Healthy People initiative to improve the nation’s health by setting objectives for health promotion and disease prevention has used health statistics when available to establish a benchmark and assess progress. Because the desired information was often unavailable, a major goal of Healthy People 2000 was to improve surveillance and data systems. This resulted in considerable effort being put into improving the data collection and management infrastructure. The 467 objectives in Healthy People 2010 are being tracked by 190 data sources. The recently released Tracking Healthy People 2010 states:

Systematically collecting, analyzing, interpreting, disseminating, and using health data is essential to understanding the health status of a population, to assessing progress, and to planning effective prevention programs. Therefore, data are the foundation of Healthy People objectives. (p.1)

Improved data systems developed at the same time that the Federal government began issuing more information in electronic formats—first on diskette and CD-ROM and more recently on the Internet. This allowed an individual user the potential to access and manipulate data selectively. Because computer applications provide for more than the handling of data in a textual or tabular format, we are also now seeing the manipulation of data so as to show spatial and temporal relationships. Geographical Information Systems (GIS) are being used increasingly to display geographically referenced health information. A GIS provides an integrated set of tools that makes it possible to link data and geography digitally and display the results in map form. Within public health, this is seen as a powerful way to understand the relationship of geography to such issues as health outcomes, disease transmission, and access to health care. This Web page from CDC provides useful links to understanding the use of GIS in the public health arena: www.cdc.gov/epiinfo/EIhlgeog.htm.

This column will highlight some of the key health statistics resources available on the Internet. While more and more information is becoming available in this way, it is important to remember that not all data is to be found there—certainly the amount of available retrospective information is limited. An annotated bibliography published by the Medical Library Association (Weise, 1997) is a useful guide to what print publications have been issued and for what types of statistics.

FEDERAL AGENCIES

Four Federal agencies are key sources for U. S. health statistics.

1. National Center for Health Statistics (www.cdc.gov/nchs/): NCHS is part of the Centers for Disease Control and Prevention, U. S. Department of Health and Human Services and "is the Federal Government’s principal vital and health statistics agency." In addition to vital statistics, NCHS data cover "health status, lifestyle and exposure to unhealthy influences, the onset and diagnosis of illness and disability, and the use of health care." The NCHS has two major types of data systems (www.cdc.gov/nchs/express.htm): one based on survey data collected through personal interviews or examinations; the other based on data collected through vital and medical records.

• Surveys:
• National Health Interview Survey (www.cdc.gov/nchs/nhis.htm)
• National Health and Nutrition Examination Survey/NHANES (www.cdc.gov/nchs/nhanes.htm)
• National Health Care Survey (www.cdc.gov/nchs/nhcs.htm): includes ambulatory health care data, hospital discharge and ambulatory surgery data, national home and hospice care survey, national nursing home survey, and national employer health insurance survey.
• National Mortality Followback Survey (www.cdc.gov/nchs/about/major/nmfs/nmfs.htm)
• National Survey of Family Growth (www.cdc.gov/nchs/nsfg.htm)
• National Maternal and Infant Health Survey (www.cdc.gov/nchs/about/major/nmihs/abnmihs.htm)
• National Immunization Survey (www.cdc.gov/nis/)
• State and Local Area Integrated Telephone Survey (www.cdc.gov/nchs/slaits.htm)

• National Vital Statistics System (www.cdc.gov/nchs/nvss.htm): The registration of vital events (births, deaths, marriages, divorces, and fetal deaths) is a State function. States provide this data to this System, which compiles the official national vital statistics.

There is a rich set of links at the NCHS Web site to statistical content. These include the following:

• Data Warehouse (www.cdc.gov/nchs/datawh.htm): provides tabulated data, including by state, information on public use data files, and links to doing searches on databases through FERRET and CDC Wonder (see section on "Tools for Finding and Using Statistics" below).
• FASTATS A to Z (www.cdc.gov/nchs/fastats/Default.htm): provides summary health statistics on a variety of topics with a link to sources.
• Health, United States (www.cdc.gov/nchs/products/pubs/pubd/hus/hus.htm): is the NCHS annual report on the health of the nation (see below for more detail).
• Atlas of United States Mortality (www.cdc.gov/nchs/products/pubs/pubd/other/atlas/atlas.htm): "is the first to show all leading causes of death by race and sex for small U.S. geographic areas referred to as Health Service Areas (HSA's)." This publication is also available in print and CD-ROM. The maps by cause of death can be downloaded.
• Births (www.cdc.gov/nchs/births.htm), Mortality (www.cdc.gov/nchs/about/major/dvs/mortdata.htm), Fetal Death Data (www.cdc.gov/nchs/about/major/fetaldth/abfetal.htm), Linked Births/Infant Deaths (www.cdc.gov/nchs/about/major/lbid/linked.htm): provides data highlights and statistical tables.
• National Vital Statistics Reports (www.cdc.gov/nchs/products/pubs/pubd/nvsr/nvsr.htm): provides monthly report on provisional statistics for birth, death, marriage, and divorce; formerly Monthly Vital Statistics Report/MVSR.
• International Classification of Diseases (www.cdc.gov/nchs/icd9.htm): provides information on access to both the ICD and ICD-CM codes.
• Reports available online in PDF (portable document file) format (www.cdc.gov/nchs/products/pubs/pubd/netpubs.htm): offers online access to familiar print publications, including the "rainbow" Vital and Health Statistics Series.
• Life Tables (www.cdc.gov/nchs/products/pubs/pubd/lftbls/lftbls.htm)

2. Centers for Disease Control and Prevention (www.cdc.gov/): "The Centers for Disease Control and Prevention (CDC) is recognized as the lead federal agency for protecting the health and safety of people - at home and abroad, providing credible information to enhance health decisions, and promoting health through strong partnerships." CDC Wonder (www.wonder.cdc.gov/) is a key search tool available at this site (this search feature is discussed further below under "Tools for Finding and Using Statistics"). There are a number of cross linkages between the NCHS and CDC sites. The CDC site includes information from these surveillance and data systems:

• Assisted Reproductive Technology Success Rates (www.cdc.gov/nccdphp/drh/art.htm)
• Behavioral Risk Factor Surveillance System (www.cdc.gov/nccdphp/brfss/) *
• Birth Defects Surveillance (www.cdc.gov/ncbddd/bd/bdsurv.htm)
• Cancer Registries Program (www.cdc.gov/cancer/npcr/)
• Hazardous Substance Release/Health Effects Database/HAZDAT (http://atsdr1.atsdr.cdc.gov:8080/hazdat.html): the scientific and administrative database developed to provide access to information on the release of hazardous substances from Superfund sites or from emergency events and on the effects of hazardous substances on the health of human populations."
• HealthComm Key (www.cdc.gov/od/oc/hcomm/): "The database contains comprehensive summaries of more than 200 articles about health communication research and practice. Articles selected for the database were published between 1986 and 1996 and describe U.S.-based public health interventions that have communication as a major component."
• HIV/AIDS Surveillance Report (www.cdc.gov/nchstp/hiv_aids/stats/hasrlink.htm)
• Morbidity and Mortality:
• MMWR/Morbidity and Mortality Weekly Report (www.cdc.gov/mmwr/): provides statistics on selected diseases reported to the Center for Disease Control by state health departments.
• MMWR Summary of Notifiable Diseases, United States: published annually as the last issue of each volume of MMWR.
• Pregnancy Risk Assessment Monitoring System (www.cdc.gov/nccdphp/drh/srv_prams.htm)
• Sexually Transmitted Diseases (www.cdc.gov/nchstp/dstd/Stats_Trends/Stats_and_Trends.htm)
• Tuberculosis Surveillance Reports (www.cdc.gov/nchstp/tb/surv/surv.htm)
• WISQARS -- Web-based Injury Statistics Query and Reporting System (www.cdc.gov/ncipc/wisqars/): "WISQARSTM (Web-based Injury Statistics Query and Reporting System) is an interactive system that provides customized injury-related mortality data useful for research and for making informed public health decisions."
• Youth Risk Behavior Surveillance System (www.cdc.gov/nccdphp/dash/yrbs/)

3. Health Care Financing Administration/HCFA (http://cms.hhs.gov): HCFA is the Federal agency that administers Medicare, Medicaid and the State Children's Health Insurance Program (SCHIP). Available statistics include:

• Health Care Indicators (cms.hhs.gov/statistics/health-indicators): contains data and analysis of recent trends in health care spending, employment, and prices.
• Medicare Enrollment, Utilization and Expenditures (http://cms.hhs.gov/researchers)
• Medicare Managed Care Statistics and Reports (http://cms.hhs.gov/healthplans)
• Medicaid Statistical and Data Information ( http://cms.hhs.gov/medicaid/mcaidsad.asp)
• National Health Care Expenditures (http://cms.hhs.gov/statistics/nhe): measures spending for health care in the U.S. by type of service delivered (hospital care, physician services, nursing home care, etc.) and source of funding for those services (private health insurance, Medicare, Medicaid, out-of-pocket spending, etc.).

4. Health Resources and Services Administration/HRSA (www.hrsa.gov): The agency’s mission is to improve "the nation's health by assuring equal access to comprehensive, culturally competent, quality health care for all." Available data include:

• Health Professional Shortage Area (http://bphc.hrsa.gov/databases/newhpsa/newhpsa.cfm): identifies health professional shortages areas for primary medical care, mental health, and dental care.
• State Health Workforce Profiles (http://bhpr.hrsa.gov/healthworkforce/profiles/default.htm): provides accurate and current data on supply, demand, distribution, education and use of physicians, nurses, dentists and 20 other health professionals in each state and the District of Columbia.

GENERAL HEALTH COMPILATIONS

Health, United States (www.cdc.gov/nchs/products/pubs/pubd/hus/hus.htm): NCHS annual report on the health of the nation. This homepage contains electronic versions of the latest edition of Health, United States and previous editions back to 1993.  Users may download a complete copy of Health, United States or selected sections, such as the chartbook, or individual tables.  In addition, spreadsheet files for further data analysis or graphical presentation are available on this site. The 2000 edition included an Adolescent Health Chartbook. The 2001 edition, to be released soon, will have an Urban and Rural Health Chartbook.

Healthy People 2010 (http://web.health.gov/healthypeople/) "Healthy People 2010 is the prevention agenda for the Nation. It is a statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats." Healthy People 2010 presents 467 objectives to improve the health of Americans by the year 2010. The objectives are being tracked by 190 data sources. A major data source is defined as a data system responsible for tracking five or more objectives.

• DATA2010 (http://web.health.gov/healthypeople/Data/data2010.htm): The National Center for Health Statistics, Centers for Disease Control and Prevention, has developed a new data system to track all 467 Healthy People 2010 objectives. The data are updated quarterly on this Web site.
• Healthy People 2000 Review (www.cdc.gov/nchs/products/pubs/pubd/hp2k/review/review.htm): NCHS publishes a statistical review of Healthy People objectives annually. The current document is the Healthy People 2000 Review, 1998-99. 

DEMOGRAPHIC DATA

• U.S. Bureau of the Census
• American FactFinder (http://factfinder.census.gov): important source for accessing census information by population, housing, or economic data. It is possible to search by specific geographic area and to display results in tabular or map format.
• State and County QuickFacts (http://quickfacts.census.gov/qfd/): offers quick, easy access facts by population, business, and geographical area and includes Census 2000 data.
• U.S. Department of Commerce
• County and City Data Book; a Statistical Abstract supplement (http://fisher.lib.virginia.edu/ccdb/): electronic versions of the 1988 and 1994 County and City Data Books, available for creating customized data subsets.
• Statistical Abstract of the United States (www.census.gov/prod/www/statistical-abstract-us.html): considered the national data book with a collection of statistics on social and economic conditions in the United States and selected international data. Sources of data are identified.

STATE and COMMUNITY DATA

By State: NCHS provides tabulated data by state for the following:

• Births (www.cdc.gov/nchs/births.htm#Statebirths)
• Deaths (www.cdc.gov/nchs/datawh/statab/unpubd/mortabs/gmwkiii.htm)
• Deaths, Infant (www.cdc.gov/nchs/datawh/statab/unpubd/mortabs/lfwk71.htm)
• Health, United States (www.cdc.gov/nchs/products/pubs/pubd/hus/hus.htm)
• Healthy People 2000, State Data (www.cdc.gov/nchs/datawh/ftpserv/hstatus/hstatus.htm)
• 2000 State Health Profiles (www.cdc.gov/nchs/datawh/stprofiles.htm)
• State Health Statistics by Sex and Race/Ethnicity (www.cdc.gov/nchs/statestatsbysexrace.htm)
• Trends in Health and Aging (www.cdc.gov/nchs/about/otheract/aging/trendsoverview.htm)

By Community: HRSA funded this collaboration among the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and the Public Health Foundation (PHF) to publish reports for all 3,082 U.S. counties

• Community Health Status Indicators Project (www.communityhealth.hrsa.gov/)

INTERNATIONAL

World Health Organization

• WHOSIS/WHO Statistical Information System (www.who.int/whosis/): The purpose of this site "is to describe - and to the extent possible provide access to - statistical and epidemiological data and information presently available from the World Health Organization and elsewhere in electronic or other forms." This site is searchable and offers valuable links to world health data. The following are some of the major resources available:
• Mortality (www-nt.who.int/whosis/statistics/menu.cfm?): Online version of the World Health Statistics Annual.
• World Health Report 2000(www-nt.who.int/whosis/statistics/menu.cfm?)
• Healthy Life Expectancy Rankings (www.who.int/whosis/dale/)
• Weekly Epidemiological Record (www.who.int/wer/)
• Links to National Health-Related Websites (www-nt.who.int/whosis/statistics/sites)

Pan American Health Organization

• Basic Country Health Profiles for the Americas (www.paho.org/english/sha/profiles.htm): Provides information by countries in the Americas including demographic, socioeconomic, health risk indicators, data relating to health care delivery, and statement of general situation and trends.

International Data Base/IDB (www.census.gov/ftp/pub/ipc/www/idbnew.html): This database includes statistical tables with demographic, vital statistic, and socioeconomic data for 227 countries and areas of the world.

United Nations Statistics Division (www.un.org/Depts/unsd/): Statistics include demographic and social statistics and indicators.

NURSING

Interagency Conference on Nursing Statistics/ICONS (www.ncsbn.org/icons.html): ICONS is an interagency committee that deals with statistics on nurses, nurses' employment settings and nursing education.

TOOLS for FINDING and USING STATISTICS

CDC Wonder (http://wonder.cdc.gov/): This search tool at the Centers for Disease Control and Prevention site is designed specifically for public health and provides access to a wide variety of reports. A user can search for and retrieve MMWR articles and Prevention Guidelines published by CDC; query dozens of numeric data sets on CDC's mainframe and other computers, via "fill-in-the blank" request screens. Public-use data sets about mortality, cancer incidence, hospital discharges, AIDS, behavioral risk factors, diabetes, and many other topics are available for query, and the requested data can be readily summarized and analyzed.

Epi Info – Epi Map (www.cdc.gov/epiinfo/): "Epi Info and Epi Map are public domain software packages designed for the global community of public health practitioners and researchers. Both provide for easy form and database construction, data entry, and analysis with epidemiologic statistics, maps, and graphs. Although ‘Epi Info’ is a CDC trademark, the programs, documentation, and teaching materials are in the public domain and may be freely copied, distributed, and translated."

Federal Electronic Research and Review Extraction Tool (FERRET) (www.cdc.gov/nchs/datawh/ferret/ferret.htm): This project represents a collaborative effort between NCHS and the Bureau of the Census to provide full access to complex large data sets through the Internet. It provides the capabilities to create crosstabs, frequencies, a SAS data set for downloading, an ASCII output file for downloading or importing into a spreadsheet. Currently available are: the 1994 Underlying Cause-of-Death File, the 1993 National Health Interview Survey and the third National Health and Nutrition Examination Survey, NHANES III.  

FedStats (www.fedstats.gov/): FedStats is a gateway to all types of statistics from over 100 U.S. Federal agencies. In addition to links to statistical agencies, it allows for searches by topic across agency Websites.

Statistical Export and Tabulation System/SETS (www.cdc.gov/nchs/sets.htm): SETS gives data users the tools to access and manipulate large data files on their personal computers. Some data have already been configured as SETS files. SETS 2.0 has been optimized for use with Windows 95, Windows 98, and Windows NT. The SETS Designer Kit contains software to create, build, and edit large data sets, as well as the SETS Interface.

Online Statistics Study Aids

Finding and Using Health Statistics: A Self-Study Course (www.nlm.nih.gov/nichsr/usestats/index.htm): Dan Melnick created this online self-study course for the National Library of Medicine.

Royal Windsor Society for Nursing Research On-Line Workshop on Study Design and Analysis (www.windsor.igs.net/~nhodgins/design_and_analysis.html): Online workshop includes coverage of analyzing study data and statistical tests, including "STAT! Statistics" for a quick overview and general guidelines about statistics.

SISA: Simple Interactive Statistical Analysis (http://home.clara.net/sisa/): "SISA allows you to do statistical analysis directly on the Internet. Click on one of the procedure names below, fill in the form, click the button, and the analysis will take place on the spot. Study the user friendly guides to statistical procedures to see what procedure is appropriate for your problem."

Statistics at Square One (www.bmj.com/collections/statsbk/index.shtml): This medical statistics textbook (9^th ed., by T.D.V. Swinscow, revised by M. J. Campbell, University of Southampton under copyright by BMJ Publishing Group 1997) covers various statistical tests as well as a chapter on study design and choosing a test.

THE AUTHOR

Barbara F. Schloman, PhD, AHIP
Assistant Dean, Library Information Services
Libraries & Media Services
Kent State University
Kent, OH 44242
E-mail Address: schloman@kent.edu

REFERENCES

Dossey, B. M. (1999). Florence Nightingale: Mystic, visionary, healer. Springhouse, PA: Springhouse.

U.S. Department of Health and Human Services. (2000). Tracking Healthy People 2010. Washington, DC: U.S. Government Printing Office. Retrieved July 31, 2001 from the World Wide Web: www.cdc.gov/nchs/hphome.htm.

Weise, F. O., (Ed.). (1997). Health statistics: An annotated bibliographic guide to information resources. 2^nd ed. Lanham, MD: Medical Library Association and Scarecrow Press.

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