Slide 1

Motor Vehicle Crash Mortality among Northwest American Indians & Alaska Natives

Improving Data & Enhancing Access (IDEA-NW) Project, NW Tribal EpiCenter

Megan Hoopes, MPH

ideanw@npaihb.org

Jenine Dankovchik
Luella Azule
Bridget Canniff
Erik Kakuska
Victoria Warren-Mears

Logo Northwest Portland Area Indian Health Board, Indian Leadership for Indian Health

Presented at:
Oregon Public Health Association
Corvallis, OR Oct. 8, 2012

Slide 2

Background

Slide 3

Excess mortality among AI/ANs

• AI/AN life span 6 years below U.S. average
• After declining in 1900s, AI/AN death rates rose in mid-1980s
• Large racial disparities in injury deaths
  • Motor vehicle crashes account for majority of unintentional injury deaths
• Injury prevention has become a public health priority area for Indian Country

Slide 4

AI/AN race often misclassified on death certificates

• Race not often based on family's own report
• AI/ANs misclassified more frequently than other races/ethnicities
• Misclassification errors may follow a patient between data systems
• Net result: morbidity and mortality measures are underestimated for AI/AN

Slide 5

IDEA-NW Project

• Improving Data & Enhancing Access (IDEA-NW)
  • Goal: Reduce misclassification of AI/AN race in surveillance systems; disseminate local-level health data to NW tribes.
  • Grant funding: AHRQ (2010 to 2013), OMH (2012-2017)
• Northwest Tribal Registry ("The Tribal Registry")
  • All AI/AN registered at IHS or tribal clinic in the NW
  • Augmented with data from urban clinics
• Linkages conducted with public health datasets

Slide 6

Linkages in the Northwest

Map showing where numerous Portland area tribes reside, the largest being Colville and Yakama Nation in Washington, Warm Springs in Oregon, and Coeur d'Alene, Nez Perce, and Shoshones in Idaho.

• Cancer registries
• Hospital discharge systems
• Death certificates
• STD/HIV and other communicable diseases
• Trauma registries

Slide 7

Methods

Slide 8

Data Sources

• Death certificates
  • Washington: 1980-2009
  • Oregon: 2006-2010
  • Idaho: 2006-2010
• Linked with The Tribal Registry(known AI/AN)
  • Using LinkPlus software, compared data sets to find individuals who appear in both
  • Names, birthdates, SSN, etc. are compared
  • Probabilistic linkage — allow for errors, misspellings, missing data, nick names, etc.
  • Each pair given a score indicating likelihood of a match
  • "Grey area" matches reviewed by hand

Slide 9

Analysis

• Cause of Death defined using ICD-9/10 only underlying COD
• AI/AN in analysis = AI/AN (any mention) on death certificate and/or matched NTR
  • White race (alone) selected for comparison
  • AI/AN & White comprised 95% of the data
• Rates: 2006-2009
• Trends (Washington only): 1990-2009
• NCHS bridged-race population estimates used as population denominators
• Rates age-adjusted and presented per 100,000 population

Slide 10

Results

Slide 11

Racial misclassification

• Idaho: 8.3%
  • 95% coded as white
• Oregon: 12.9%
  • 98% coded as white
• Washington: 9.3%
  • 94% coded as white

Slide 12

Unintentional injury mortality, 2006-2009

Bar chart. Age adjusted rate per 100,000. Idaho: AI/AN 67.0, white 42.0, RR = 1.6. Oregon: AI/AN 63.7, white 37.7, RR = 1.7. Washington:AI/AN 95.9, white 40.3, RR = 2.4.

Slide 13

Leading causes of unintentional injury deaths, NW region, 2006-2009

Bar chart. Percentage of UI deaths. Motor vehicle crashes:AI/AN 39.4, white 26.1. Accidental poisoning: AI/AN 33.4, white 26.0. Falls: AI/AN 8.5, white 27.6. Accidental drowning:AI/AN 4.2, white 3.2. Other: AI/AN 14.5, white 17.0.

Slide 14

Motor vehicle crash mortality, 2006-2009

Bar chart. Age adjusted rate per 100,000. Idaho: AI/AN 34.5, white 16.1, RR = 2.1. Oregon: AI/AN 20.9, white 10.6, RR = 2.0. Washington: AI/AN 32.8, white 9.4, RR = 3.5.

Slide 15

MVC mortality by sex, 2006-2009

Bar chart. Age adjusted rate per 100,000. Idaho: AI/AN male 40.1, AI/AN female 28.9, white male 22.4, white female 9.8. Oregon: AI/AN male 24.1, AI/AN female 17.4, white male 15.2, white female 6.2. Washington: AI/AN male 40.6, AI/AN female 25.0, white male 13.9, white female 4.9.

Slide 16

AI/AN MVC mortality by age, 2006-2009

Bar chart. Percentage of MVC deaths. Idaho: Under 8 years 5.4, 8 to 16 years 10.8, 17 to 25 years 45.9, 26 to 54 years 29.7, 55 years and older 8.1. Oregon: Under 8 years 5.7, 8 to 16 years 5.7, 17 to 25 years 20.8, 26 to 54 years 52.8, 55 years and older 15.1. Washington: Under 8 years 2.4, 8 to 16 years 4.2, 17 to 25 years 39.8, 26 to 54 years 41.6, 55 years and older 12.0.

Slide 17

AI/AN urban vs. rural MVC mortality, 2006-2009

Bar chart. Age adjusted rate per 100,000. Idaho: Urban 27.2, rural 32.2, RR = 1.2. Oregon: Urban 15.3, rural 34.0, RR = 2.2. Washington: Urban 29.5, rural 33.5, RR = 1.1.

Slide 18

MVC mortality 20-year trend, Washington, 1990-2009

Line chart. Age adjusted rate per 100,000 for 3 year rolling averages. Line for A I A N starts at about 35 in 1990 to 92 and jumps moderately above and below best fit line, ending at about 30 in 2007 to 9. The line for whites trends smoothly downward along best fit line from about 14 in 1990 to 92 to about 9 in 2007 to 9. The line for whites is labeled A P C = negative 2.6 %.

Slide 19

Discussion

Slide 20

• Correct racial classification is a critical factor in accurate surveillance of mortality
  • Linkage can help address misclassification
• Unintentional injury & MVC mortality in particular remain disproportionately high for AI/ANs
• Some improvements experienced by Whites (significant decrease in MVC rates) have not occurred for AI/ANs

Slide 21

Tribal uses of data

• Tribes use mortality data for:
  • Health assessment
  • Grant writing and reporting
  • Program planning and evaluation
  • Policy and advocacy
• Comprehensive 3-state mortality report to be published in November, 2012

Slide 22

Partners

• Injury prevention projects at NPAIHB
  • Injury Prevention Program
    • NW Tribal Injury Prevention Coalition → 5-year Tribal Injury Prevention Action Plan
    • Focus on motor vehicle safety & elder falls
• Native CARS (Children Always Ride Safe)
  • Randomized delayed-intervention CBPR study in 6 NW Tribes
  • Goal: to design, implement, and test the effectiveness of tribal interventions to improve the use of child safety seats among AI/AN children

Slide 23

Limitations & challenges

• Tribal Registry under-represents urban AI/AN and those with private insurance
  • Captures 75-80% of AI/AN population
• Even with combined data years, small numbers make AI/AN rates unstable
  • Local-level analysis/reporting even more difficult
• Death certificate data does not answer the "why" questions

Slide 24

Thank You!

• The Tribes of Idaho, Oregon, and Washington
• Victoria Warren-Mears, PhD (P.I.)
• Bridget Canniff & Luella Azule, Injury Prevention Program
• Tam Lutz, Jodi Lapidus, & Nicole Smith, Native CARS Project
• Idaho, Oregon, and Washington vital statistics staff
• Urban Indian Health Institute, Seattle Indian Health Board
• AHRQ Grant #R01HS19972