The Joinpoint-Jump and Joinpoint-Comparability Ratio Model for Trend Analysis with Applications to Coding Changes in Health Statistics.

Analysis of trends in health data collected over time can be affected by instantaneous changes in coding that cause sudden increases/decreases, or "jumps," in data. Despite these sudden changes, the underlying continuous trends can present valuable information related to the changing risk profile of the population, the introduction of screening, new diagnostic technologies, or other causes. The joinpoint model is a well-established methodology for modeling trends over time using connected linear segments, usually on a logarithmic scale. Joinpoint models that ignore data jumps due to coding changes may produce biased estimates of trends. In this article, we introduce methods to incorporate a sudden discontinuous jump in an otherwise continuous joinpoint model. The size of the jump is either estimated directly (the Joinpoint-Jump model) or estimated using supplementary data (the Joinpoint-Comparability Ratio model). Examples using ICD-9/ICD-10 cause of death coding changes, and coding changes in the staging of cancer illustrate the use of these models.

Disparities in Cancer Incidence and Trends among American Indians and Alaska Natives in the United States, 2010-2015.

BACKGROUND: Cancer incidence rates for American Indian and Alaska Native (AI/AN) populations vary by geographic region in the United States. The purpose of this study is to examine cancer incidence rates and trends in the AI/AN population compared with the non-Hispanic white population in the United States for the years 2010 to 2015. METHODS: Cases diagnosed during 2010 to 2015 were identified from population-based cancer registries and linked with the Indian Health Service (IHS) patient registration databases to describe cancer incidence rates in non-Hispanic AI/AN persons compared with non-Hispanic whites (whites) living in IHS purchased/referred care delivery area counties. Age-adjusted rates were calculated for the 15 most common cancer sites, expressed per 100,000 per year. Incidence rates are presented overall as well as by region. Trends were estimated using joinpoint regression analyses. RESULTS: Lung and colorectal cancer incidence rates were nearly 20% to 2.5 times higher in AI/AN males and nearly 20% to nearly 3 times higher in AI/AN females compared with whites in the Northern Plains, Southern Plains, Pacific Coast, and Alaska. Cancers of the liver, kidney, and stomach were significantly higher in the AI/AN compared with the white population in all regions. We observed more significant decreases in cancer incidence rates in the white population compared with the AI/AN population. CONCLUSIONS: Findings demonstrate the importance of examining cancer disparities between AI/AN and white populations. Disparities have widened for lung, female breast, and liver cancers. IMPACT: These findings highlight opportunities for targeted public health interventions to reduce AI/AN cancer incidence.

A Holistic Approach to Chronic Disease Prevention: Good Health and Wellness in Indian Country.

The National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention funds the agency's largest investment in Indian Country, Good Health and Wellness in Indian Country. This 5-year program, launched in 2014, supports American Indian and Alaska Native communities and tribal organizations to address chronic diseases and risk factors simultaneously and in coordination. This article describes the development, funding, and implementation of the program. Dialogue with tribal members and leaders helped shape the program, and unlike previous programs that funded a small number of tribes to work on specific diseases, this program funds multiple tribal entities to reach widely into Indian Country. Implementation included culturally developed and adapted practices and opportunities for peer sharing and problem solving. This program identified approaches useful for the Centers for Disease Control and Prevention, other federal agencies, or other organizations working with American Indians and Alaska Natives.

Stomach cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study.

BACKGROUND: Stomach cancer was a leading cause of cancer-related deaths early in the 20th century and has steadily declined over the last century in the United States. Although incidence and death rates are now low, stomach cancer remains an important cause of morbidity and mortality in black, Asian and Pacific Islander, and American Indian/Alaska Native populations. METHODS: Data from the CONCORD-2 study were used to analyze stomach cancer survival among males and females aged 15 to 99 years who were diagnosed in 37 states covering 80% of the US population. Survival analyses were corrected for background mortality using state-specific and race-specific (white and black) life tables and age-standardized using the International Cancer Survival Standard weights. Net survival is presented up to 5 years after diagnosis by race (all, black, and white) for 2001 through 2003 and 2004 through 2009 to account for changes in collecting Surveillance, Epidemiology, and End Results Summary Stage 2000 data from 2004. RESULTS: Almost one-third of stomach cancers were diagnosed at a distant stage among both whites and blacks. Age-standardized 5-year net survival increased between 2001 to 2003 and 2004 to 2009 (26.1% and 29%, respectively), and no differences were observed by race. The 1-year, 3-year, and 5-year survival estimates were 53.1%, 33.8%, and 29%, respectively. Survival improved in most states. Survival by stage was 64% (local), 28.2% (regional), and 5.3% (distant). CONCLUSIONS: The current results indicate high fatality for stomach cancer, especially soon after diagnosis. Although improvements in stomach cancer survival were observed, survival remained relatively low for both blacks and whites. Primary prevention through the control of well-established risk factors would be expected to have the greatest impact on further reducing deaths from stomach cancer. Cancer 2017;123:4994-5013. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Causes and Disparities in Death Rates Among Urban American Indian and Alaska Native Populations, 1999-2009.

OBJECTIVES: To characterize the leading causes of death for the urban American Indian/Alaska Native (AI/AN) population and compare with urban White and rural AI/AN populations. METHODS: We linked Indian Health Service patient registration records with the National Death Index to reduce racial misclassification in death certificate data. We calculated age-adjusted urban AI/AN death rates for the period 1999-2009 and compared those with corresponding urban White and rural AI/AN death rates. RESULTS: The top-5 leading causes of death among urban AI/AN persons were heart disease, cancer, unintentional injury, diabetes, and chronic liver disease and cirrhosis. Compared with urban White persons, urban AI/AN persons experienced significantly higher death rates for all top-5 leading causes. The largest disparities were for diabetes and chronic liver disease and cirrhosis. In general, urban and rural AI/AN persons had the same leading causes of death, although urban AI/AN persons had lower death rates for most conditions. CONCLUSIONS: Urban AI/AN persons experience significant disparities in death rates compared with their White counterparts. Public health and clinical interventions should target urban AI/AN persons to address behaviors and conditions contributing to health disparities.

Leading causes of death and all-cause mortality in American Indians and Alaska Natives.

OBJECTIVES: We present regional patterns and trends in all-cause mortality and leading causes of death in American Indians and Alaska Natives (AI/ANs). METHODS: US National Death Index records were linked with Indian Health Service (IHS) registration records to identify AI/AN deaths misclassified as non-AI/AN. We analyzed temporal trends for 1990 to 2009 and comparisons between non-Hispanic AI/AN and non-Hispanic White persons by geographic region for 1999 to 2009. Results focus on IHS Contract Health Service Delivery Area counties in which less race misclassification occurs. RESULTS: From 1990 to 2009 AI/AN persons did not experience the significant decreases in all-cause mortality seen for Whites. For 1999 to 2009 the all-cause death rate in CHSDA counties for AI/AN persons was 46% more than that for Whites. Death rates for AI/AN persons varied as much as 50% among regions. Except for heart disease and cancer, subsequent ranking of specific causes of death differed considerably between AI/AN and White persons. CONCLUSIONS: AI/AN populations continue to experience much higher death rates than Whites. Patterns of mortality are strongly influenced by the high incidence of diabetes, smoking prevalence, problem drinking, and social determinants. Much of the observed excess mortality can be addressed through known public health interventions.

Methods for improving the quality and completeness of mortality data for American Indians and Alaska Natives.

OBJECTIVES: We describe methods used to mitigate the effect of race misclassification in mortality records and the data sets used to improve mortality estimates for American Indians and Alaska Natives (AI/ANs). METHODS: We linked US National Death Index (NDI) records with Indian Health Service (IHS) registration records to identify AI/AN deaths misclassified as non-AI/AN deaths. Analyses excluded decedents of Hispanic origin and focused on Contract Health Service Delivery Area (CHSDA) counties. We compared death rates for AI/AN persons and Whites across 6 US regions. RESULTS: IHS registration records merged to 176,137 NDI records. Misclassification of AI/AN race in mortality data ranged from 6.3% in the Southwest to 35.6% in the Southern Plains. From 1999 to 2009, the all-cause death rate in CHSDA counties for AI/AN persons varied by geographic region and was 46% greater than that for Whites. Analyses for CHSDA counties resulted in higher death rates for AI/AN persons than in all counties combined. CONCLUSIONS: Improving race classification among AI/AN decedents strengthens AI/AN mortality data, and analyzing deaths by geographic region can aid in planning, implementation, and evaluation of efforts to reduce health disparities in this population.

Disparities in cancer mortality and incidence among American Indians and Alaska Natives in the United States.

OBJECTIVES: We used improved data on American Indian and Alaska Native (AI/AN) ancestry to provide an updated and comprehensive description of cancer mortality and incidence among AI/AN populations from 1990 to 2009. METHODS: We linked the National Death Index and central cancer registry records independently to the Indian Health Service (IHS) patient registration database to improve identification of AI/AN persons in cancer mortality and incidence data, respectively. Analyses were restricted to non-Hispanic persons residing in Contract Health Service Delivery Area counties in 6 geographic regions of the United States. We compared age-adjusted mortality and incidence rates for AI/AN populations with White populations using rate ratios and mortality-to-incidence ratios. Trends were described using joinpoint analysis. RESULTS: Cancer mortality and incidence rates for AI/AN persons compared with Whites varied by region and type of cancer. Trends in death rates showed that greater progress in cancer control was achieved for White populations compared with AI/AN populations over the last 2 decades. CONCLUSIONS: Spatial variations in mortality and incidence by type of cancer demonstrated both persistent and emerging challenges for cancer control in AI/AN populations.

Colorectal cancer incidence and mortality disparities in new Mexico.

Background. Previous analyses indicated that New Mexican Hispanics and American Indians (AI) did not experience the declining colorectal cancer (CRC) incidence and mortality rates observed among non-Hispanic whites (NHW). We evaluated more recent data to determine whether racial/ethnic differences persisted. Methods. We used New Mexico Surveillance Epidemiology and End Results data from 1995 to 2009 to calculate age-specific incidence rates and age-adjusted incidence rates overall and by tumor stage. We calculated mortality rates using National Center for Health Statistics' data. We used joinpoint regression to determine annual percentage change (APC) in age-adjusted incidence rates. Analyses were stratified by race/ethnicity and gender. Results. Incidence rates continued declining in NHW (APC -1.45% men, -1.06% women), while nonsignificantly increasing for AI (1.67% men, 1.26% women) and Hispanic women (0.24%). The APC initially increased in Hispanic men through 2001 (3.33%, P = 0.06), before declining (-3.10%, P = 0.003). Incidence rates declined in NHW and Hispanics aged 75 and older. Incidence rates for distant-stage cancer remained stable for all groups. Mortality rates declined significantly in NHW and Hispanics. Conclusions. Racial/ethnic disparities in CRC persist in New Mexico. Incidence differences could be related to risk factors or access to screening; mortality differences could be due to patterns of care for screening or treatment.

Human papillomavirus vaccination practices among providers in Indian health service, tribal and urban Indian healthcare facilities.

PURPOSE: The human papillomavirus (HPV) vaccine is of particular importance in American Indian/Alaska Native women because of the higher rate of cervical cancer incidence compared to non-Hispanic white women. To better understand HPV vaccine knowledge, attitudes, and practices among providers working with American Indian/Alaska Native populations, we conducted a provider survey in Indian Health Service, Tribal and Urban Indian (I/T/U) facilities. METHODS: During December 2009 and January 2010, we distributed an on-line survey to providers working in I/T/U facilities. We also conducted semistructured interviews with a subset of providers. RESULTS: There were 268 surveys and 51 provider interviews completed. Providers were more likely to administer vaccine to 13-18-year-olds (96%) than to other recommended age groups (89% to 11-12-year-olds and 64% to 19-26-year-olds). Perceived barriers to HPV vaccination for 9-18-year-olds included parental safety and moral/religious concerns. Funding was the main barrier for 19-26-year-olds. Overall, providers were very knowledgeable about HPV, although nearly half of all providers and most obstetricians/gynecologists thought that a pregnancy test should precede vaccination. Sixty-four percent of providers of patients receiving the vaccine do not routinely discuss the importance of cervical cancer screening. CONCLUSIONS: Recommendations for HPV vaccination have been broadly implemented in I/T/U settings. Vaccination barriers identified by I/T/U providers are similar to those reported in other provider surveys. Provider education efforts should stress that pregnancy testing is not needed before vaccination and the importance of communicating the need for continued cervical cancer screening.

Geographic variation in trends and characteristics of teen childbearing among American Indians and Alaska Natives, 1990-2007.

To study teen birth rates, trends, and socio-demographic and pregnancy characteristics of AI/AN across geographic regions in the US. The birth rate for US teenagers 15-19 years reached a historic low in 2009 (39.1 per 1,000) and yet remains one of the highest teen birth rates among industrialized nations. In the US, teen birth rates among Hispanic, non-Hispanic black, and American Indian/Alaska Native (AI/AN) youth are consistently two to three times the rate among non-Hispanic white teens. Birth certificate data for females younger than age 20 were used to calculate birth rates (live births per 1,000 women) and joinpoint regression to describe trends in teen birth rates by age (<15, 15-17, 18-19) and region (Aberdeen, Alaska, Bemidji, Billings, California, Nashville, Oklahoma, Portland, Southwest). Birth rates for AI/AN teens varied across geographic regions. Among 15-19-year-old AI/AN, rates ranged from 24.35 (California) to 123.24 (Aberdeen). AI/AN teen birth rates declined from the early 1990s into the 2000s for all three age groups. Among 15-17-year-olds, trends were approximately level during the early 2000s-2007 in six regions and declined in the others. Among 18-19-year-olds, trends were significantly increasing during the early 2000s-2007 in three regions, significantly decreasing in one, and were level in the remaining regions. Among AI/AN, cesarean section rates were lower in Alaska (4.1%) than in other regions (16.4-26.6%). This is the first national study to describe regional variation in AI/AN teen birth rates. These data may be used to target limited resources for teen pregnancy intervention programs and guide research.

Impact of hysterectomy and bilateral oophorectomy prevalence on rates of cervical, uterine, and ovarian cancer among American Indian and Alaska Native women, 1999-2004.

OBJECTIVE: To present more accurate incidence rates of cervical, uterine, and ovarian cancer by geographic region in American Indian/Alaska Native (AI/AN) women. METHODS: The authors used data from central cancer registries linked to Indian Health Service (IHS) patient registration database, the Behavioral Risk Factor Surveillance System, IHS National Data Warehouse, and the National Hospital Discharge Survey. Cancer incidence rates were adjusted for hysterectomy and oophorectomy prevalence and presented by region for non-Hispanic White (NHW) and AI/AN women. RESULTS: AI/AN women had a higher prevalence of hysterectomy (23.1%) compared with NHW women (20.9%). Correcting cancer rates for population-at-risk significantly increased the cancer incidence rates among AI/AN women: 43% for cervical cancer, 67% for uterine cancer, and 37% for ovarian cancer. Risk-correction led to increased differences in cervical cancer incidence between AI/AN and NHW women in certain regions. CONCLUSIONS: Current reporting of cervical, uterine, and ovarian cancer underestimates the incidence in women at risk and can affect the measure of cancer disparities. Improved cancer surveillance using methodology to correct for population-at-risk may better inform disease control priorities for AI/AN populations.

Screening prevalence and incidence of colorectal cancer among American Indian/Alaskan natives in the Indian Health Service.

BACKGROUND: Studies on colorectal cancer (CRC) screening and incidence among American Indian/Alaska Natives (AI/AN) are few. AIMS: Our aim was to determine CRC screening prevalence and to calculate CRC incidence among AI/AN receiving care within the Indian Health Service (IHS). METHODS: A retrospective cohort study of AI/AN who utilized IHS from 1996 to 2004. AI/AN who were average-risk for CRC and received primary care within IHS were identified by searching the IHS Resource Patient Management System for selected ICD-9/CPT codes (n = 142,051). CRC screening prevalence was calculated and predictors of screening were determined for this group. CRC incidence rates were ascertained for the entire AI/AN population ages 50-80 who received IHS medical care between 1996 and 2004 (n = 283,717). RESULTS: CRC screening was performed in 4.0% of average-risk AI/AN. CRC screening was more common among women than men (RR = 1.6, 95% CI 1.4-1.7) and among AI/AN living in the Alaska region compared to the Pacific Coast region (RR = 2.5, 95% CI 2.2-2.8) while patients living in the Northern Plains (RR = 0.4, 95% CI 0.3-0.4) were less likely to have been screened. CRC screening was less common among patients with a greater number of primary care visits. The age-adjusted CRC incidence among AI/AN ages 50-80 was 227 cancers per 100,000 person-years. CONCLUSIONS: CRC was common among AI/AN receiving medical care within IHS. However, CRC screening prevalence was far lower than has been reported for the U.S. population.

Methods for improving cancer surveillance data in American Indian and Alaska Native populations.

BACKGROUND: The misclassification of race decreases the accuracy of cancer incidence data for American Indians and Alaska Natives (AI/ANs) in some central cancer registries. This article describes the data sources and methods that were used to address this misclassification and to produce the cancer statistics used by most of the articles in this supplement. METHODS: Records from United States cancer registries were linked with Indian Health Service (IHS) records to identify AI/AN cases that were misclassified as non-AI/AN. Data were available from 47 registries that linked their data with IHS, met quality criteria, and agreed to participate. Analyses focused on cases among AI/AN residents in IHS Contract Health Service Delivery Area (CHSDA) counties in 33 states. Cancer incidence and stage data were compiled for non-Hispanic whites (NHWs) and AI/ANs across 6 IHS regions of the United States for 1999 through 2004. RESULTS: Misclassification of AI/AN race as nonnative in central cancer registries ranged from 85 individuals in Alaska (3.4%) to 5297 individuals in the Southern Plains (44.5%). Cancer incidence rates among AI/ANs for all cancers combined were lower than for NHWs, but incidence rates varied by geographic region for AI/ANs. Restricting the rate calculations to CHSDA counties generally resulted in higher rates than those obtained for all counties combined. CONCLUSIONS: The classification of race for AI/AN cases in cancer registries can be improved by linking records to the IHS and stratifying by CHSDA counties. Cancer in the AI/AN population is clarified further by describing incidence rates by geographic region. Improved cancer surveillance data for AI/AN communities should aid in the planning, implementation, and evaluation of more effective cancer control and should reduce health disparities in this population.

Cancer among American Indians and Alaska Natives in the United States, 1999-2004.

BACKGROUND: Cancer incidence rates vary among American Indian and Alaska Native (AI/AN) populations and often differ from rates among non-Hispanic whites (NHWs). However, the misclassification of race for AI/AN cancer cases in central cancer registries may have led to underestimates of the AI/AN cancer burden in previous reports. METHODS: Cases diagnosed during 1999 through 2004 were identified from population-based cancer registries in the United States. Age-adjusted rates were calculated for the 25 most common sites for AI/ANs and NHWs. To minimize the misclassification of race, cancer registry records were linked with patient registration files from the Indian Health Service (IHS). Analyses were restricted to Contract Health Service Delivery Area (CHSDA) counties and were stratified by IHS region. RESULTS: In CHSDA counties, cancer incidence rates among AI/ANs varied widely by region, whereas rates among NHWs did not. For all cancer sites combined, AI/AN rates were higher than NHW rates among both males and females in the Northern and Southern Plains, and among Alaska Native Females; AI/AN rates were lower than NHW rates in the Southwest, the Pacific Coast, and the East. Lung cancer and colorectal cancer rates for AI/ANs exceeded rates for NHWs in Alaska and the Northern Plains. Rates for stomach, gallbladder, kidney, and liver cancer were higher among AI/ANs than among NHWs overall, in Alaska, in the Plains regions, and in the Southwest. CONCLUSIONS: Regional differences in cancer incidence rates among AI/AN populations were not obvious from nationwide data and highlighted opportunities for cancer control and prevention. It is unlikely that such differences are explained by race misclassification.

Prostate cancer incidence among American Indian and Alaska Native men, US, 1999-2004.

BACKGROUND: American Indian and Alaska Native (AI/AN) men experience lower incidence of prostate cancer than other race/ethnic populations in the US, but racial misclassification of AI/AN men threatens the validity of these estimates. To the authors' knowledge, little is known concerning prostate-specific antigen (PSA) testing in AI/AN men. METHODS: The authors linked cancer registry data with Indian Health Service enrollment records to improve race classification. Analyses comparing cancer incidence rates and stage at diagnosis for AI/AN and non-Hispanic white (NHW) men for 6 geographic regions focused on counties known to have less race misclassification. The authors also used Behavioral Risk Factors Surveillance System data to characterize PSA testing in AI/AN men. RESULTS: Prostate cancer incidence rates were generally lower in AI/AN than in NHW men for all regions combined (rate ratio of 0.68). However, regional variation was noted among AI/AN men, with incidence rates (per 100,000 population) ranging from 65.7 in the Southwest to 174.5 on the Northern Plains. The rate of distant stage disease was somewhat higher among AI/AN (7.8) than NHW (6.2) men. Nationally, AI/AN men were less likely than NHW men to have undergone recent PSA testing (48.4% vs 58.0%), with prominent regional variation in screening rates noted. CONCLUSIONS: Prostate cancer incidence rates and the proportion of men with recent PSA testing were lower for AI/AN men than for NHW men. However, incident rates and rate of distant stage varied by region more for AI/AN than for NHW. Further research is needed among AI/AN men to evaluate strategies for better understanding the causes of the regional variation in prostate cancer incidence.

Gastric cancer among American Indians and Alaska Natives in the United States, 1999-2004.

BACKGROUND: Gastric cancer incidence rates for American Indians and Alaska Natives (AI/ANs) historically have exceeded those for non-Hispanic whites (NHWs). Previous reports may have underestimated the true burden of gastric cancer in AI/AN populations because of misclassification of AI/AN race in cancer registries. METHODS: Population-based cancer registry data from 1999 through 2004 were used to describe gastric cancer incidence in AI/ANs and NHWs in the US. To address misclassification of race, registry data were linked with Indian Health Service administrative records, and analyses were restricted to residents of Contract Health Service Delivery Areas (CHSDA). Disease patterns were assessed for 6 geographic regions and for all regions combined. Rates were expressed per 100,000 population and were age-adjusted to the 2000 US standard population. RESULTS: In CHSDA counties, gastric cancer incidence rates for AI/ANs were higher than the rates for NHWs across most regions. For both sexes combined, AI/AN rates ranged from 6.1 in the East region to 24.5 in Alaska; there was relatively little regional variation in NHW rates. Most patients with gastric cancer were diagnosed with late-stage disease, regardless of race, age, or sex. In some regions, cancer rates in the central/distal portions of the stomach were higher among AI/ANs than among NHWs, whereas rates in the proximal stomach were similar between the 2 populations. CONCLUSIONS: AI/ANs are generally at greater risk for gastric cancer than NHWs. Relatively high rates of cancer in the central/distal portions of the stomach among AI/ANs in some geographic regions may indicate a disproportional burden of Helicobacter pylori-associated disease.

Regional differences in cervical cancer incidence among American Indians and Alaska Natives, 1999-2004.

BACKGROUND: Reports from limited geographic regions indicate higher rates of cervical cancer incidence in American Indian and Alaska Native (AI/AN) women than in women of other races. However, accurate determinations of cervical cancer incidence in AI/AN women have been hampered by racial misclassification in central cancer registries. METHODS: The authors linked data from cancer registries participating in the National Program of Cancer Registries (NPCR) and the Surveillance, Epidemiology, and End Results (SEER) Program with Indian Health Service (IHS) enrollment records to improve identification of AI/AN race. NPCR and SEER data were combined to estimate annualized age-adjusted rates (expressed per 100,000 persons) for the diagnosis years 1999 to 2004. Analyses focused on counties known to have less racial misclassification, and results were stratified by IHS Region. Approximately 56% of AI/ANs in the US reside in these counties. The authors examined overall and age-specific incidence rates and stage at diagnosis for AI/AN women compared with non-Hispanic white (NHW) women. RESULTS: Invasive cervical cancer incidence rates among AI/AN women varied nearly 2-fold across IHS regions, with the highest rates reported in the Southern Plains (14.1) and Northern Plains (12.5); the lowest rates were in the Eastern region and the Pacific Coast. Overall, AI/AN women had higher rates of cervical cancer than NHW women and were more likely to be diagnosed with later stage disease. CONCLUSIONS: The wide regional variation of invasive cervical cancer incidence indicates an important need for health services research regarding cervical cancer screening and prevention education as well as policy development regarding human papillomavirus vaccine use, particularly in the regions with high incidence rates. Cancer 2008;113(5 suppl):1234-43. Published 2008 by the American Cancer Society.