Appendix C Potential Health Outcome and Risk Status Measures

The health outcome and risk status measures in this appendix are presented to illustrate the types of measures that might be included in performance partnership grants (PPG) between state agencies and the U.S. Department of Health and Human Services (DHHS). These measures were selected from among the many proposed to the panel by participants at four regional meetings sponsored by DHHS, as well as by professional health associations and private agencies and individuals. The panel chose the measures—listed in the first section of this appendix and detailed in the second section—using the guidelines described in Chapter 1 of this report: a measure should be specific and results oriented; it should be meaningful and understandable; data should be adequate to support the measure; and the measure should be as valid, reliable, and responsive as possible.

These health outcome and risk status measures are not meant to represent a mandated list. Few states are likely to have all of the data necessary to support all of these measures. In addition, state agencies may well have major priorities in addition to those represented by the categories of outcome measures listed here (e.g., injury prevention, oral health, hearing and vision, environmental health, etc.) and are responsible for administering major programs relevant to public health that are not covered by this report (e.g., Medicaid). In addition, the panel did not attempt to identify all of the measures that might be relevant for specific important subpopulations (i.e., groups defined by demographic or risk categories). Consequently, the health outcome and risk status measures described below should be considered an important subset, but not an exhaustive listing, of those that will be of interest to state agencies.

A major goal of this report is to provide an analytic framework for use by the



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Appendix C Potential Health Outcome and Risk Status Measures The health outcome and risk status measures in this appendix are presented to illustrate the types of measures that might be included in performance partnership grants (PPG) between state agencies and the U.S. Department of Health and Human Services (DHHS). These measures were selected from among the many proposed to the panel by participants at four regional meetings sponsored by DHHS, as well as by professional health associations and private agencies and individuals. The panel chose the measures—listed in the first section of this appendix and detailed in the second section—using the guidelines described in Chapter 1 of this report: a measure should be specific and results oriented; it should be meaningful and understandable; data should be adequate to support the measure; and the measure should be as valid, reliable, and responsive as possible. These health outcome and risk status measures are not meant to represent a mandated list. Few states are likely to have all of the data necessary to support all of these measures. In addition, state agencies may well have major priorities in addition to those represented by the categories of outcome measures listed here (e.g., injury prevention, oral health, hearing and vision, environmental health, etc.) and are responsible for administering major programs relevant to public health that are not covered by this report (e.g., Medicaid). In addition, the panel did not attempt to identify all of the measures that might be relevant for specific important subpopulations (i.e., groups defined by demographic or risk categories). Consequently, the health outcome and risk status measures described below should be considered an important subset, but not an exhaustive listing, of those that will be of interest to state agencies. A major goal of this report is to provide an analytic framework for use by the

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states and DHHS in assessing the appropriateness of specific outcome, process, and capacity measures proposed for PPG agreements in the future. The panel hopes that the field of performance measure evaluation will evolve, as new health outcome measures are defined, studied, and become available. It is anticipated that many of the measures described in this report can, in time, be modified or replaced by others that meet the selection guidelines listed above. Potential Measures: Overview Chronic Disease Tobacco Percentage of (a) persons aged 18–24 and (b) persons aged 25 and older currently smoking tobacco Percentage of persons aged 14–17 (grades 9–12) currently smoking tobacco Percentage of women who gave birth in the past year and reported smoking tobacco during pregnancy Percentage of employed adults whose workplace has an official policy that bans smoking Nutrition Percentage of persons aged 18 and older who eat five or more servings of fruits and vegetables per day1 Percentage of persons aged 14–17 (grades 9–12) who eat five or more servings of fruits and vegetables per day2 Percentage of persons aged 18 and older who are 20 percent or more above optimal body mass index3 Exercise Percentage of persons aged 18 and older who do not engage in physical activity or exercise Percentage of persons aged 14–17 (grades 9–12) who do not engage in physical activity or exercise 1   The numerical value in this measure is the level that is generally regarded as appropriate by the medical community; it does not represent a level that has been independently determined or endorsed by the panel. 2   See fn. 1. 3   See fn. 1.

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Screenings and Tests Percentage of persons aged 18 and older who had their blood pressure checked within past 2 years4 Percentage of women aged 45 and older and men aged 35 and older who had their cholesterol checked within past 5 years5 Percentage of women aged 50 and older who received a mammogram within past 2 years6 Percentage of adults aged 50 and older who had a fecal occult blood test within past 12 months or a flexible sigmoidoscopy within past 5 years7 Percentage of women aged 18 and older who received a Pap smear within past 3 years8 Percentage of persons with diabetes who had HbA1C checked within past 12 months9 Percentage of persons with diabetes who had a health professional examine their feet at least once within past 12 months10 Percentage of persons with diabetes who received a dilated eye exam within past 12 months11 STDs, HIV Infection, and Tuberculosis Incidence rates of selected STDs Incidence rates of HIV infection Prevalence rates of selected STDs Prevalence rates of HIV infection Consumer satisfaction with STD, HIV, and tuberculosis treatment programs Rates of sexual activity among adolescents aged 14–17 Rates of sexual activity with multiple sex partners among people aged 18 and older Rates of condom use during last episode of sexual intercourse among sexually active adolescents aged 14–17 Rates of condom use by persons aged 18 and older with multiple sex partners during last episode of sexual intercourse 4   See fn. 1. 5   See fn. 1. 6   Cancer incidence by diagnosed stage may be a better alternative in cancer registry areas; see fn. 1. 7   See fns 1 and 6. 8   See fns. 1 and 6. 9   See fn. 1. 10   See fn. 1. 11   See fn. 1.

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Rates of condom use during last episode of sexual intercourse among men having sex with men Rates of injection drug use among adolescents and adults Completion rates of treatment for STDs, HIV infection, and tuberculosis Mental Health Percentage of persons aged 18 and older receiving mental health services who experience reduced psychological distress Percentage of persons aged 18 and older receiving mental health services who experience increased level of functioning Percentage of persons aged 18 and older receiving mental health services who report increased employment (including volunteer time) Percentage of persons aged 18 and older with serious and persistent mental illness receiving mental health services who live in integrated, independent living situations or with family members Percentage of children aged 17 and younger with serious emotional disorders receiving mental health services who live in noncustodial living situations Percentage of persons aged 18 and older with serious mental illness who are in prisons and jails Percentage of children aged 17 and younger with serious emotional disorders who are in juvenile justice facilities Percentage of homeless persons aged 18 and older who have a serious mental illness Percentage of adolescents aged 14–17 or family members of children and adolescents or both who are satisfied with: (a) access to services, (b) appropriateness of services, and (c) perceptions of gain in personal outcomes Percentage of persons (aged 18 and older) or their family members or both who are satisfied with: (a) access to mental health services, (b) appropriateness of services, and (c) perceptions of gain in personal outcomes Immunization Reported incidence rate of representative vaccine-preventable diseases Age-appropriate vaccination rates for target age groups (children aged 2 years; children entering school at approximately 5 years of age; and adults aged 65 and older) for each major vaccine group Substance Abuse Death rate of persons aged 15–65 attributed to (a) alcohol, (b) other drug use, and (c) combined agents Percentage of emergency room encounters for alcohol or other drug-related causes

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Prevalence rate of substance abuse clients who report experiencing diminished severity of problems after completing treatment as measured by the Addiction Severity Index (ASI) or a similar measure12 Ratio of substance abuse clients involved with the criminal justice system before and after completing treatment Prevalence rate of adolescents aged 14–17 engaged in heavy drinking or other drug use13 Prevalence rate of persons aged 18 and older engaged in heavy drinking or other drug use14 Percentage of women who gave birth in the past year and reported using alcohol or other drugs during pregnancy Mean age at first use of ''gateway" drugs (tobacco, marijuana, alcohol) Percentage of adolescents aged 14–17 stating disapproval of marijuana use Percentage of adolescents aged 14–17 who report parents or guardians who communicate non-use expectations Percentage of drug abuse clients who engage in risk behaviors related to HIV/AIDS after completing treatment plan Sexual Assault Prevention Incidence rate of sexual assault reported by females Disabilities Percentage of newborns with neural tube defects Percentage of persons aged 18–65 with disabilities who are in the workforce Percentage of children aged 6 or younger with blood lead greater that 10 micrograms per deciliter15 Percentage of women who gave birth in the past year and reported alcohol, tobacco, or other drugs during pregnancy Emergency Medical Services Percentage of persons who suffer out-of-hospital cardiac arrest who survive 12   Although the estimated incidence rate would be a more appropriate measure for monitoring progress by the state substance abuse agencies, the currently available data source for this measure provides prevalence data. 13   See fn. 12. 14   See fn. 12. 15   See fn. 1.

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POTENTIAL MEASURES Measure Type: Chronic disease risk status Measure: Percentage of (a) persons aged 18–24 and (b) persons aged 25 and older currently smoking tobacco. Numerator: All adults in each age group smoking tobacco (either statewide or in selected subgroups). Denominator: All adults in each age group (in the selected subgroup). Rationale for Measure: Use of smoking tobacco is the leading preventable cause of death in this country and a major cause of a wide range of chronic diseases. (This measure corresponds to Healthy People 2000 Objective 3.4.) Limitations of Measure: Tobacco use by a state's population can be affected by many factors, including exposure to advertising, availability of vending machines, and other factors that may not be under the direct control of the state health agencies. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources: Behavioral Risk Factor Surveillance System (BRFSS). Limitations of Data: The methodology used to collect BRFSS data may vary significantly across states, making interstate comparisons with these data alone problematic.

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Measure Type: Chronic disease risk status Measure: Percentage of persons aged 14–17 (grades 9–12) currently smoking tobacco. Numerator: Young adults aged 14–17 currently smoking tobacco (either statewide or in selected subgroup). Denominator: Young adults aged 14–17 (in the selected subgroup). Rationale for Measure: Use of smoking tobacco is the leading preventable cause of death in this country and a major cause of a wide range of chronic diseases. Use generally begins during youth. (This measure corresponds to Healthy People 2000 Objective 3.5.) Limitations of Measure: Tobacco use by a state's population can be affected by many factors, including exposure to advertising, availability of vending machines, and other factors that may not be under the direct control of the state health agencies. A school-based measure misses dropouts who may be at an increased risk for tobacco use, so supplemental surveys of dropouts and absentees are needed for the most accurate measurement. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources: Youth Risk Behavior Surveillance System (YRBSS). Limitations of Data: The methodology used to collect YRBSS data may vary significantly across states, making interstate comparisons with these data alone problematic. It should also be noted that YRBSS is currently conducted in fewer than half of all states and often does not involve a representative sampling of schools in a given state.

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Measure Type: Chronic disease risk status Measure: Percentage of women who gave birth in the past year and reported smoking tobacco during pregnancy. Numerator: All women who gave birth in the past year and reported smoking tobacco (either statewide or in selected subgroups). Denominator: All women giving birth (in selected subgroups). Rationale for Measure: Use of tobacco is the leading preventable cause of death in this country and a major cause of a wide range of chronic diseases. Use in pregnancy has deleterious effects on fetus and can raise the likelihood of one or more chronic diseases affecting the newborn. (This measure corresponds to Healthy People 2000 Objective 14.10.) Limitations of Measure: Tobacco use by a state's childbearing-age female population can be affected by many factors, including exposure to advertising, availability of vending machines, and other factors that may not be under the direct control of the state health agencies. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources:   Numerator: Birth certificate data; states with alternative methods for measuring tobacco use during pregnancy (for example, PRAMS) may opt to use these data instead. Denominator: Official state population estimate. Limitations of Data: It is widely understood that birth certificate data may understate the actual use of tobacco by pregnant women. Nevertheless, this should not be a problem in examining trends over time or making interstate comparisons if the reporting bias is consistent from one time period to another or across jurisdictions.

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Measure Type: Chronic disease risk status Measure: Percentage of employed adults whose workplace has an official policy that bans smoking. Numerator: All employed persons in worksites with tobacco policies (either statewide or in selected subgroups). Denominator: All employed persons (in selected subgroups). Rationale for Measure: Exposure to tobacco smoke by nonsmokers is a significant cause of chronic disease, including lung cancer. Limitations of Measure: Policies that limit tobacco use by a state's working population can be affected by many factors that may not be under the direct control of the state health agencies. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources: Current Population Survey (CPS), tobacco risk supplement. Limitations of Data: While the general CPS only provides state-level estimates for approximately ten states, data from the tobacco risk supplement to the CPS can be used to produce annual state level estimates for all states.

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Measure Type: Chronic disease risk status Measure: Percentage of persons aged 18 and older who eat five or more servings of fruits and vegetables per day.* Numerator: Persons aged 18 and older who eat five or more servings of fruits and vegetables per day (either statewide or in selected subgroups). Denominator: All persons aged 18 and older (in the selected subgroup). Rationale for Measure: Eating five or more servings of fruits and vegetables per day is an important strategy for reducing dietary fat content, reducing obesity, and increasing the consumption of fiber and other nutrients, leading to reduced heart disease, colon cancer, and other diseases. (This measure corresponds to Healthy People 2000 Objective 2.6.) Limitations of Measure: Although diet has been demonstrated to have a causal link in reducing heart disease and some cancers, other factors, such as heredity, are known to affect the incidence of these diseases. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources: Behavioral Risk Factor Surveillance System (BRFSS). Limitations of Data: The methodology used to collect BRFSS data may vary significantly across states, making interstate comparisons with these data alone problematic. * The numerical value in this measure is the level that is generally regarded as appropriate by the medical community; it does not represent a level that has been independently determined or endorsed by the panel.

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Measure Type: Chronic disease risk status Measure: Percentage of persons aged 14–17 (grades 9–12) who eat five or more servings of fruits and vegetables per day.* Numerator: Persons aged 14–17 who eat five or more servings of fruits and vegetables per day (either statewide or in selected subgroups). Denominator: All persons aged 14–17 (in the selected subgroup). Rationale for Measure: Eating five or more servings of fruits and vegetables per day is an important strategy for reducing dietary fat content, reducing obesity, and increasing the consumption of fiber and other nutrients, leading to reduced heart disease, colon cancer, and other diseases. Dietary habits may be established during childhood or adolescence. (This measure corresponds to Healthy People 2000 Objective 2.6.) Limitations of Measure: Although diet has been demonstrated to have a causal link in reducing heart disease and some cancers, other factors, such as heredity, are known to affect the incidence of these diseases. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources: Youth Risk Behavior Surveillance System (YRBSS). Limitations of Data: The methodology used to collect YRBSS data may vary significantly across states, making interstate comparisons with these data alone problematic. It should also be noted that YRBSS is currently conducted in fewer than half of all states and often does not involve a representative sampling of schools in a given state. * The numerical value in this measure is the level that is generally regarded as appropriate by the medical community; it does not represent a level that has been independently determined or endorsed by the panel.

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Measure Type: Substance abuse risk status Measure: Percentage of women who gave birth in the past year and reported using alcohol or other drugs during pregnancy. Numerator: Number of pregnant women who gave birth in the past year and reported using alcohol or other drugs. Denominator: All women giving birth in the state. Rationale for Measure: The use of these substances during pregnancy can lead to adverse birth outcomes (e.g., fetal alcohol syndrome). (This measure corresponds to Healthy People 2000 Objective 14.10.) Limitations of Measure: Alcohol and drug use by a state's pregnant female population can be affected by many factors, including exposure to advertising, that may not be under the direct control of state agencies. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state agencies are having the desired impact. Data Resources: Birth records; Behavioral Risk Factor Surveillance System (BRFSS); adverse pregnancy outcome registry; maternal and child health case management records Limitations of Data: The methodology used to collect BRFSS may vary significantly across states, making interstate comparisons problematic, unless supported by other data sources, such as state screening and reporting systems or medical information systems. Sample sizes may not be sufficiently large to accurately identify rates of substance abuse among the subpopulation of pregnant women.

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Measure Type: Substance abuse risk status Measure: Mean age at first use of ''gateway" drugs (tobacco, marijuana, alcohol) Numerator: Mean age of children and adolescents reporting first use of tobacco, marijuana or alcohol. Denominator: Number of children and adolescents. Rationale for Measure: Early use of these substances may be a precursor of more serious drug use or abuse. Limitations of Measure: Measure does not distinguish between those who use gateway drugs and subsequently go on to further use and those whose first use does not lead to any subsequent behavior. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state agencies are having the desired impact. Data Resources: Youth Risk Behavior Surveillance System (YRBSS); state student surveys Limitations of Data: The methodology used to collect YRBSS data may vary significantly across states, making interstate comparisons with these data alone problematic. It should also be noted that the YRBSS is currently conducted in fewer than half of all states and often does not involve a representative sampling of schools in a given state.

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Measure Type: Substance abuse risk status Measure: Percentage of adolescents aged 14–17 stating disapproval of marijuana use. Numerator: Number of adolescents indicating disapproval of marijuana use. Denominator: Number of adolescents. Rationale for Measure: Peer disapproval of marijuana use is a strong protective factor; when the percentage of youth with this attitude is high, marijuana rates tend to be low. (This measure corresponds to Healthy People 2000 Objective 4.9) Limitations of Measure: Indirect measures may understate actual use, as high-risk populations (dropouts, incarcerated adolescents) are often not included in surveys. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state agencies are having the desired impact. Data Resources: State surveys. Limitations of Data: Surveys are not available in many states, and where available may be limited by numerous sources of error: e.g., coverage error, which is the result of neglecting to measure all parts of the population; nonresponse error, which is caused by individuals who refuse the survey or cannot be located; and sampling error, which reflects the difference between the general population and the specific sample chosen for the survey.

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Measure Type: Substance abuse risk status Measure: Percentage of adolescents aged 14–17 who report parents or guardians who communicate non-use expectations. Numerator: Number of adolescents who report that parents or guardians clearly communicate the expectations of non-use. Denominator: Number of adolescents. Rationale for Measure: Parental expectation for non-use by their children is a significant protective factor. When the percentage of parents or guardians who clearly communicate a non-use message is high, use rates tend to be low. Limitations of Measure: Indirect measures may understate actual use, as high-risk populations (dropouts, incarcerated adolescents) are often not included in surveys. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state agencies are having the desired impact. Data Resources: State surveys. Limitations of Data: Surveys are not available in many states, and where available may be limited by numerous sources of error: e.g., coverage error, which is the result of neglecting to measure all parts of the population; nonresponse error, which is caused by individuals who refuse the survey or cannot be located; and sampling error, which reflects the difference between the general population and the specific sample chosen for the survey.

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Measure Type: Substance abuse risk status Measure: Percentage of drug abuse clients who engage in risk behaviors related to HIV/AIDS after completing treatment plan. Numerator: Number of clients engaging in needle sharing and unprotected sex after completing treatment plan. Denominator: Number of clients followed up after completing treatment plan. Rationale for Measure: Drug and alcohol abusers are at high risk for HIV/AIDS due to needle sharing and unprotected sex. Limitations of Measure: Many personal and socioeconomic factors can influence alcohol and drug use that are difficult for a state agency to measure in the short term. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state agencies are having the desired impact. Data Resources: State client data systems (e.g., Minnesota Drug and Alcohol Abuse Normative Evaluation System). Limitations of Data: Most states do not collect these data; collecting data on sexual behaviors can be controversial. State surveys may be limited by numerous sources of error: e.g., coverage error, which is the result of neglecting to measure all parts of the population; nonresponse error, which is caused by individuals who refuse the survey or cannot be located; and sampling error, which reflects the difference between the general population and the specific sample chosen for the survey.

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Measure Type: Sexual assault health status outcome Measure: Incidence rate of sexual assault reported by females. Numerator: Total number of sexual assaults reported by females. Denominator: State female population. Rationale for Measure: This is the key sexual assault indicator currently available. (This measure corresponds to Healthy People 2000 Objective 7.12.) Limitations of Measure: Sexual assault experienced by a state's female population can be affected by many factors, including state law enforcement, availability of special educational programs for young adolescents, availability of counseling services for offenders, and other factors that may not be under the direct control of the state's health agency. The rate of sexual assaults of males, particularly those in prison, is omitted by this measure. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agency are having the desired impact. Data Resources:   Numerator: Sexual assault victims service providers; FBI; state police; criminal justice data systems. Denominator: Official state population estimate. Limitations of Data: The reported rate of sexual assault is widely regarded as understating the actual incidence of sexual assault; however, this may not be a problem if the ratio of reported to unreported assault remains relatively stable.

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Measure Type: Disability health status outcome Measure: Percentage of newborns with neural tube defects. Numerator: Infants birth with neural tube defects. Denominator: Total births. Rationale for Measure: Neural tube defects are dramatically reduced by appropriate folic acid intake prior to conception. (This measure corresponds to Healthy People 2000 Objective 14.17.) Limitations of Measure: Neural tube defects may be affected by other factors that are not under the direct control of the state health agencies. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources:   Numerator: Birth records or adverse pregnancy outcome registries. Denominator: Birth records. Limitations of Data: Neural tube defects may not always be recorded by medical or hospital staff.

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Measure Type: Disability social functioning Measure: Percentage of persons aged 18–65 with disabilities who are in the workforce. Numerator: Number of people aged 18–65 with disabilities who are in the workforce. Denominator: Number of people aged 18–65 with disabilities. Rationale for Measure: One measurement of functionality for an individual with a disability is employment. Limitations of Measure: There may be individuals with certain disabilities for whom working is not possible. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources: Current Population Survey (CPS); National Health Interview Survey (NHIS). Limitations of Data: The CPS only provides state-level estimates for approximately ten states.

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Measure Type: Disability risk status Measure: Percentage of children aged 6 or younger with blood lead greater than 10 micrograms per deciliter.* Numerator: Number of children less than 6 years of age with blood lead levels greater than 10 micrograms per deciliter. Denominator: Number of children less than six years of age in state. Rationale for Measure: Lead intoxication has been demonstrated to result in decreased intelligence and social functionality. (This measure corresponds to Healthy People 2000 Objective 11.4.) Limitations of Measure: Lead intoxication in young children living in a state can be affected by many factors, such as the average age of the housing stock, that may not be under the direct control of the health agencies. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources:   Numerator: Reports of children with lead greater than 10 micrograms per deciliter to state health agencies. (In most states physicians and clinical labs are required to report these results.) Denominator: Official state population estimate. Limitations of Data: Physicians and clinical labs may not always report each incident of high blood lead levels; not all at-risk children may be tested. * The numerical value in this measure is the level that is generally regarded as appropriate by the medical community; it does not represent a level that has been independently determined or endorsed by the panel.

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Measure Type: Disability risk status Measure: Percentage of women who gave birth during the past year and reported using alcohol, tobacco, or other drugs during pregnancy. Numerator: Number of women who gave birth during the past year and reported using alcohol, tobacco, or other drugs during pregnancy. Denominator: All women giving birth in the state. Rationale for Measure: Alcohol, tobacco, and other drug use during pregnancy is a leading cause of birth defects that can result in disability of newborns and in later stages of life. (This measure corresponds to Healthy People 2000 Objective 14.10.) Limitations of Measure: Alcohol, tobacco, and other drug use by a state's pregnant female population can be affected by many factors, including exposure to advertising, availability of vending machines, and other factors that may not be under the direct control of the health agencies. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by the state health agencies are having the desired impact. Data Resources: Birth records; Behavioral Risk Factor Surveillance System (BRFSS); adverse pregnancy outcome registry; maternal and child health case management records. Limitations of Data: It is widely understood that birth record data may understate the actual use of alcohol, tobacco, and other drugs by pregnant women. Nevertheless, this should not be a problem in examining trends over time or making intrastate comparisons if the reporting bias is consistent from one time period to another across jurisdictions. The methodology used to collect BRFSS data may vary significantly across states, making interstate comparisons problematic. Sample sizes may not be sufficiently large to accurately identify rates of substance abuse among the subpopulation of pregnant women.

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Measure Type: Emergency medical services health status outcome Measure: Percentage of persons who suffer out-of-hospital cardiac arrest who survive. Numerator: Number of people discharged from hospitals following out-of-hospital cardiac arrest. Denominator: All cases of out-of-hospital cardiac arrest. Rationale for Measures: Cardiac arrests are a leading cause of death. Promptly provided emergency medical services can increase the likelihood of survival. Limitations of Measure: The rate of cardiac arrest survival of a state's population can be affected by many factors, including the average age of its population, the percentage of its elderly population living in rural areas, and the quality of care provided by its hospitals' emergency medical rooms. None of these factors is within the control of a local or regional emergency medical services system. Use of Measure: This outcome measure should be used in conjunction with relevant process and capacity measures in order to gain a sense of whether the actions taken by EMS providers are having the desired impact. Data Resources: State EMS data systems. Limitations of Data: EMS data systems may vary significantly across states, making interstate comparisons problematic.