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LETTER |
Judith M. Graber is with the Environmental Health Unit, Maine Bureau of Health, Augusta, Maine. Brenda E. Corkum, Nancy Sonnenfeld, and Paul L. Kuehnert are with the Maine Department of Health and Human Services, Maine Bureau of Health, Augusta. Nancy Sonnenfeld is also with the University of Southern Maine, Portland.
Correspondence: Requests for reprints should be sent to Judith Graber, MS, Environmental Health Unit, Maine Bureau of Health, 286 Water St, SHS 11, Augusta ME 04333 (e-mail: judith.graber{at}maine.gov).
My colleagues and I thank Rosenberg for his comments and interpretation regarding our work on the deterioration of American Indian mortality statistics in Maine. Rosenberg cites improvements made by the National Center for Health Statistics (NCHS) in processing procedures for race-specific data. Undoubtedly these new procedures have improved the overall quality of race coding. However, these procedures involve the systematic review and editing of electronic records, which have already undergone data entry. These procedures would not address the problem associated with data entry that we documented.
The gold standard for detecting and resolving data entry errors is double data entry. Historically, in Maine, all vital records data were double entered, the 2 files were compared, and any discrepancies were resolved. In the early 1990s, Maine death certificate data processing was restructured because of reductions in the Maine State General Fund; double data entry was discontinued. It is therefore not surprising that we found no data entry errors before 1988.
NCHS randomly selects a 10% sample of Maine’s records; these are reentered and compared with the original electronic files. In states with small non-White populations, this procedure may not identify systematic race-specific coding errors. One approach for validating the American Indian race is to select all deaths among residents of towns in or adjacent to American Indian reservations. However, this approach would capture information only about American Indians residing on reservations.
While using rosters of American Indian populations has been successful (Indian Health Service rosters,1–3 lists of tribal decedents4), these methodologies are not routine tools of public health surveillance, and they require collaborative relationships and significant resource commitments. For state-based public health leadership to consider collaborative approaches to including American Indian governmental entities in the management of their own vital records is likely the most comprehensive and productive approach.
Rosenberg correctly states that we did not discuss undercounting of race in denominators of death rates, which can also bias mortality estimates. He and his colleagues at NCHS reported that when the combined effect of these biases in American Indian populations is estimated, the numerator effects outweigh the denominator effects and death rates are underestimated. Consistent with our findings, NCHS adjustments for both numerator and denominator errors, demonstrating the combined effect of these biases in American Indian populations, underestimate death rates by 21%.5 The direction and magnitude of the effect of our findings were consistent with previously published reports concerned specifically with validity of the numerator.1–4 We agree with Rosenberg that any analysis of racial miscoding should take into consideration corrections to both the numerator and denominator.
Rosenthal is also correct in noting that we mistakenly used the term "immediate cause" rather than "underlying cause."
References
1. Frost F, Tollestrup K, Ross A, Sabotta E, Kimball E. Correctness of racial coding of American Indians and Alaskan Natives on the Washington State death certificate. Am J Prev Med. 1994;10:290–294.[ISI][Medline]
2. Harwell TS, Hansen D, Moore KR, Jeanotte, D, Gohdes D, Helgerson SD. Accuracy of race coding on American Indian death certificates, Montana 1996–1998. Public Health Rep. 2002;117:44–49.[CrossRef][ISI][Medline]
3. Thoroughman DA, Frederickson D, Cameron HD, Shelby LK, Cheek JE. Racial misclassification of American Indians in Oklahoma State surveillance data for sexually transmitted diseases. Am J Epidemiol. 2002; 155:1137–1141.
4. Graber JM, Corkum BE, Sonnenfeld N, Kuehnert PL. Underestimation of cardiovascular disease mortality among Maine American Indians: the role of procedural and data errors. Am J Public Health. 2005;95: 827–830.
5. Rosenberg HM, Maurer JD, Sorlie PD, et al. Quality of death rates by race and Hispanic origin: a summary of current research, 1999. Vital Health Stat 2. 1999;No. 128:1–13.
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