Preface

Chartbook

The 2016 Chartbook contains 27 figures on long-term trends in health. As Health, United States enters its 40th year of reporting on the health of the nation, this year’s Chartbook focuses on trends in health and health care since 1975. Examining long-term trends in health informs the development and implementation of effective health policies and programs. The Chartbook has been grouped into five sections. The first section (Figures 1–5) presents an overview of the demographic and socioeconomic factors that have influenced the health of the nation over the last 40 years. The second section (Figures 6–14) focuses on health status and determinants: life expectancy, infant mortality, leading causes of death, birth rates, cigarette smoking, obesity, untreated dental caries, diabetes prevalence, and uncontrolled hypertension. The third section (Figures 15–19) presents trends in health care utilization: use of prescription drugs, health care and emergency department visits, overnight hospital stays, and cancer screening tests. The fourth section (Figures 20–22) focuses on changes in health care resources: hospitals, primary and specialist physicians, and nursing homes. The fifth section (Figures 23–27) describes trends in health care expenditures: personal health care expenditures, mental health and substance use expenditures, Medicare managed care enrollment by state, and health insurance coverage.

Trend Tables

The Chartbook is followed by 114 detailed Trend Tables that highlight major trends in health statistics. Comparability across editions of Health, United States is fostered by including similar Trend Tables in each volume, and timeliness is maintained by improving the content of tables to reflect key topics in public health. An important criterion used in selecting these tables is the availability of comparable national data over a period of several years.

Appendixes

Appendix I. Data Sources describes each data source used in Health, United States, 2016 and provides references for further information about the sources. Data sources are listed alphabetically within two broad categories: Government Sources, and Private and Global Sources.

Appendix II. Definitions and Methods is an alphabetical listing of selected terms used in Health, United States, 2016. It also contains information on the statistical methodologies used in the report.

Index

The Index to the Trend Tables and Chartbook figures is a useful tool for locating data by topic. Tables and figures are cross-referenced by such topics as child and adolescent health; older population aged 65 and over; women’s health; men’s health; state data; American Indian or Alaska Native, Asian, black or African American, Hispanic-origin, and white populations; education; injury; disability; and metropolitan and nonmetropolitan data. Many of the Index topics are also available as conveniently grouped data packages on the Health, United States website at: http://www.cdc.gov/nchs/hus.htm.

Racial and Ethnic Data

Many tables in Health, United States present data according to race and Hispanic origin, consistent with a department-wide emphasis on ensuring that health data on racial and ethnic minority populations are presented whenever possible. Trend data on race and ethnicity are presented in the greatest detail possible after taking into account the quality of the data, the amount of missing data, and the number of observations. These issues significantly affect the availability of reportable data for certain populations, such as the Native Hawaiian or Other Pacific Islander populations and the American Indian or Alaska Native populations. Standards for the classification of federal data on race and ethnicity are described in an appendix. (See Appendix II, Race.)

Education and Income Data

Many Trend Tables in Health, United States present data according to socioeconomic status, using education and family income as proxy measures. Education and income data are generally obtained directly from survey respondents and are not usually available from records-based data collection systems. (See Appendix II, Education; Family income; Poverty.)

Disability Data

Disability can include the presence of physical or mental impairments that limit a person’s ability to perform an important activity and affect the use of or need for support, accommodation, or intervention to improve functioning. Information on disability in the U.S. population is critical to health planning and policy. Disability may be measured based on a specific disability or a composite measure designed to identify persons with any of a variety of disabilities. Health, United States includes data from the National Health Interview Survey to examine specific types of disability and to create composite disability measures consistent with two of the conceptual components that have been identified in disability models and legislation: basic actions difficulty and complex activity limitation.

Basic actions difficulty captures limitations or difficulties in movement and sensory, emotional, or mental functioning that are associated with a health problem. Complex activity limitation describes limitations or restrictions in a person’s ability to participate fully in social role activities such as working or maintaining a household. Health, United States, 2016 includes the following disability-related information: basic actions difficulty and complex activity limitation (Table 42), vision and hearing limitations for adults (Tables 43 and 44), and disability-related information for Medicare enrollees (Table 108), Medicaid recipients (Table 109), and veterans with service-connected disabilities (Table 111). For more information on disability statistics, see Altman and Bernstein (1) and Brault (2).

Statistical Significance

All statements in the text describing differences, or lack thereof, in estimates indicate that statistical testing was performed. Differences between two point estimates were determined to be statistically significant at the 0.05 level using two-sided significance tests (z-tests) without correction for multiple comparisons. Data tables include point estimates and standard errors for users who would like to perform additional statistical tests. In the text, the standard terminology used when a difference between two point estimates was tested is, “Between (estimate 1) and (estimate 2).” For example, the statement “Between 2014 and 2015” indicates that the difference between the point estimate for 2014 and that for 2015 was tested for statistical significance.

The statistical significance of a time trend was assessed using weighted least squares regression applied to data for all years in the time period. (For a description of the trend testing technique, see the Technical Notes that follow the Chartbook.) The terminology used in the text to indicate testing of a trend is “During (time period 1)–(time period 2).” For example, the statement “During 2005–2015” indicates that a statistical test of trend was conducted that included estimates for all 11 years in the time period. Because statistically significant differences or trends are partly a function of sample size (i.e., the larger the sample, the smaller the change that can be detected), statistically significant differences or trends do not necessarily have public health significance (3).

Terms such as “similar,” “stable,” and “no difference” indicate that the statistics being compared were not significantly different. Lack of comment regarding the difference between statistics does not necessarily suggest that the difference was tested and found to not be significant.

Overall estimates generally have relatively small standard errors, but estimates for certain population subgroups may be based on small numbers and have relatively large standard errors. Although numbers of births and deaths from the Vital Statistics System represent complete counts (except for births in those states where data are based on a 50% sample for selected years) and are not subject to sampling error, the counts are subject to random variation, which means that the number of events that actually occur in a given year may be considered as one of a large series of possible results that could have arisen under the same circumstances. When the number of events is small and the probability of such an event is small, considerable caution must be observed in interpreting the conditions described by the estimates. Estimates that are unreliable because of large standard errors or small numbers of events are noted with an asterisk. The criteria used to designate or suppress unreliable estimates are indicated in the table footnotes.

For NCHS surveys, point estimates and their corresponding variances were calculated using the SUDAAN software package (4), which takes into consideration the complex survey design. Standard errors for other surveys or data sets were computed using the methodology recommended by the programs providing the data, or were provided directly by those programs. Standard errors are available for selected tables in the spreadsheet version on the Health, United States website at: http://www.cdc.gov/nchs/hus.htm.