Mapping Rates and Proportions

Mapping Rates and Proportions

Incidence rates Prevalence

Mortality rates Proportions
Birth rates Percentages
 Sample Data:
Breast Cancer Incidence in Iowa
Years: 1993-1996
7813 Cases (including in-situ)
For each case: Age, county
Source: State Health Registry of Iowa
 Geography and Population
99 counties
Number of women: 1,061,096 (ages 20+)
Population available for each county by age
group.
Age groups: 20-24, 25-29, , 80-84, 85+
Source: 1990 census
The 99 Iowa Counties

IO W A
 Poisson Data

Numerator: Number of events over time,

such as incidence or mortality cancer cases.

Denominator: Population years at risk.

Rates and Relative Risks
c = # cancer cases in e.g. a county
n = county population
C = # cancer cases in e.g. a state
N = state population

Rate = c/n
c /n
Relative Risk =
C / N
Breast Cancer Incidence, Relative Risks

N o t a d ju s te d
< 0 .7 5
0 .7 5 -0 .8 5
0 .8 5 -0 .9 5
0 .9 5 -1 .0 5
1 .0 5 -1 .1 5
> 1 .2 5
 Bernoulli Data (0/1 data)
Individual people with one of two traits,
such as cancer vs. no cancer, late vs. early
disease or two different treatments.

Numerator: The trait of interest.

Denominator: All individuals.

The denominator may be a complete count

or a random sample.
Proportions and Relative Risks
c = # late stage cancer cases in a county
n = total number of cases
C = # late stage cancer cases in state
N = total cases in state

Crude Rate = c/n

c /n
Crude Relative Risk =
C / N
The statistical methods used are slightly
different for Poisson and Bernoulli data,
but in terms of mapping, the principles
are the same.
 Age Adjustment
Indirect vs. Direct Standardization
Internal vs. External Standard
Relative Risk vs. Rate
 Age Adjustment
Notation
Area to be mapped (e.g. Johnson county, Iowa)
cs = cancer cases in age group s
ns = population in age group s

Area used as the standard (e.g. State of Iowa)

Cs = cancer cases in age group s
Ns = population in age group s
Indirect Standardization
(relative risk)

cs

o b s e rv e d in c o u n ty
C e x p e c te d in c o u n ty
ns
N
s

s
 Direct Standardization
(relative risk)

cs c a s e s in s ta te if it h a d th e s a m e
N s
ns a g e - s p e c ific ra te s a s th e c o u n ty

C s
o b s e rv e d in s ta te
 Direct Standardization
(rate)

cs
N s
ns
The crude state rate, if the
whole state had the same

N s
age-specific rates as the
county.
 Indirect Direct
Standardization Standardization

Relative cs N s
cs
ns
Risk C
ns
N
s
C s
s

Rate
C s cs
C N s
cs
ns
N s
cs
ns
N s
ns
C s
N
s

C

N
N s
s s s
 Indirect vs. Direct Standardization
Population Cases
county state state
Children, 0-19 1 200,000 400
Young Adults, 20-69 19 600,000 2200
Old Adults, 70+ 80 200,000 2400
Expected cases in county: 1.03
 Indirect vs. Direct Standardization
Population Cases
county state state
Children, 0-19 1 200,000 400
Young Adults, 20-69 19 600,000 2200
Old Adults, 70+ 80 200,000 2400
Expected cases in county: 1.03

County Cases

Children, 0-19 0 0 1
Young Adults, 20-69 0 1 0
Old Adults, 70+ 1 0 0
Direct Standardization 0.5 6.3 40.0
Indirect Standardization 1.0 1.0 1.0
 Indirect vs. Direct Standardization
Population Cases
county state state
Children, 0-19 1 200,000 400
Young Adults, 20-69 19 600,000 2200
Old Adults, 70+ 80 200,000 2400
Expected cases in county: 1.03

County Cases

Children, 0-19 0 0 1 0 0 1
Young Adults, 20-69 0 1 0 0 1 0
Old Adults, 70+ 1 0 0 2 1 1
Direct Standardization 0.5 6.3 40.0 1.0 6.8 40.5
Indirect Standardization 1.0 1.0 1.0 1.9 1.9 1.9
 Indirect vs. Direct Standardization
Population Cases
county state state
Children, 0-19 1 200,000 400
Young Adults, 20-69 19 600,000 2200
Old Adults, 70+ 80 200,000 2400
Expected cases in county: 1.03

County Cases

Children, 0-19 0 0 1 0 0 1 0 0 1
Young Adults, 20-69 0 1 0 0 1 0 1 2 1
Old Adults, 70+ 1 0 0 2 1 1 2 1 1
Direct Standardization 0.5 6.3 40.0 1.0 6.8 40.5 7.3 13.1 46.8
Indirect Standardization 1.0 1.0 1.0 1.9 1.9 1.9 2.9 2.9 2.9
 Indirect vs. Direct Standardization
Population Cases
county state state
Children, 0-19 20 200,000 400
Young Adults, 20-69 60 600,000 2200
Old Adults, 70+ 20 200,000 2400
Expected cases in county: 0.5

County Cases

Children, 0-19 0 0 1 0 0 1 0 0 1
Young Adults, 20-69 0 1 0 0 1 0 1 2 1
Old Adults, 70+ 1 0 0 2 1 1 2 1 1
Direct Standardization 2.0 2.0 2.0 4.0 4.0 4.0 6.0 6.0 6.0
Indirect Standardization 2.0 2.0 2.0 4.0 4.0 4.0 6.0 6.0 6.0
 Indirect vs. Direct Standardization
Population Cases
county state state
Children, 0-19 1 200,000 2000
Young Adults, 20-69 19 600,000 6000
Old Adults, 70+ 80 200,000 2000
Expected cases in county: 1.0

County Cases

Children, 0-19 0 0 1 0 0 1 0 0 1
Young Adults, 20-69 0 1 0 0 1 0 1 2 1
Old Adults, 70+ 1 0 0 2 1 1 2 1 1
Direct Standardization 0.25 3.2 20.0 0.5 3.4 20.2 0.7 6.6 23.4
Indirect Standardization 1.0 1.0 1.0 2.0 2.0 2.0 3.0 3.0 3.0
 Indirect Standardization
With indirect standardization, estimates of rates
and relative risks have lower variance. This is
especially important for small areas such as
counties or census tracts.

Method of choice for maps with estimates of

multiple areas, showing geographical
variation.
Use internal standard.
Breast Cancer Incidence, Relative Risks
Age-Adjusted, Indirect Standardization

A g e a d ju s te d
< 0 .7 5
0 .7 5 -0 .8 5
0 .8 5 -0 .9 5
0 .9 5 -1 .0 5
1 .0 5 -1 .1 5
> 1 .2 5
Breast Cancer Incidence, Relative Risks
Not Age-Adjusted

N o t a d ju s te d
< 0 .7 5
0 .7 5 -0 .8 5
0 .8 5 -0 .9 5
0 .9 5 -1 .0 5
1 .0 5 -1 .1 5
> 1 .2 5
 Indirect Standardization
(relative risk)

cs
No need to know
age-specific case
C
ns
N
s counts in the county,
only the total.
s
 Direct Standardization
(rate)

cs
N s
ns
No need to know case
counts for the reference
N s area.
 Direct Standardization
Very useful to compare rates for areas studied
at different times, by different people, using
different data sets.

Use external standards:

1970 United States Population Standard
2000 United States Population Standard
European Standard
World Standard
 U.S 1970 and World Standards
U.S. 1970 World U.S. 1970 World
0-4 8,442 12,000 45-49 5,962 5,000
5-9 9,820 10,000 50-54 5,464 5,000
10-14 10,230 9,000 55-59 4,908 4,000
15-19 9,384 9,000 60-64 4,240 4,000
20-24 8,056 8,000 65-69 3,441 3,000
25-29 6,632 8,000 70-74 2,679 2,000
30-34 5,625 6,000 75-79 1,887 1,000
35-39 5,466 6,000 80-84 1,124 500
40-44 5,896 6,000 85+ 743 500
World Standard From:
Waterhouse et al., Cancer Incidence in Five Continents, 1976
Iowa Breast Cancer Incidence Rates
1993-1996
Crude Rate: 136.4 / 100,000 women

Age-Adjusted, Direct Standardization

U.S. 1970 Standard Population: 106.4 / 100,000

U.S. 2000 Standard Population: 129.3 / 100,000
World Standard Population: 91.0 / 100,000
 Conclusions
Use indirect standardization, with an
internal standard, for mapping geographical
variation.
Use direct standardization, with a few
different standards, to calculate the rate for
the map as a whole.
 Uncertainty of Rate Estimates
In a regular map, a relative risk of 2 could mean
that there are 2000 cases with 1000 expected in an
urban county, or 2 cases with 1 expected in a rural
county.

For the urban county, the relative risk of 2 is a

good estimate of the true relative risk, but not for
the rural county.
 Probability Map
For a particular county, one can test whether the
observed cases are significantly more than
expected, providing a p-value for that county.

A map of these p-values is called a probability

map.
Reference: Chownowski M. Maps Based on Probabilities.
Journal of the American Statistical Association, 54:385-388,
1959.
 Probability Map
(Poisson Data)

m = expected number of cases

c = observed number of cases

m i

c 1 m
P (# cases c|H 0) 1 e
i0 i!
Probability Map

IO W A

p<0.05 0.05<p<0.10
 County p-values
County Obs Exp RR p=
Dubuque 275 235 1.17 0.004
Polk 892 817 1.09 0.004
Clayton 77 57 1.34 0.006
Mills 51 36 1.43 0.006
Scott 411368 1.12 0.012
Linn 467 429 1.09 0.033
Marion 97 82 1.18 0.048
Regular vs. Probability Map p<0.05 0.05<p<0.10

A g e a d ju s te d
< 0 .7 5
0 .7 5 -0 .8 5
0 .8 5 -0 .9 5
0 .9 5 -1 .0 5
1 .0 5 -1 .1 5
> 1 .2 5
 Warning
By chance, 5% of the counties will by chance
have a statistically significant
p-value at the 0.05 level.

Need to adjust for multiple testing.

Pickle et al: United States Mortality Atlas
Pickle et al: United States Mortality
 Dilemma
- Too little aggregation: Unstable rates.
- Too much aggregation: Geographical
variation in disease may not follow
political boundaries.

Solution: Smoothed Maps