1 / 47

Evaluation of Maternal Smoking Surveillance Systems in Massachusetts

Evaluation of Maternal Smoking Surveillance Systems in Massachusetts. Lizzie Harvey, MPH CDC/CSTE Applied Epidemiology Fellow Massachusetts Department of Public Health June 14, 2011. Disclosure.

ocean
Download Presentation

Evaluation of Maternal Smoking Surveillance Systems in Massachusetts

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Evaluation of Maternal Smoking Surveillance Systems in Massachusetts Lizzie Harvey, MPH CDC/CSTE Applied Epidemiology Fellow Massachusetts Department of Public Health June 14, 2011

  2. Disclosure • No significant financial interest or other relationships with the manufacturer(s) ofany commercial product(s) or provider(s) of any commercial services discussed in this presentation and with any commercial supports of the activity • Massachusetts Department of Public Health RaDAR and PRAMS clearance

  3. Objective • To evaluate maternal smoking surveillance through the Massachusetts Pregnancy Risk Assessment Monitoring System (PRAMS)

  4. Importance of Maternal Smoking Surveillance • Maternal smoking during pregnancy is associated with babies who are: • 1.4-3.0 times more likely to die of Sudden Infant Death Syndrome (SIDS) • at 30% higher odds of premature delivery • 2.3 times more likely to deliver term low birth weight infants

  5. Maternal Smoking Relevance in US and Massachusetts • Healthy People 2020 Objective • Increase smoking cessation during pregnancy • CDC Winnable battle • National Performance Measure • Smoking in the last trimester • MA Priorities • Improve the health and well being of women in their childbearing years • Support reproductive and sexual health by improving access to education and services • Opportunity for Intervention in MA • Tobacco Cessation and Prevention Program

  6. Existing Surveillance System:Massachusetts Birth Certificate (BC)

  7. MA Birth Certificate • Maternal smoking questions since 1986 • Since 1996, two questions:

  8. Maternal Smoking in Massachusetts: Birth Certificate Data MA PRAMS initiation

  9. Massachusetts Pregnancy and Risk Assessment Monitoring System (MA PRAMS) as a Surveillance System

  10. PRAMS Background Population-based data on maternal attitudes and behaviors, before, during, and shortly after pregnancy

  11. MA PRAMS Background • Initiated in 2007 • 80 questions (54 Core, 16 Standard, 10 MA developed) • 2-6 months post-partum • Administered in English and Spanish only

  12. MA PRAMS Screener 3 months before pregnancy Last 3 months of pregnancy Current use

  13. BC Maternal Smoking Data Comparison Pregnancy Post-partum Pre-Pregnancy Conception 12 mo. 3 mo. Delivery 3.8 mo. PRAMS

  14. Methods • Data Sources: • 2007-2008 MA PRAMS (N=2,997) • Linked to 2007-2008 MA BC data (N=2,997) • Analysis: • Frequencies, prevalence estimates, sensitivity, positive predictive value, kappa coefficients, chi square • SAS 9.2 and SUDAAN 10.0 • Reference: • CDC: Updated Guidelines for Evaluating Public Health Surveillance Systems (2001)

  15. CDC: System Attributes • Simplicity • Flexibility • Data Quality • Acceptability • Sensitivity • Positive Value Predictive • Representativeness • Timeliness • Stability

  16. MA BC Entire population (~75,000 births/year) DPH Parent Worksheet with 2 smoking questions 49 licensed birth hospitals in MA MA PRAMS Population-based mixed-methodology survey (~1,500/year) 4 questions on 80 question survey Mail survey to stratified sample of birth population Simplicity

  17. MA BC Iterations of maternal smoking surveillance 1986 1996 2011 2011 implementation of electronic 2003 standard birth certificate MA PRAMS Maternal smoking questions Core Compare to other states Opportunity to select standard and state-specific questions Other measures related to smoking knowledge and behaviors Flexibility

  18. Data Quality N=156,734 N=2,997 N=2,997

  19. MA BC Mandatory participation General Law (Ch. 111, s.24B) Stigma on maternal smoking MA PRAMS Not required by law Can refuse survey and refuse individual questions Infant outcome at 4 months post-partum may determine how mother will respond Acceptability

  20. Sensitivity Analysis Smoking DURING Pregnancy MA BC S NS MA PRAMS S NS 192 2734 133 2793 2926 Sensitivity: 113/ (113 + 20) = 0.850 MA PRAMS captured 85% of all maternal smoking during pregnancy identified by the BC

  21. Predictive Value Positive (PVP) Smoking DURING Pregnancy MA BC S NS MA PRAMS S NS 192 2734 133 2793 2926 PVP: 113/ (113 + 79) = 0.589 58.9% of all maternal smoking during pregnancy identified by MA PRAMS were cases identified by the birth certificate

  22. But wait…the BC is not a gold standard! True maternal smoking rate unknown Kappa Coefficients measure agreement between categorical items taking chance into account

  23. Kappa Coefficient Analysis Maternal Smoking DURING Pregnancy N=2,997 20 113 79 BC PRAMS Κ = 0.68 (95% CI = 0.62 – 0.74) Good Agreement

  24. Kappa Coefficient Analysis MA PRAMS Non Quitter # cigs # cigs NS Smoker dec. sa/inc. resumed MA BC Κ = 0.53 95% CI: 0.49 – 0.57 Moderate Agreement Non smoker Quitter # cigs dec. # cigs sa/inc. NS resumed --: 1-4 values suppressed

  25. Representativeness

  26. Representativeness: Maternal Smoking by Data Source ↑34% ↑42%

  27. Representativeness: Differences in Reporting Maternal Smoking DURING Pregnancy 20 113 79 BC PRAMS Who is reporting on PRAMS but not on BC?

  28. Demographic Characteristics of those who report maternal smoking during pregnancy on PRAMS (N=192)

  29. MA BC Population data Stigma of maternal smoking Self-report Recall bias MA PRAMS Stratified sampling by race/ethnicity 30% non response English and Spanish only Stigma of maternal smoking potentially decreased Self-report Recall bias Representativeness

  30. MA BC MA PRAMS Timeliness PRAMS Survey completed DPH Parent Worksheet completed Limiting Step 49 Registrars Data Entry Data Entry Limiting Step Registry of Vital Records and Statistics Birth File Closed Data weighted by CDC MDPH Birth Report Public Health Action! PRAMS Report Public Health Action!

  31. MA BC Required by law 2003 Revised Birth Certificate Implementation 2011 Investment in Vital Information Partnership System (VIP) 2011 MassCHIP MA PRAMS 5 year funding approved 2011-2016 Decreased funding than previous cycle PRAMS website PONDER (MA specific) and CPONDER Stability

  32. Simplicity: 4 questions Flexibility: Ability to add state specific questions Data Quality: Low % missing; survey data Acceptability: Overall stigma potentially decreased Sensitivity: Increased case Positive Predictive Value: ascertainment Representativeness: Higher ascertainment of maternal smoking; Additional measure of post-partum smoking Timeliness: No real time data; 2 year lag Stability: 5 year competitive funding from CDC (2011-16) Conclusions: MA PRAMS System Attributes Kappa statistic

  33. Recommendations • Use PRAMS as a valuable data source in addition to BC to understand burden of maternal smoking • Use PRAMS to fill the data gap regarding maternal smoking in post-partum period • Use other PRAMS data to inform actionable interventions in maternal smoking Prenatal patient education Postpartum smoking environment

  34. Next Steps • Add 2009 MA PRAMS data to analysis • Assess impact of new BC data on maternal smoking • Continue work with the Tobacco Cessation and Prevention Program • Identify women who are not reporting on the birth certificate but reporting in PRAMS • Reach out to prenatal providers for universal screening of maternal smoking behaviors and referrals to cessation programs

  35. Acknowledgements Hafsatou Diop, MDPH Office of Data Translation Karin Downs, MDPH Bureau of Family Health and Nutrition Thomas Land, MDPH Tobacco Cessation and Prevention Program Emily Lu, MDPH PRAMS Coordinator Alice Mroszczyk, MDPH Privacy and Data Access Office Maria Vu, MDPH Registry of Vital Records and Statistics CDC/CSTE Applied Epidemiology Fellowship Program

  36. References/Resources CDC Tobacco Use and Pregnancy: http://www.cdc.gov/reproductivehealth/TobaccoUsePregnancy/index.htm (Accessed 6/2011) CDC Winnable Battle: Tobacco: http://www.cdc.gov/WinnableBattles/Tobacco/index.html (Accessed 6/2011) CDC PRAMS: http://www.cdc.gov/prams/ (Accessed 6/2011) CPONDER: http://www.cdc.gov/prams/CPONDER.htm (Accessed 6/2011) MA PRAMS: http://www.mass.gov/dph/prams (Accessed 6/2011) MassCHIP: http://www.mass.gov/dph/masschip (Accessed 6/2011) MA General Laws regarding birth information collection: http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXVI/Chapter111/Section24B (Accessed (6/2011) 2003 Revised Birth Certificate: http://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf (Accessed 6/2011) CDC Updated Guidelines for Evaluating Public Health Surveillance Systems: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm (Accessed 6/2011) Kappa Statistics: Cohen, J. (1968). Weighted kappa: Nominal scale agreement provision for scaled disagreement or partial credit. Psychological Bulletin, 70(4), 213. Dietz, PM, et al. Infant Morbidity and Mortality Attributable to Prenatal Smoking in the U.S. Am J Prev Med 2010;39(1) 45-52.

  37. Questions? Contact Information: Lizzie Harvey, MPH CDC/CSTE Applied Epidemiology Fellow Massachusetts Department of Public Health Lizzie.Harvey@state.ma.us (617) 624-5559

  38. Extra Slides

  39. Resources in MA • Massachusetts Smokers’ Helpline • QuitWorks

  40. Additional PRAMS Questions on Maternal Smoking New 2009 Core: Which of the following statements best describes the rules about smoking inside your home now? Check one answer No one is allowed to smoke anywhere inside my home Smoking is allowed in some rooms or at some times Smoking is permitted anywhere inside my home

  41. 2003 Standard BC

  42. BC Impact of 2003 BC Pregnancy Post-partum Pre-Pregnancy Conception 12 mo. 3 mo. Delivery 3.8 mo. PRAMS

  43. Demographic Characteristics of those who report maternal smoking before pregnancy on PRAMS (N=372)

  44. Sensitivity Analysis Smoking BEFORE Pregnancy Smoking DURING Pregnancy MA BC S NS MA BC S NS MA PRAMS S NS MA PRAMS S NS 372 192 2539 2734 133 254 2657 2911 2793 2926 Sensitivity: 214 / (214 + 40) = 0.842 Sensitivity: 113/ (113 + 20) = 0.850 MA PRAMS captured 84.2% of all maternal smoking prior to pregnancy and 85% of all maternal smoking during pregnancy identified by the BC

  45. Predictive Value Positive Smoking BEFORE Pregnancy Smoking DURING Pregnancy MA BC S NS MA BC S NS MA PRAMS S NS MA PRAMS S NS 372 192 2539 2734 133 254 2657 2911 2793 2926 PVP: 214 / (214 + 158) = 0.575 PVP: 113/ (113 + 79) = 0.589 57.5% of all maternal smoking prior to pregnancy and 58.9% of all maternal smoking during pregnancy identified by MA PRAMS were cases identified by the birth certificate

  46. Kappa Coefficient Analysis Maternal Smoking DURING Pregnancy N=2,997 Maternal Smoking PRIOR to Pregnancy N=2,997 20 113 79 40 214 158 BC BC PRAMS PRAMS Κ = 0.64 (95% CI = 0.60 – 0.69) Good Agreement Κ = 0.68 (95% CI = 0.62 – 0.74) Good Agreement

  47. Representativeness: Differences in Reporting Maternal Smoking DURING Pregnancy Maternal Smoking PRIOR to Pregnancy 20 113 79 40 214 158 BC BC PRAMS PRAMS Who is reporting on PRAMS but not on BC?

More Related