STANDARDISASI

UKURAN MORTALITAS

Suatu indeks atau angka

yang digunakan sebagai dasar untuk
menentukan tinggi rendahnya
suatu tingkat suatu kematian penduduk
 MORTALITAS
• Mortality is clearly an index of the severity of a disease from
both clinical and public health standpoints, but mortality can
also be used as an index of the risk of disease.

• In general, mortality data are easier to obtain than incidence

data for a given disease, and it therefore may be more feasible
to use mortality data as a proxy indicator for incidence.

• However, when a disease is mild and not fatal, mortality may

not be a good index of incidence.
 MORTALITAS
A mortality rate is a good reflection of the incidence rate under two
conditions:
1. first, when the case-fatality rate is high (as in untreated rabies),
2. second, when the duration of disease (survival) is short.

Under these conditions, mortality is a good measure of incidence, and

thus a measure of the risk of disease.
For example, cancer of the pancreas is a highly lethal disease: death
generally occurs within a few months of diagnosis, and long-term
survival is rare. Thus, unfortunately, mortality from pancreatic cancer is a
good surrogate for incidence of the disease.
 Jenis Jenis Ukuran Mortalitas
•CDR (Crude Death Rate ) /Angka
Kematian Kasar

•ASDR (Age Specific Death Rate ) /Angka

Kematian berhubungan dengan umur .
Adalah banyaknya kematian pada
suatu tahun tertentu dibagi dengan
jml penddk pada pertghan tahun
tsb, biasanya dinyatakan untuk
1000 org.
CDR disebut kasar karena tidak
memperhitungkan tentang usia,
jenis kelamin, atau variabel lain.
 Jml kematian menurut kelompok usia tertentu
ASDR xk
Jml penduduk kelompok usia tertentu
 CDR

The data may seem surprising because we would expect rates to

have been higher for blacks, given the problems associated with
poorer living conditions and less access to medical care.
 CDR - ASDR

In each age-specific group, mortality is higher in blacks than in whites,

the overall mortality (also called crude or unadjusted mortality) is higher
in whites than in blacks. Why is this so?
 CDR - ASDR
This is a reflection of the fact that in both whites and blacks, mortality increases
markedly in the oldest age groups; older age is the major contributor to mortality.

However, the white population in this example is older than the black population, and
in 2015, there were few blacks in the oldest age groups.

 Thus, in whites, the overall mortality is heavily weighted by high rates in the oldest
age groups.

The overall (or crude) mortality rate in whites is increased by the greater number of
deaths in the large subgroup of older whites, but the overall mortality rate in blacks is
not increased as much because there are so many fewer deaths in the small number
of blacks in the older age groups.

 Clearly, the crude mortality reflects both differences in the force of mortality and
differences in the age composition of the population
 CDR (angka kematian kasar)
populasi A dan B

Komunitas Populasi Jumlah Tingkat Kematian

kematian (death rates)
Per 100.000
A 100.000 109 109 per 100.000

B 100.000 991 991 per 100.000

35
 Numerical Illustration
Table 7.2 (p. 144)

In this illustration, the crude rate is much higher in

Population B (109 vs. 991). Rates are per 100,000.

Population A Population B

Age Deaths Pop’n Rate Deaths Pop’n Rate

Young 99 99,000 100 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

Overall 109 100,000 109 991 100,000 991

(c) B. Gerstman 2007 Chapter 7: Age Adjustment 36

 Illustrative Example (Table 7.2, cont.)

Population A Population B
Age Cases Persons Rate Cases Persons Rate

Young 99 99,000 100* 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

Within young, rates are identical

37
* Rates are per 100,000. Example of calculation: R = 99 ÷ 99,000 × 100,000 = 100
 Illustrative Example (Table 7.2 cont.)

Population A Population B
Age Cases Persons Rate Cases Persons Rate

Young 99 99,000 100 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

Within old, rates are identical

38
 Numerical Illustration (cont.)
However, age-specific rates are identical

Population A Population B

Age Deaths Persons Rate Deaths Persons Rate

Young 99 99,000 100 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

(c) B. Gerstman 2007 Chapter 7: Age Adjustment 39

 Why the apparent paradox?

Population A Population B
Age Cases Persons Rate Cases Persons Rate

Young 99 99,000 100 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

Pop. A mostly young, Pop. B mostly old

40
 And rates are age-related

Population A Population B
Age Cases Persons Rate Cases Persons Rate

Young 99 99,000 100 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

You’re OK as long as you

41
compare like-to-like
 Confounding
• Problems occur when groups being compared differ with respect
extraneous factors that confound the comparison

• Confounding = a systematic error due to extraneous factors that lurk

in the background  errors in inference.

• Various techniques exist to adjust for confounding

• One such technique is rate adjustment (also called rate

standardization)
(c) B. Gerstman 2007 Chapter 7: Age Adjustment 42
 Properties of Confounding
Confounding occurs when:

• The exposure is associated [Age]

with the confounder Confounder

• The confounder is a risk

factor
Exposure Disease
• The confounder is not [Population [Mortality]
intermediary in the causal
pathway [variable in illustration]

(c) B. Gerstman 2007 Chapter 7: Age Adjustment 43

 Confounding
• Explanatory factor
associated with age

• Extraneous factor
confounder
associated with disease
Age
rate

• Extraneous factor
confounds relation
between explanatory factor Population Rate
explanatory disease
and disease rate factor

44
 Confounding
Ecologic study to determine whether country of
residence is associated with mortality.

Age

Country Mortality

Non-causal
Causal

Average age may be different among countries.

46
Perbadingan rate tadi tidak komparabel jika :

distribusi frekwensi faktor-faktor yang mempengaruhi kejadian

kematian tidak mirip/sama diantara populasi yang dibandingkan

Faktor2 yang dapat mempengaruhi kejadian kematian a.l :

• Umur
• Sex
• Ras
• Status social ekonomi
• Faktor risiko lain nya ( mis : status Kesehatan)
 Confounding
• Design
• Restriction
• Matching
• Individual matching
• Group matching
• Randomization
• Analysis
• Stratified analysis
• Adjustment
• Age-adjustment / Standardiazation
• Regression analysis
 STANDARDISASI
Menurut Webb et al (2005),

standardisasi merupakan suatu metode yang digunakan untuk menghasilkan

ukuran yang setara atau komparabel antara beberapa populasi atau sub- grup,
dengan memperhitungkan konfounding utama, seperti perbedaan umur dan sex
pada komposisi populasi atau sub grop yang berbeda

Menurut Rothman (2002)

Standardisasi adalah sebuah metode dengan menggabungkan angka rata-rata kategori

spesifik ke dalam nilai kesimpulan tunggal dengan mengambil rata-rata yang telah
ditakar
 Standardisasi
• Kapan Standardisasi?
– Membandingkan rate penyakit pada populasi yg mempunyai
distribusi karakteristik populasi yg berbeda dan karakteristik
tersebut berhubungan dengan penyakit

• 2 cara membandingkan:
– Menggunakan category-specific rate
– Menggunakan adjusted rate

50
Agar perbandingan rate diantara populasi dapat komparabel
maka crude rate harus distandarisisasi dengan faktor-
faktor konfounding tadi

Metode standarisasi :

• Direct standardization (standarisasi langsung)

• Indirect standardization (standarisasi tak langsung)

51
 Metode standarisasi langsung
cara kalkulasi
• menggunakan specific rate berdasarkan variabel yang akan dikontrol
(misal umur, sex dll) pada populasi studi

• specific rate tadi diaplikasikan pada populasi standard berdasarkan

variabel yang akan dikontrol (umur, sex dll)

standarisasi ini menggambarkan :

• apa yang akan terjadi dengan crude rate pada populasi studi jika distribusi
dari variabel yang dikontrol (misal umur, sex) sama dengan populasi
standard
52
METODA STANDARDISASI LANGSUNG
DATA YANG HARUS TERSEDIA :

• SPECIFIC RATE DARI VARIABEL POPULASI STUDI

/POPULASI YANG AKAN DIKONTROL

• DISTRIBUSI VARIABEL YANG AKAN DI KONTROL

PADA POPULASI STANDARD

53
54
 AGE SPECIFIC DEATH RATES PER 1000
PERSONS IN TWO FLORIDA COUNTIES (1960)
IM IM
AGE GROUP X X
PINELLAS COUNTY DADE COUNTY
0-1 28.2 28.8
2-4 1.4 1.2
5-14 0.6 0.4
15-24 0.8 1.2
25-34 1.4 1.7
35-44 3.0 3.3
45-54 7.7 8.2
55-64 15.9 16.7
65-74 28.9 31.1
75+ 82.8 84.2
CRUDE DEATH RATE
Total 15.3 8.9 55
AGE DISTRIBUTION OF TWO FLORIDA COUNTIES (1960)
AGE % OF POPULATION IN EACH AGE
GROUP GROUPS
PINELLAS COUNTY DADE COUNTY
0-1 1.5 2.0
2-4 5.9 8.0
5-14 13.9 17.4
15-24 8.7 11.6
25-34 9.0 13.3
35-44 11.1 15.0
45-54 11.1 12.6
55-64 13.9 10.0
65-74 17.6 7.3
75+ 7.3 2.8

56
 AGE ADJUSTED DEATH RATES
(Direct Method)

AGE IM
X
IM
X Standard Expected death: sEX = IMX . spX
GROUP PINELLAS DADE population PINELLAS DADE
COUNTY COUNTY structure (spX) COUNTY COUNTY
0-1 28.2 28.8 23000 649 662
2-4 1.4 1.2 90000 126 108
5-14 0.6 0.4 199000 119 80
15-24 0.8 1.2 134000 107 161
25-34 1.4 1.7 127000 179 216
35-44 3.0 3.3 134000 402 442
45-54 7.7 8.2 114000 878 935
55-64 15.9 16.7 87000 1383 1453
65-74 28.9 31.1 61000 1763 1897
75+ 82.8 84.2 31000 2558 2613
All ages 15.3 8.9 8164 8567
1000000
57
AGE ADJUSTED DEATH RATES
(Direct Method)

58
 Mortality in a population in two different time periods.
The mortality rate is considerably higher in the later period
Here, we see three age groups, and age-specific mortality for the later
period is lower in each group. How, then, is it possible to account for the
higher overall mortality in the later period in this example?
How, then, is it possible to account for the higher overall mortality in the later period
in this example?

The answer lies in the changing age structure of the population

Mortality is highest in the oldest age groups, and during the later period, the size of
the oldest group doubled from 100,000 to 200,000, whereas the number of young
people declined substantially, from 500,000 to 300,000.

We would like to eliminate this age difference and, in effect, ask: if the age
composition of the populations were the same, would there be any differences in
mortality between the early period and the later period?
= 124.3 = 101.7
Hillsborough 1995 (top) Pinellas 1995 (bottom)
Age Popul. # Deaths % of Popul. Death Rate
0 to 14 190,703 174 21.4% 0.0009
15 to 24 115,928 115 13.0% 0.0010
25 to 44 289,441 620 32.4% 0.0021
45 to 64 180,396 1,435 20.2% 0.0080
65 + 116,406 5,657 13.0% 0.0486
TOTAL 892,874 8,001 100.0% 0.0090

Age Popul. # Deaths % of Popul. Death Rate

0 to 14 138,986 116 15.9% 0.0008
15 to 24 83,815 63 9.6% 0.0008
25 to 44 239,396 498 27.3% 0.0021
45 to 64 190,427 1,421 21.7% 0.0075
65 + 223,576 10,326 25.5% 0.0462
TOTAL 876,200 12,424 100.0% 0.0142
 STANDARDIZATION
H+P Death Rate Expected Deaths
Age Popul. H P H P
0 to 14 329,689 .0009 .0008 296 263
15 to 24 199,743 .0010 .0008 199 159
25 to 44 528,837 .0021 .0021 1,110 1,110
45 to 64 370,823 .0080 .0075 2,966 2,781
65 + 339,982 .0486 .0462 16,523 15,707
TOTAL 1,769,074 ----- ----- 21,094 20,020

Adjusted Death Rate (H) = 21094 / 1,769,074 = 1,192 per 100K

Adjusted Death Rate (P) = 20020 / 1,769,074 = 1,132 per 100K
 STANDARDIZATION
Adjusted Death Rate (H) = 21094 / 1,769,074 = 1,192 per 100K
Adjusted Death Rate (P) = 20020 / 1,769,074 = 1,132 per 100K

Age-adjusted rate ratio = 1,192 / 1,132 = 1.05

Using Hillsborough + Pinellas county as the standard population

The age-adjusted 1995 death rate appears to be approximately

5% higher in Hillsborough county compared to Pinellas county.
 STANDARDIZATION

Direct Standardization:

Another way to select the standard population is to use an

external standard population, such as the United States
population.

As before, we can then apply the category-specific death rates to

the standard population to calculate and compare the
expected number of deaths in each population.
 STANDARDIZATION
U.S. Death Rate Expected Deaths
Age Popul. H P H P
0 to 14 55,961,000 .0009 .0008
15 to 24 36,124,000 .0010 .0008
25 to 44 82,366,000 .0021 .0021
45 to 64 48,345,000 .0080 .0075
65 + 32,283,000 .0486 .0462
Total 255,079,000 ----- -----

Adjusted Death Rate (H) =

Adjusted Death Rate (P) =

 STANDARDIZATION
U.S. Death Rate Expected Deaths
Age Popul. H P H P
0 to 14 55,961,000 .0009 .0008 50,364 44,768
15 to 24 36,124,000 .0010 .0008 36,124 28,899
25 to 44 82,366,000 .0021 .0021 172,968 172,968
45 to 64 48,345,000 .0080 .0075 386,760 362,587
65 + 32,283,000 .0486 .0462 1,568,953 1,491,474
Total 255,079,000 ----- ----- 2,215,169 2,100,696

Adj. Death Rate (H) = 2,215,169 / 255,079,000 = 868 per 100K

Adj. Death Rate (P) = 2,100,696 / 255,079,000 = 824 per 100K

 STANDARDIZATION
Adj. Death Rate (H) = 2,215,169 / 255,079,000 = 868 per 100K
Adj. Death Rate (P) = 2,100,696 / 255,079,000 = 824 per 100K

Age-adjusted rate ratio = 868 / 824 = 1.05

Using the United States as the standard population

The age-adjusted 1995 death rate appears to be approximately 5%

higher in Hillsborough county compared to Pinellas county.
70
71
72
 Prosedur Perhitungan:
Direct Standardization
• Dapatkan category-specific rates populasi yang
dibandingkan

• Tentukan standard populasi

• Hitung jumlah “expexted deaths/cases”

• Hitung rate yang distandardisasi:

Total “expected deaths/cases”
Total populasi standard
89
 Metode standarisasi tidak langsung

• cara kalkulasi
menggunakan specific rate berdasarkan variabel yang akan dikontrol (misal umur, sex dll) pada
standard populasi

standard spesific rate tadi diaplikasikan pada populasi studi berdasarkan variabel yang akan
dikontrol (umur, sex/ konfounder lain )

• standarisasi ini menggambarkan :

• apa yang akan terjadi dengan crude rate pada populasi studi jika distribusi dari specific rate
nya sama dengan populasi standard

90
 METODA STANDARDISASI
TIDAK LANGSUNG

DATA YANG HARUS TERSEDIA :

1. DISTRIBUSI VARIABEL YANG AKAN DIKONTROL PADA POPULASI

STUDI (distribusi umur ,sex)

2. DISTRIBUSI SPECIFIC RATE BERDASARKAN VARIABEL YANG

DIKONTROL PADA POPULASI STANDARD
.
3. CDR POPULASI STUDI

4. CDR POPULASI STANDARD

92
 Prosedur Perhitungan: Indirect
• Tentukan category-specific rates populasi standard

• Dapatkan distribusi populasi yang dibandingkan

• Hitung jumlah “expexted deaths/cases”

• Hitung SMR :
Jumlah kematian yang diobservasi
Jumlah “expected deaths”

• Hitung rate yang distandardisasi secara indirect:

SMR x Crude Death Rate populasi standard

93
AGE ADJUSTED DEATH RATES
(Indirect Method)
AGE IP
X
IP
X Death rates per Expected death: IEX = sMX . ipX
GROUP 1000 in std.pop PINELLAS DADE
PINELLAS DADE
COUNTY COUNTY (sMX) COUNTY COUNTY
0-1 5674 18819 27.0 153 508
2-4 22167 74554 1.1 24 82
5-14 51932 162633 0.5 26 81
15-24 32565 108310 1.1 36 119
25-34 33877 126938 1.5 51 187
35-44 41633 140768 3.0 125 422
45-54 41670 118013 7.6 317 897
55-64 51985 93058 17.4 905 1619
65-74 65783 67994 38.2 2513 2597
75+ 27379 25960 106 2902 2752
All ages 374665 935047 9.5 7052 9264
Observed 5732 8245
death IDX 94
 AGE ADJUSTED DEATH RATES
(Indirect Method)

Diketahui : CDR pop standard = 9.5 per 1000

 ADJUSTED RATES

statistically constructed summary rates

that account for the difference between population
with respect to these other variable
 Standard population

1. Distribution of one of the population of interest

2. Combining the two population of interest

3. Other population (outside standard of interest)

 ADVANTAGES AND DISADVANTAGES
CRUDE, SPECIFIC, ADJUSTED RATES
Rates Advantages Disadvantages

Crude 1. Actual summary rates 1. Difference crude rates

2. Readily calculable for international difficult to interpret (vary in
comparison widely used composition)

Specific 1. Comparison is made between 1. Cumbersome to compare

homogens sub-group (more subgroup several
accurate) subgroups of two or more
2. Detailed rates are useful for populations
epidemiologic and public health 2. No summary figure
purpose
113
 ADVANTAGES AND DISADVANTAGES
CRUDE, SPECIFIC, ADJUSTED RATES

Rates Advantages Disadvantages

Adjusted 1. Summary statement 1. Fictional rates

2. Differences in composition of 2. Absolute magnitudes
groups are removed permitting depend on standard
unbiased comparisons population chosen
3. Permits group comparison 3. Actual value of adjusted is
meaningless

114
 ADVANTAGES AND DISADVANTAGES
CRUDE, SPECIFIC, ADJUSTED RATES
Rates Advantages Disadvantages

Crude 1. Actual summary rates 1. Difference crude rates

2. Readily calculable for international difficult to interpret (vary in
comparison widely used composition)

Specific 1. Comparison is made between 1. Cumbersome to compare

homogens sub-group (more subgroup several
accurate) subgroups of two or more
2. Detailed rates are useful for populations
epidemiologic and public health
purpose
115
 ADVANTAGES AND DISADVANTAGES
CRUDE, SPECIFIC, ADJUSTED RATES
Rates Advantages
Adjusted 1. Summary statement
2. Differences in composition of
groups are removed
permitting unbiased
comparisons
Disadvantages
1. Fictional rates
2. Absolute magnitudes
depend on standard
population chosen
3. Actual value of adjusted is
meaningless
116
 CHAPTER 4
THE OCCURRENCE OF DISEASE II
Mortality and Other Measures of Disease Impact
 CHAPTER 3
Epidemiologic Measures