Standardization of Rates

Clara Ejembi
 Objectives

• Explain
– Crude rates
– Age specific rates
– Standardized rates
• Calculate standardized rates of disease or
death in two or more populations and
describe their mean
• Calculate standardized mortality ratio and
standardized incidence ratio and interpret
them
 Rates of Disease
Are the basic measure of disease occurrence
because they most clearly express probability
or risk of disease in a defined population over
a period of time

• Incidence
• Prevalence
• Mortality
 Comparing health outcomes

• Crude rates
• Age specific rates
• Standardized rates
Crude Mortality Rates

Number of deaths
in a specified year
___________________  1000

Number of individuals
in the population
in the specified year
 Crude Rates

• Calculated by dividing total number of cases

by total population

Population A Population B
50000 people 52000 people
4000 cancer 5080 cancer
deaths in a year deaths in a year
Crude Death Rate Crude Death Rate
800/1000 997/1000

Is the risk of cancer death higher in population B?

 Crude Rates

• A crude rate(overall rate) is a weighted average of

stratum-specific rates (the weights are the
population totals of the strata)

• The difference between crude rates of two

populations involves differences in both the
stratum-specific rates and population
composition (distribution of characteristics)
 Crude Rates
• Comparison of crude rates misleading as
they ignore heterogeneity of populations

• Populations may differ by a number of

variables (age, sex etc), which are
confounders

• Confounders are risk factors of outcomes of

interest

• Age very important determinant of health

outcomes
 Crude Rates

Advantages
Actual Summary rates
Easy calculation for international comparisons

Disadvantages
Since population vary in composition (e.g., age)
differences in crude rates difficult to interpret
 Specific Rates
Stratifies populations into more homogeneous

groups (strata) based on the demographic

characteristic thought to be related to the

outcome of interest (e.g. age-specific,

sex-specific, race-specific)
 Age Specific Rates
Population A Population B
Age # Deaths Population Rate per # Deaths Population Rate per
Size 10,000 Size 10,000
30-39 400 10,000 400 80 2,000 400
40-49 600 10,000 600 300 5,000 600
50-59 800 10,000 800 800 10,000 800
60-69 1,000 10,000 1,000 1,500 15,000 1,000
70-79 1,200 10,000 1,200 2,400 20,000 1,200
Totals 4,000 50,000 800 5,080 52,000 977
(crude rate) (crude rate)

 Population B higher crude death rate, but weighted with larger

population of elderly

 Age specific rates same in both populations

 An appropriate Comparison?

• The comparison of crude death rates is

confounded by the differences in population
composition(age distribution) between the two
populations
• Population B has an older age distribution
• A comparison of age-specific incidence rates
between the two populations reflects the risk of
disease in each age group
• An adjustment procedure is needed to make an
appropriate comparison of the overall risk of
dying between the two populations
 Adjustment Procedures

• Adjustment procedures are any of a variety of

procedures performed during data analysis to
attempt to remove the effect of one or more
extraneous sources of variation that could affect
(or are believed to affect) a particular result
(Meinert, 1996)
 Goal of adjustment

• Appropriately combine data

• Make appropriate comparisons among
groups
• Reach appropriate conclusions and
inferences
 Procedures of Adjustment

• Stratified or subgroup analyses

• Direct or indirect standardization of rates
• Life tables
• Multivariable statistical analyses
 Age-Specific Mortality Rate

Number of deaths among

persons aged 0-14 in a given
year
Aged 0 –14 = _________________________  100000
years
Total number of persons
aged 0-14 in the same
year
 Specific Rates

Advantages
Homogenous subgroups
Detailed rates useful for public health and
Epidemiological aims

Disadvantages
Cumbersome to compare subgroups of two or
more populations
 Standardizing Rates
Also referred to as adjusting rates

Allows comparisons of summary rates between

populations that differ by variables that
can influence the rate (e.g., age, race, gender)

Direct method

Indirect method
 Standardized Rates
Advantages
Summary statement
Differences in group composition “removed”
allows unbiased comparison

Disadvantages
Fictional rates
Absolute magnitude dependent on standard
population chosen
Opposing trends in subgroup masked
 Methods of Standardization
• Direct method Apply stratum-specific rates
observed in the populations of interest to a
reference or standard population in order to
obtain the number of deaths expected in the
reference population
• Calculate an adjusted rate based on expected
number of deaths in the reference population
• Indirect method Apply stratum-specific
reference rates to the populations of interest to
obtain the number of expected deaths in each of
those populations
• Compare the observed number of deaths to the
expected number of deaths for each population
 Standard Population
 Select a reference or standard population
similar to the age distribution of the
populations being compared

 The characteristics of the reference

population are used for each of the two
populations being compared.
Selection of Standard Population

 A standard population can be

obtained from the appropriate life-
table

 For two populations of the same size,

take the average of the corresponding
figures in age distribution of the two
populations OR use the sum of the
two populations
 Direct Standardization of Rates

• Use the event rates (experience) of the

population of interest to calculate the number
of deaths expected in the reference population

• The adjusted rate in the population of interest is

the expected number of deaths divided by the
total reference population
 Direct Standardization of Rates
Requires:

- Age distribution of a standard population

- Age specific rates of the populations to be compared

Compute

- Expected number of cases for each age group of the

different populations assuming each population has

the same age structure as the standard population

Multiply standard population by age-specific rates

for populations A and B to determine the standardized rates

 Direct Standardization of Rates
Divide the total number of expected cases for each

population by total standard population to get the

standardized rate

Choice of the standard population may affect the

magnitude of the age-adjusted rates, but not the

ranking of the population

 Population, Deaths, and Death Rate by
Community and by Age
Community A Community B
Age Population Deaths Death Rate Population Deaths Death Rate
(year) (per 1000) (per 1000)
Under 1 1,000 15 15.0 5,000 100 20.0
1 – 14 3,000 3 1.0 20,000 35 1.0
15 – 34 6,000 6 1.0 35,000 35 1.0
35 – 54 13,000 52 4.0 17,000 85 5.0
55 – 64 7,000 105 15.0 8,000 160 20.0
Over 64 20,000 1,600 80.0 15,000 1,350 90.0
All ages 50,000 1,781 35.6 100,000 1,740 17.4
Standard Population by Age and Age-Specific Death Rates
Age Standard Death rate Expected Death rate Expected
(years) population in A deaths at in B deaths at
(per 1,000) A’s rate (per 1,000) B’s rate

Under 1 6,000 15.0 90 20.0 120.0

1 – 14 23,000 1.0 23 0.5 11.5
15 – 34 41,000 1.0 41 1.0 41.0
35 – 54 30,000 4.0 120 5.0 150.0
55 – 64 15,000 15.0 225 20.0 300.0
Over 64 35,000 80.0 2,800 90.0 3,150
Total 150,000 35,6 3,299 17.4 3,772.5
Age –
adjusted
death rate
22.0 25.0
(per 1000)
 Compute Standardized Incidence
Rate for Population A and B

Age Group Population A Population B Standard

population
Population Number of Population Number of Population
cases cases
0–4 1500 63 2500 90 4000
5 -14 2500 50 3500 84 6000
< 15 6000 12 4000 8 10000
Total 10000 125 10000 182 20000
 Compute Standardized Incidence
Rate for Population A and B

Age Group Population A Population B Standard

population
Age Expected Population Expected Population
Specific number of Number of
Rates cases cases
0–4 4000
5 -14 6000
< 15 10000
Total 20000
Standardized Incidence Rate
Population A = Total expected cases in population A/Total standard population X1000
Population B =Total expected cases in population B/Total standard population X100
 Check

• Compare the crude rates, is the risk of

disease higher in population B?
• Compare the adjusted rates, what inference
can you draw?
• What type of disease is likely to give this
distribution?
 Summary of direct method of
adjustment
• Age-adjusted rate is an index measure, the
magnitude of which has no intrinsic value
• Actual rates are only meaningful when directly
compared to each other
• Adjusted rates are useful for comparison
purposes only
• Choice of the reference population is important. It
should not be abnormal or unnatural
• Adjustment (standardization) is not a substitute
for the examination of age-specific rates in the
populations of interest
 Review Questions

• What is an age-adjusted rate?

• Can directly-adjusted rates be compared?

• Using the direct method of adjustment, what data

are needed from the reference (standard)
population?
 Direct versus Indirect
standardization
• Direct method Assume that the observed population
had the same distribution of characteristics as the
reference population

• Apply the experience of the observed population to

the reference population

• Indirect method Assume that the observed population

had the experience of the reference population
• Apply the experience of the reference population to
the observed population
– Experience = morbidity rate or mortality rate
• - Characteristics = age, gender, …
 Indirect Standardization of Rates

Used if age-specific rates cannot be estimated

Mirror image of the direct method

Require

- Age Specific rates of Standard Population

- Age distribution of populations to be compared

- Total number of cases in each population

 Indirect Standardization of Rates

Based on applying the age-specific rates of the

standard population to the population of interest
to determine the number of “expected” deaths
Compute
- Expected number of cases for each age group
assuming population bas same age distribution as
standard population


Standardized Mortality Ratio
Standardized Mortality Ratio

Total observed deaths

in a population
____________________

Total expected deaths

in a population

Multiply SMR by the crude rate (C)of the

reference population to get the Indirect
Adjusted Rate(IAR)
Population of Community A by Age
and Standard Death Rates

Age Population Standard

(years) in A death rate
(per 1,000)

Under 1 1,000 20.0

1 – 14 3,000 0.5
15 – 34 6,000 1.0
35 – 54 13,000 5.0
55 – 64 7,000 20.0
Over 64 20,000 90.0
Total 50,000 17.4
Population and Expected Deaths of
Community A by Age

Age Populat Standard Expected

(years) ion in A death rate deaths in A
(per 1,000) at standard
rates
Under 1 1,000 20.0 20.0
1 – 14 3,000 0.5 1.5
15 – 34 6,000 1.0 6.0
35 – 54 13,000 5.0 65.0
55 – 64 7,000 20.0 140.0
Over 64 20,000 90.0 1,800.0
Total 50,000 17.4 2,032.5

SMRA = 1781 / 2032.5 = 0.876

SMRB = 1.0
 Standardized Mortality Ratio
If the SMR is greater than 1, risk is higher than
anticipated. Higher deaths than reference population

If SMR is 1 then risk as expected, it is the same in

reference population

If the SMR is less than 1, risk is lower than

anticipated. Fewer deaths in population compared to
reference population
 Comparisons of SMRs

• Since the number of deaths in a population depends

on age distribution, the number of observed deaths
and the calculation of the expected deaths must
depend on the age distribution of the population of
interest. Consequently, SMR must also depend on
the age distribution of population of interest

• Therefore, when using the same reference population

in the calculation of SMR, the SMR from one
population cannot be compared to the SMR from
another population unless the two populations are
similar in age distribution
 Merits of Indirect Standardization

• No need to know the age-specific (mortality) rates of

the population of interest. These rates may be difficult
to obtain (in a developing country or an industry)

The direct method of adjustment cannot be

conducted without these rates

• The rates of the standard population are often based

on large population, while the rates calculated from
the observed population may be based on small
number and be unstable
Recap: what does standardization
do?

1. Standardization is used to remove the effect

of an confounding variable, such as age, from
a comparison between two populations

2. Direct standardization is used whenever

stable stratum-specific rates of the
populations are available
3. Indirect standardization is used when stratum-
specific rates are unavailable or unstable
because of small numbers

4. Remember than standardized rates are averaged

across all strata: a standardized rate can conceal
interesting differences between strata - therefore
looking at a standardized rates should not
substitute for looking at specific rates whenever
possible.