Racial Misclassification in Mortality Records Among American Indians/Alaska Natives in Oklahoma From 1991 to 2015

Abstract

OBJECTIVE: The primary purpose of this study was to compare age-adjusted mortality rates before and after linkage with Indian Health Service records, adjusting for racial misclassification. We focused on differences in racial misclassification by gender, age, geographic differences, substate planning districts, and cause of death. Our secondary purpose was to evaluate time trends in misclassification from 1991 to 2015. DESIGN: Retrospective, descriptive study. SETTING: Oklahoma. PARTICIPANTS: Persons contained in the Oklahoma State Health Department Vital Records. MAIN OUTCOME MEASURES: To evaluate the age-adjusted mortality ratio pre- and post-Indian Health Service record linkage (misclassification rate ratio) and to evaluate the overall trend of racial misclassification on mortality records measured through annual percent change (APC) and average annual percent change (AAPC). RESULTS: We identified 2 stable trends of racial misclassification upon death for American Indians/Alaska Natives (AI/ANs) from 1991 to 2001 (APC: -0.2%; 95% confidence interval: -1.4% to 1.0%) and from 2001 to 2005 (APC: -6.9%; 95% confidence interval: -13.7% to 0.4%). However, the trend identified from 2005 to 2015 decreased significantly (APC: -1.4%; 95% confidence interval: -2.5% to -0.2%). For the last 5 years available (2011-2015), the racial misclassification adjustment resulted in higher mortality rates for AI/ANs reflecting an increase from 1008 per 100 000 to 1305 per 100 000 with the linkage process. There were an estimated 3939 AI/ANs in Oklahoma who were misclassified as another race upon death in those 5 years, resulting in an underestimation of actual AI/AN deaths by nearly 29%. CONCLUSIONS: An important result of this study is that misclassification is improving; however, this effort needs to be maintained and further improved. Continued linkage efforts and public access to linked data are essential throughout the United States to better understand the burden of disease in the AI/AN population.