Health of Wisconsin Report Card 2013
Frequently Asked Questions (PDF)
Why do we need a report card on health and health disparities in Wisconsin?
Public and private sector policy makers are making decisions every day regarding programs and policies
that affect health in the state, from medical care to public health to socioeconomic status. Knowing
how healthy the population is overall and for specific subpopulations can be useful in resource allocation
decisions for health improvement.
Why does Wisconsin receive two separate grades for health and health disparity instead of one overall grade?
This Report Card grades Wisconsin separately on health and health disparity in order to assess the
state's progress towards achieving two of the goals outlined by the Healthiest Wisconsin 2020 state health
plan: to protect and promote health for all, and eliminate health disparities. Wisconsin's health grade of
B- is based on the average health of its residents and, therefore, is dominated by the health of the majority
population. Even if Wisconsin were to receive a grade of A for health, it could still be performing poorly in
terms of health disparities and have numerous population subgroups in need of improved health. For these
reasons, health and health disparity were assessed separately in this report.
How does this report card relate to other recent reports on state health?
Every fall, the United Health Foundation
"America's Health Rankings", ranking the health of the 50 states. However, the focus of this
report is almost entirely on health, not health disparities. Other reports from the federal
Agency for Healthcare Research and
and from the Commonwealth Fund
focus on the quality of the State's health care systems (e.g., hospitals, doctors, home health care) and not on the
overall health outcomes of the population and subpopulations.
How were the subgroups included in the report selected?
The population subgroups graded in the Report Card were selected to illustrate the variety of
characteristics, or domains, across which health disparities exist. A total of four domains were selected
for inclusion in the Report Card: gender, education, urbanization of county, and race/ethnicity. This list
does not cover all of the disparity domains reflected in the Healthy People 2020 goal to eliminate health
disparities, such as income, disability, and sexual orientation, because comparable and reliable data on
populations defined by those important characteristics were not readily available.
Gender: Although some differences in health between males and females may be
due to biological differences between the sexes, other gender differences in health represent inequities –
or differences in health that are unfair or unjust. For example, homicide rates are higher for men and
depression is more common among women.
Education: The domain of education was included in the Report Card as an illustration
of socioeconomic disparities in health. Educational attainment was examined for adults 25 years of age
and older, but this same descriptor is not applicable for children who are currently in school. Therefore,
the domain of education was not included for children and young adults. For infants, the education of the
mother was used for this domain.
Urbanization: Where someone lives can have an impact on their health, so the domain of
urbanization was included to illustrate differences in health based on the physical and social environment.
Urbanization is a measure of the degree of urban, or city-like, character of the county in which a person
Race/ethnicity: Health disparities between racial and ethnic groups exist in Wisconsin
and across the entire United States. For this Report Card, health is assessed for five racial/ethnic groups,
with all groups other than Hispanic/Latino representing non-Hispanic ethnicity. Racial and ethnic groups
with a substantial population in Wisconsin but for whom reliable data were not available for a particular
measure are noted in the Report Card with a grade of "I" representing "incomplete" data.
How do the results in the 2013 Report Card differ from previous versions?
The overall health grade for the state of Wisconsin has remained a B-. The health disparity grade has worsened
from a C- to a D indicating that the state is not doing enough to reduce health disparity.
Most subgroup death rates or unhealthy days per month values differ from the 2010 Report Card. Many subgroups
improved the health of their subgroup but did not improve rapidly enough to result in a grade change in the
2013 Report Card. To see a comparison of results and grades between 2013 and 2010 see the tables below.
If you prepared the Report Card by population subgroup rather than by life stage, what would the reports look like?
The Health of Wisconsin Report Card is organized so that the disparities existing between subgroups within life
stages can be examined. Therefore, we examine the different grades within each life stage and do not focus our
analysis on the grades Wisconsin receives for each subgroup across its life course. However, for those interested,
report cards organized by subgroup are below.
Calculating Grades and Ranks (PDF)
How were the life stage grades for health assigned?
In order to give Wisconsin and its residents grades for the health outcomes of death and unhealthy days, we created
grading scales. We looked at the distribution of health within each life stage for Wisconsin to see how far the rate
was from the average for the life stage:
We then assigned cutoff points for grades based on distance from the average (i.e., based on standard deviations
from the mean). Rates that were closest to the average (between 0.5 standard deviations below the mean to 0.5
standard deviations above the mean) were assigned a C. Rates that were further away above and below the average
were assigned a D (0.5 to 1.5 standard deviations above the mean) or a B (1.5 to 0.5 standard deviations below the
mean) respectively. The highest (worst) rates were assigned Fs (more than 1.5 standard deviations above the mean)
and the lowest (best rates) were assigned As (more than 1.5 standard deviations below the mean). The grading scales
are listed in the table below. For the working-age and older adult life stages, the life stage health grades are an
average of the grades for mortality and unhealthy days.
What scales were used for the life stage grades for health?
||2010 WI Population (%)
How was the state grade for health assigned?
To determine Wisconsin's health grade, we averaged the four life stage health grades to calculate an
overall GPA. We then converted the overall GPA back to a grade.
What scale did you use to convert GPA scores back to grades?
|3.75 – 4.0
|3.50 – 3.74
|3.26 – 3.49
|2.75 – 3.25
|2.50 – 2.74
|2.26 – 2.49
|1.75 – 2.25
|1.50 – 1.74
|1.26 – 1.49
|0.75 – 1.25
How are all of the grades for the different outcomes and life stages weighted in order to combine all of these measures into an overall grade for health?
The health grades from the four life stages are equally weighted when they are averaged to calculate the
overall grade for health, so each life stage grade contributes one-forth of the final health grade. However,
the working-age adult and older adult life stage health grades are created by equally combining the life stage
health grades for mortality and unhealthy days, while the infant and children/young adult health grades are
based solely on mortality rates. The unhealthy days measure only contributes to the overall health grade through
these life stages, making the overall health grade effectively based 75% on mortality rates and 25% on unhealthy
How were the subgroup grades for health assigned within each life stage?
The outcome/life stage grading scales constructed to assign each state a life stage grade for health were also
used to assign grades for each population subgroup within that outcome and life stage.
How were the life stage grades for health disparity assigned?
The life stage health disparity grades are based on a weighted proportion of subgroup grades that were less
than the best grade achieved by any subgroup. The method is based on an approach recommended by the U.S.
Department of Health and Human Services (Keppel K, Pamuk E, Lynch J, et al. Methodological issues in
measuring health disparities. National Center for Health Statistics. Vital Health Stat 2(141. 2005). This
approach is being used to monitor progress towards the Healthy People 2010 goals to eliminate health
disparities by assessing disparity across multiple subgroups using an index of disparity.
To calculate life stage health disparity scores, we assigned a score of 4 for an A, 3 for a B, 2 for a C,
1 for a D, and 0 for an F to each subgroup's grade for mortality, and where applicable, unhealthy days.
We then summed the differences between the best subgroup grade and each subgroup score, divided this sum
by the number of subgroups minus one, and converted this score to a percent scale by dividing by four.
The resulting disparity score can range from a value of zero percent disparity when all subgroups have the
same grade to 100% disparity where one subgroup grade is an A and all other subgroup grades are Fs. (For
the two younger life stages, the disparity score was based solely on available mortality rates for
subgroups, whereas the disparity score for the two older life stages was based on an average of the scores
for mortality and unhealthy days.) We then assigned grades to these scores.
What scale was used for grading the life stage health disparity scores?
How was the stage grade for health disparity assigned?
To determine Wisconsin's health disparity grade, we averaged the four life stage health disparity grades to
calculate an overall GPA. We then converted the overall GPA back to a grade.
How are all of the different subgroups, outcomes, and life stages weighted in combining all these measures into an overall grade for health disparity?
Within every life stage, each subgroup with available data contributed equally to the calculation of
the life stage disparity grade. However, because there were not equal numbers of subgroups within each
domain (gender, education, type of county, race/ethnicity), the domains are not given equal weight in
the life stage disparity grade. For example, for infants there are four subgroups under "type of
county" and only two subgroups under "gender," so the domain of type of county contributes
twice as much to the calculation of the life stage disparity grade as the domain of gender. In addition,
subgroup data are not available for some racial/ethnic groups in every life stage and for the education
domain for children and young adults; only the subgroups with available data were included in the life
stage health disparity calculations. In calculating the overall health disparity grade for Wisconsin,
the four life stage health disparity grades were given equal weight.
How were the life stage ranks for health and health disparity calculated?
For health, mean state values were used to assign ranks. The average of the two outcomes ranks was used for
working-age and older adults. Life stage health disparities ranks were based on the state disparity scores
described above. Because the ranks were constructed in a slightly different manner for working-age and
older adults than the grades were constructed, the ranks displayed below do not necessarily reflect a ranked
order of the grades received by each state.
Detailed Information on Measures and Data Sources (PDF)
What are death rates?
Death rates are based on counts of the number of deaths occurring in a population group divided by the total
number of people in that group. These numbers are then converted to reflect rates of death per 100,000 people
(per 1,000 births for infants). We report rates based on the most recent 3-year period for which data are
available nationally: 2008-2010. The death rates are adjusted for age (except the rates for infants and older
adults by education).
Where do the death data used in this Report Card come from?
What are unhealthy days?
Unhealthy days are a measure of health-related quality of life. We report the mean (average) number of unhealthy
days reported per month. The numbers are based on adult (age 25+) respondents' answers to two questions about
their health in the past month:
- how many days was your physical health poor?
- how many days was your mental health poor?
We report data for the most recent 3-year period for which data on unhealthy days are available nationally:
2008-2010. The mean number of unhealthy days per month are adjusted for age.
For more information on unhealthy days, see How
Should We Measure Health-Related Quality of Life in Wisconsin?
on the UWPHI website.
Where do the unhealthy days data used in this Report Card come from?
Why isn't a measure of health-related quality of life included for infants and children?
The unhealthy days data used in this Report Card are from the Behavioral Risk Factor Surveillance System, which conducts surveys
of adults ages 18 and older. Although some other measures of health-related quality of life – such as general health status
– exist for children and adolescents, the measure of healthy days is not readily available for individuals under 18 across the
United States. Unhealthy days data for young adults ages 18-24 were not included in the Report Card because this age group is
combined with children, for whom unhealthy days data are not available nationally.
Which measures are adjusted for age?
Death rates: All death rates are adjusted for age, except the rates for infants – because these rates are
not typically adjusted for age – and older adults by education – because census denominators by age were not readily
available for those 65 years and older. Data obtained from WONDER and WISH were requested as age-adjusted numbers in the queries.
Death rates by education for working age adults were adjusted using the age groups of 25-34, 35-44, and 45-64, and population
weights from the U.S. 2000 Standard Population.
Unhealthy days: The mean values for unhealthy days per month for working age adults were adjusted for age using
the age groups of 25-34, 35-44, 45-54, and 55-64 and population weights from the U.S. 2000 standard population. The mean values
for unhealthy days per month for older adults were adjusted for age using the age groups 65-74 and 75+ and population weights from
the US 2000 standard population.
How were the urbanization classifications created?
The four urbanization classifications used in this Report Card were based on the set of six urbanization
classifications outlined by the National Center for Health Statistic (NCHS). The "large central
metro" NCHS classification is represented in the report as "large urban"; the NCHS classes
of "large fringe metro" and "medium metro" were combined to create the report
classification of "suburban/urban"; the NCHS classes of "small metro" and
"micropolitan" were combined to create the "non-urban" classification; and the NCHS
classification of "non-core" is reflected in the report as "rural." A detailed
description of the classifications can be found in the table below.
|Health of Wisconsin Report Card Urbanization Classification
||National Center for Health Statistics 2006 Urban-Rural Classification*
||National Center for Health Statistics Classification Description*
||Large central metro
Counties in a metropolitan statistical area of 1 million or more population:
1) that contain the entire population of the largest principal city of the metropolitan
statistical area, or
2) whose entire population resides in the largest principal city of the metropolitan
statistical area, or
3) that contain at least 250,000 of the population of any principal city in the metropolitan
||Large fringe metro
Counties in a metropolitan statistical area of 1 million or more population that do not qualify
as large central
||Counties in a metropolitan statistical area of 250,000 to 999,999 population
||Counties in a metropolitan statistical area of 50,000 to 249,999 population
||Counties in a micropolitan (urban cluster of 10,000 or more people) statistical area
||Counties that are neither metropolitan nor micropolitan
*Ingram DD and Franco S. 2006 Urban-Rural Classification Scheme for Counties. Online at
What are the urbanization classifications for each Wisconsin county?
The urbanization classifications
for each county in
Wisconsin are listed on the UWPHI website. Wisconsin has one large urban county, 13 suburban/urban
counties, 24 non-urban counties, and 34 rural counties.
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