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Random sample surveys have been used for public health surveillance for about 50 years and have grown in size over that time. Such surveys are sufficiently large to estimate the sizes of relatively small subpopulations, such as pa- tients with chronic diseases, helped by pooling multiple years of the same survey. Survey estimates of population sizes have been used as denominators to estimate death rates from specific causes within specific subpopulations. Since these are ratio estimates, with both numerator and denominator being estimates, additional examination is required to evaluate their reliability. We illustrate these methods for rates using deaths due to diabetes and the estimated population of diabet- ics to compute death rates due to diabetes among diabetics by age and sex. Substituting the much smaller population of people at risk for the total population yields useful information about the burden of disease. Modern public health surveillance systems that use random sample surveys of the population have been in use for 50 years and are now large enough to estimate, often with fairly high accuracy, the sizes of small subpopulations of people with a chronic disease. These estimated populations have been used as denominators to compute cause-specific death rates within such subpopulations (1). In this paper, we illustrate the proper statistical use of such ratio estimates, accounting for random variation in the denominator as well as the numerator, with death rates due to diabetes in the subpopulation of persons with diabetes. Substituting the much smaller diabetic population for the total population to compute death rates better informs our understanding of the burden of disease. We compute estimated death rates using the Behavioral Risk Factor Surveillance System (BRFSS), a large, nation- wide sample, to estimate the population of diabetics and counts of deaths due to diabetes in the United States. The estimated death rates due to diabetes within the diabetic population are ratios estimated as the number of deaths due to diabetes over the survey estimate of the size of the diabetic population. METHODS The BRFSS is a random digit dialed (RDD) telephone survey of the U.S. adult population that is conducted by state and territorial health departments under the sponsorship of the Centers for Disease Control (CDC). The BRFSS includes questions on a range of health topics related to chronic diseases and preventive behaviors. A summary description of this surveillance system has been given by Holtzman (2). States

Cause-Specific Mortality Rates in Chronic Disease Populations