 Research article
 Open Access
 Open Peer Review
Methods for confidence interval estimation of a ratio parameter with application to location quotients
 Joseph Beyene^{1, 2}Email author and
 Rahim Moineddin^{1, 3}
https://doi.org/10.1186/14712288532
© Beyene and Moineddin; licensee BioMed Central Ltd. 2005
 Received: 17 June 2005
 Accepted: 12 October 2005
 Published: 12 October 2005
Abstract
Background
The location quotient (LQ) ratio, a measure designed to quantify and benchmark the degree of relative concentration of an activity in the analysis of area localization, has received considerable attention in the geographic and economics literature. This index can also naturally be applied in the context of population health to quantify and compare health outcomes across spatial domains. However, one commonly observed limitation of LQ is its widespread use as only a point estimate without an accompanying confidence interval.
Methods
In this paper we present statistical methods that can be used to construct confidence intervals for location quotients. The delta and Fieller's methods are generic approaches for a ratio parameter and the generalized linear modelling framework is a useful reparameterization particularly helpful for generating profilelikelihood based confidence intervals for the location quotient. A simulation experiment is carried out to assess the performance of each of the analytic approaches and a health utilization data set is used for illustration.
Results
Both the simulation results as well as the findings from the empirical data show that the different analytical methods produce very similar confidence limits for location quotients. When incidence of outcome is not rare and sample sizes are large, the confidence limits are almost indistinguishable. The confidence limits from the generalized linear model approach might be preferable in small sample situations.
Conclusion
LQ is a useful measure which allows quantification and comparison of health and other outcomes across defined geographical regions. It is a very simple index to compute and has a straightforward interpretation. Reporting this estimate with appropriate confidence limits using methods presented in this paper will make the measure particularly attractive for policy and decision makers.
Keywords
 Ratio Parameter
 Delta Method
 Specialist Visit
 Location Quotient
 Census Division
Background
Effects in comparative analysis are commonly expressed as ratios. One such example is the Location Quotient (LQ), a ratio statistic widely used by geographers, economists and regional planners to measure the degree of relative concentration of an activity on a map [1, 2]. The LQ, which is sometimes referred to as concentration ratio, allows the comparison of an area's share of a specific activity with the share of a base aggregate. Furthermore, LQ can produce a rough benchmark in the analysis of localization in an area [3].
In general, statistical inference is more complicated for a ratio of parameters than measures that are expressed as linear combinations. In epidemiological studies, for example, association of risk factors with occurrence of disease in a given study population can be quantified using absolute measures such as the risk difference or by applying relative measures such as the relative risk or odds ratio [4]. Both the relative risk and the odds ratio require more caution from an inferential point of view than the simple risk difference. One of the difficulties in dealing with ratios arises in computing variance estimators.
Despite its popularity as a relative measure, the location quotient is often interpreted and reported primarily as a point estimate without an accompanying measure of precision. However, statistical reasoning and any inferential conclusion one may draw from a sample statistics should reflect uncertainty inherent in the estimation procedure, and appropriate methods that allow proper interpretation of study findings should be used. One way of proper analysis is to construct confidence limits around the sample estimates.
The objective of this paper is to present a number of alternative approaches that can be used to construct confidence limits for measures involving ratios quantities in general and the location quotient in particular.
Methods
A location quotient is a way of measuring the relative contribution of one specific area to the whole for a given outcome. Let x _{ i }and n _{ i }denote the outcome and population size of the i^{th} area, respectively. Similarly, let x = ∑x _{ i }and n = ∑n _{ i }be the outcome and population size of the whole, respectively. The location quotient for the i^{th} area is defined as
Depending upon the health outcome under study, the random variables in equation (1) may have different scales of measurements including continuous, binary or counts.
The interpretation of the LQ is as follows: (1) LQ _{ i }= 1 which indicates that the outcome in the specific region is at the same level as the aggregate, (2) LQ _{ i }> 1 indicating that the specific region is at a level greater than expected, and (3) LQ _{ i }< 1 which would indicate that the regional measure is at a level that is less than expected.
where V _{11} and V _{22} represent the variance of and , respectively, and V _{12} = V _{21}denote the covariance between and .
It can easily be shown that
where the parameter p _{ i }denotes the true incidence rate in the i^{th} area [5].
Using the notation introduced above, we now describe three analytical and computational approaches that can be used to construct confidence intervals for ratio parameters, namely: (1) Delta method (2) Fieller's method and (3) profilelikelihood based interval on generalized linear model (GLM) technique.
The delta method
The delta method is a classic technique in statistics that is based on a truncated Taylor series expansion [6]. According to the delta method, the variance of is estimated by
where z _{α/2} is the (1  α/2)% quintile of the standard normal distribution (for instance, for a 95% confidence interval α = 0.05 and z _{α/2} = 1.96) and is the squareroot of the expression in equation (3).
The Fieller method
Fieller [7] introduced a novel way of expressing ratios as linear combination of random variables which made computation of confidence intervals of ratios relatively simple.
where σ^{2} = (V _{11} + 2θV _{12} + θ^{2} V _{22}). This result implies that is a standard normal random variable and its square is a chisquared variable with 1 degree of freedom, χ_{1} ^{2}.
A (1  α)% Fieller confidence interval is then obtained by finding the set of θ values satisfying the inequality
Equation (6) is a quadratic function in the parameter of interest θ and solving for θ leads to the confidence limits
Both the delta method and Fieller's approach are quite generic and have been used in a wide range of applications [8–10]. The implementation of these two approaches (using equations (4) and (7) respectively neither require sophisticated programming nor specialized software.
Generalized linear modelling
A model that is widely applicable in a number of different distributional scenarios is generalized linear model (GLM) [11]. Among others, the normal, binomial and Poisson distributions are included in this rich family of models.
We consider a situation where we have k regions and need to estimate k location quotients along with the corresponding confidence limits. We formulate the generalized linear framework by reexpressing equation (1) as
log(p _{ i }) = log(x/n) + β_{1} I _{1} + … + β_{ k } I _{ k }, (8)
where p _{ i }is estimated by and the link function relating the outcome to the independent variables is a logarithmic transformation. The indicator variables I _{ j }, j = 1,…,k take on the value 1 if the region is j and 0 otherwise.
There are a number of attractive features with this formulation. Firstly, the model can be fitted using standard statistical software such as using the GENMOD procedure in the SAS statistical package [12]. The resulting estimators are maximum likelihood estimators that are well known to have desirable optimality properties. In fact the reason we were able to take the antilogarithm (using exponential) to get back to the natural scale for the location quotients from the logarithmic scale was due to the invariance property of the maximum likelihood estimates. The invariance property ensures that, if is the maximum likelihood estimator of θ, then g( ) is a maximum likelihood estimator of g(θ).
Secondly, confidence intervals for model parameters are by products of the modelling procedure. One of the intervals that can be extracted from fitting the generalized linear model is the profilelikelihood based interval. This approach is an iterative procedure which in general gives more accurate confidence limits, especially for small sample sizes [13]. In addition, significance levels are generated automatically that can be used along side the confidence intervals in order to test whether or not the LQ for a given region is significantly different from the null value of one (H _{0}: LQ = 1) or to make comparisons across different regions.
Thirdly, as mentioned earlier, the GLM family encompasses a large number of commonly used statistical distributions. Thus one can use this framework for modelling indices that are based on health outcome measurements with different scales including continuous scale and categorical outcomes.
Results
Simulation results
Comparison of 95% confidence intervals for three location quotients (LQ^{1}, LQ^{2}, LQ^{3}) using three methods (D = delta, F = Fieller, P = Profilelikelihood). Varying incidence rates (p _{1}, p _{2}, p _{3}) were used along with 3 sets of population size configurations (a) n _{1} = 50, n _{2} = 80, n _{3} = 60 (b) n _{1} = 500, n _{2} = 900, n _{3} = 100 (c) n _{1} = 2000, n _{2} = 2500, n _{3} = 1500. A total of 1000 simulated data sets were used to generate "benchmark" limits (designated as "S" under method)
p _{1}  p _{2}  p _{3}  Method 





 

(a)  0.25  0.3  0.2  S  0.5903  1.3959  0.8787  1.4844  0.4332  1.1237 
D  0.5789  1.3905  0.8860  1.4679  0.4380  1.1155  
F  0.5664  1.4043  0.8815  1.4824  0.4239  1.1234  
P  0.5715  1.4995  0.8109  1.5950  0.4375  1.2183  
0.2  0.4  0.7  S  0.2249  0.6926  0.7125  1.0744  1.3548  1.8404  
D  0.2235  0.6776  0.7168  1.0909  1.3309  1.8413  
F  0.2156  0.6758  0.7126  1.0918  1.3464  1.8651  
P  0.2409  0.7287  0.6719  1.1505  1.3096  1.8251  
0.9  0.1  0.5  S  1.8387  2.3249  0.0956  0.3765  0.9383  1.3492  
D  1.7335  2.3942  0.0901  0.3640  0.9040  1.3841  
F  1.7718  2.4478  0.0846  0.3624  0.9044  1.3910  
P  1.8297  2.2054  0.1088  0.4035  0.8607  1.4280  
0.02  0.01  0.1  S  0.0000  1.6889  0.0000  1.0037  1.2667  3.1667  
D  0.1536  1.1816  0.0924  0.6015  1.4479  3.3499  
F  0.5404  1.5539  0.3073  0.7883  1.0254  4.2516  
P  0.3015  1.0973  0.1272  0.6214  1.9683  3.1071  
(b)  0.25  0.3  0.2  S  0.7924  1.0245  1.0156  1.1439  0.4483  1.0191 
D  0.7917  1.0197  1.0167  1.1489  0.4517  1.0012  
F  0.7911  1.0199  1.0167  1.1493  0.4504  1.0017  
P  0.7731  1.0476  0.9765  1.1932  0.4736  1.0343  
0.2  0.4  0.7  S  0.4766  0.6536  1.0807  1.1854  1.7154  2.2426  
D  0.4789  0.6537  1.0755  1.1865  1.7326  2.2467  
F  0.4781  0.6533  1.0757  1.1870  1.7370  2.2525  
P  0.4715  0.6698  1.0411  1.2225  1.7240  2.2265  
0.9  0.1  0.5  S  2.2140  2.3684  0.2129  0.2938  1.0390  1.5164  
D  2.1557  2.4273  0.2084  0.2971  1.0277  1.5079  
F  2.1629  2.4354  0.2078  0.2967  1.0281  1.5093  
P  2.2196  2.3530  0.2060  0.3053  1.022  1.5138  
0.02  0.01  0.1  S  0.5071  1.5517  0.2381  0.8333  2.5862  7.9550  
D  0.5212  1.5436  0.2396  0.7928  2.6717  7.7130  
F  0.4819  1.5835  0.2174  0.8136  2.5448  7.9803  
P  0.5205  1.8078  0.2494  0.9322  2.6765  8.8046  
(c)  0.25  0.3  0.2  S  0.9113  1.0322  1.1066  1.2119  0.7077  0.8480 
D  0.9089  1.0296  1.1088  1.2115  0.7043  0.8439  
F  0.9088  1.0296  1.1089  1.2117  0.7041  0.8438  
P  0.8970  1.0440  1.0914  1.2305  0.6977  0.8544  
0.2  0.4  0.7  S  0.4518  0.5288  0.9424  1.0115  1.6636  1.7688  
D  0.4519  0.5285  0.9427  1.0147  1.6588  1.7717  
F  0.4518  0.5283  0.9427  1.0147  1.6595  1.7726  
P  0.4482  0.5341  0.9319  1.026  1.6577  1.7712  
0.9  0.1  0.5  S  1.8962  1.9663  0.1923  0.2365  1.0271  1.1150  
D  1.8797  1.9797  0.1903  0.2374  1.0237  1.1176  
F  1.8808  1.9808  0.1902  0.2373  1.0237  1.1177  
P  1.9004  1.9567  0.1896  0.2399  1.0165  1.1249  
0.02  0.01  0.1  S  0.4000  0.7184  0.1798  0.3847  2.5421  3.0220  
D  0.4020  0.7094  0.1776  0.3813  2.5418  3.0449  
F  0.4005  0.7106  0.1766  0.3821  2.5428  3.0504  
P  0.4018  0.7441  0.1844  0.4026  2.3876  3.2374 
Panel (a) in Table 1 shows results when area population sizes are relatively small with n _{1} = 50, n _{2} = 80, n _{3} = 60, For this scenario, the results from the different approaches can differ, specially when the incidence rates are also small. For instance, when the three incidence rates are set to p _{1} = 0.02, p _{2} = 0.01, and p _{3} = 0.10, both the delta and Fieller intervals resulted in negative lower limits, which would obviously be inappropriate for location quotients. In such cases, the profilelikelihood method may be preferable. On the other hand, we observe a remarkable agreement among the different methods when population sizes are relatively large with n _{1} = 2000, n _{2} = 2500, n _{3} = 1500. In this case, the accuracy of the results is quite good even when the incidence rates are small, i.e., the last 4 rows of Table 1. Panel (b) provides results for moderate population sizes with n _{1} = 500, n _{2} = 900, n _{3} = 100. Overall, the three methods lead to quite similar confidence intervals in this situation, with the delta method and Fieller's intervals being more close to each other.
Application to health utilization data
In this section, the different methods of estimating confidence interval for the location quotient are illustrated using a health utilization data set from Ontario, Canada. Data were extracted from the Ontario Health Insurance Plan (OHIP) database for all ambulatory specialist visits due to rheumatoid arthritis in the fiscal year 1996. The visits were assigned to census divisions based on where the patient was registered and not where services were received. Forty four censuses divisions were used for analysis. For each county, the LQ is defined as the ratio of two proportions with the numerator representing the number of visits to rheumatologists in the census division divided by the total number of specialist visits in the census division, and the denominator defined as the number of visits to rheumatologists for the province divided by the total number of specialist visits in the province.
For a given county, a location quotient of less than one indicates that the utilization of health care services is under represented compared to the provincial utilization rate. On the other hand, a location quotient of greater than one suggests that health care services utilization is greater than expected. A location quotient of one indicates lack of under or over concentration of utilization in the census division.
Location quotients for health utilization data, with 95% lower and upper confidence limits using (1) Fieller's and (2) Profilelikelihood methods (see text for details about the data and methods)
County  n _{ i }  x _{ i }  LQ _{ i }  Fieller Lower  Fieller Upper  Profile Lower  Profile Upper 

1  975  365  0.779  0.716  0.842  0.717  0.843 
2  370  115  0.647  0.549  0.745  0.552  0.747 
3  275  155  1.173  1.051  1.295  1.050  1.293 
4  635  170  0.557  0.486  0.629  0.487  0.631 
5  2405  1835  1.588  1.552  1.623  1.552  1.622 
6  655  175  0.556  0.486  0.626  0.487  0.628 
7  730  335  0.955  0.880  1.030  0.880  1.030 
8  115  60  1.086  0.896  1.276  0.896  1.273 
9  3205  1545  1.003  0.968  1.038  0.967  1.039 
10  500  220  0.916  0.825  1.006  0.826  1.007 
11  365  125  0.713  0.611  0.814  0.614  0.816 
12  915  435  0.989  0.922  1.056  0.922  1.057 
13  4920  225  0.095  0.083  0.107  0.084  0.108 
14  500  315  1.311  1.223  1.399  1.222  1.397 
15  525  215  0.852  0.765  0.939  0.766  0.940 
16  20770  11035  1.106  1.093  1.118  1.091  1.120 
17  3025  1595  1.097  1.061  1.134  1.060  1.134 
18  350  155  0.922  0.813  1.030  0.814  1.030 
19  4500  1675  0.775  0.746  0.803  0.745  0.804 
20  610  460  1.569  1.498  1.640  1.496  1.638 
21  3915  2780  1.478  1.448  1.507  1.448  1.507 
22  10550  6710  1.323  1.305  1.342  1.304  1.343 
23  720  250  0.723  0.650  0.795  0.651  0.796 
24  6080  3130  1.071  1.046  1.096  1.045  1.097 
25  350  140  0.832  0.726  0.939  0.727  0.940 
26  1840  1140  1.289  1.244  1.335  1.243  1.335 
27  685  500  1.519  1.450  1.588  1.448  1.586 
28  920  405  0.916  0.850  0.982  0.850  0.983 
29  2585  1395  1.123  1.084  1.162  1.083  1.163 
30  1020  345  0.704  0.644  0.764  0.644  0.765 
31  770  470  1.270  1.199  1.342  1.198  1.341 
32  4240  1515  0.744  0.714  0.773  0.714  0.774 
33  1580  205  0.270  0.236  0.304  0.237  0.306 
34  5505  2475  0.936  0.909  0.962  0.908  0.963 
35  3665  2420  1.374  1.343  1.405  1.342  1.406 
36  1145  310  0.563  0.510  0.617  0.511  0.618 
37  485  100  0.429  0.354  0.504  0.357  0.507 
38  400  210  1.092  0.991  1.194  0.991  1.194 
39  170  50  0.612  0.470  0.754  0.477  0.760 
40  610  115  0.392  0.328  0.457  0.330  0.460 
41  380  115  0.630  0.534  0.726  0.537  0.728 
42  2695  865  0.668  0.632  0.704  0.632  0.705 
43  1865  540  0.603  0.560  0.645  0.560  0.646 
44  165  30  0.378  0.256  0.501  0.267  0.511 
Total  98685  47425 
There is a remarkable agreement in the confidence intervals from both the Fieller and profilelikelihood approaches due to the fact that the denominator of the ratio is estimated with sufficiently high precision, which would be the case for applications with large sample sizes. Small relative differences are observed when sample sizes are small, as in counties 39 and 44 in Table 2.
The LQ was significantly greater than 1, which is the entire confidence interval falls above 1, for 32% (14/44) of the census divisions, indicating significantly higher utilization of health care services for rheumatoid arthritis than the provincial rate. Similarly, 52% (23/44) of the census divisions showed a significantly lower utilization rate. The remaining 16% experienced a utilization rate compatible with the provincial rate.
Discussion
The location quotient (LQ) is one of several spatial measures that is widely used to examine spatial variation of area characteristics [14]. However, a frequently occurring 'gap' is the widespread use of LQ as a point estimate without an accompanying confidence interval. In this paper, we have demonstrated that confidence intervals for ratio parameters in general and location quotients in particular can be obtained using a number of complimentary approaches. Three techniques – the delta method, Fieller's interval, and profilelikelihood based interval from a generalized linear model – are presented and illustrated. We also demonstrated that if the denominator of the ratio is estimated with sufficiently high precision, then the methods introduced in this paper will produce very similar confidence intervals. The normal approximation to the binomial is used for the variance estimate for the calculation by the delta and Fieller methods. Hence it is not surprising that these methods do not perform well for small sample sizes and extreme proportions.
The techniques we described are generic and can be applied to a wide range of settings where ratio parameters are in use. The generalized linear model (GLM) approach is particularly appealing since the parameters of interest (in our application the location quotients) are estimated directly along with confidence intervals and significance levels. These considerations can be important in practical applications where there are several parameters to be estimated. For instance, for the health utilization data set we analyzed in this paper, 44 location quotients and their confidence intervals had to be generated and the modelling approach was the preferred method over the delta and Fieller's techniques.
Declarations
Acknowledgements
The authors would like to acknowledge helpful comments by the reviewers. JB acknowledges the support of the Research Institute at the Hospital for Sick Children.
Authors’ Affiliations
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