1. Disparity Measurement in Healthy People 2010 John Aberle-Grasse, MPH National Center for Health Statistics

2. Healthy People 2010 goals 1.Increase quality and years of healthy life 2. Eliminate health disparities No method for measuring disparity initially specifiedNo method for measuring disparity initially specified

3. Healthy People 2000 goals 1.Increase the span of healthy life 2.Reduce health disparity in special populations Address the problems that represent the greatest needAddress the problems that represent the greatest need Separate targets set for special and total populationsSeparate targets set for special and total populations 3.Achieve access to preventive services

4. (RP l -RP b )/RP b (SP l -SP b )/SP b Chose: Percent change over time or Ratio of percent change special population reference population Baseline (b)Last data point (l) NOTE: Imaginary data

5. Healthy People 2010 2 nd goal Eliminate Health DisparitiesEliminate Health Disparities “The second goal of Healthy People 2010 is to eliminate health disparities among segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.” “The second goal of Healthy People 2010 is to eliminate health disparities among segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.”

6. Healthy People 2010 2 nd goal Eliminate Health DisparitiesEliminate Health Disparities Implement a vision for the nation’s healthImplement a vision for the nation’s health A single target for all population groupsA single target for all population groups Standard set of population subgroupsStandard set of population subgroups Applies to all population-based objectives (389 of 467 objectives)Applies to all population-based objectives (389 of 467 objectives)

7. Minimum population template Additional categories

8. Is ratio of percent change a good option for measuring disparity in Healthy People 2010? Healthy People 2000 was concerned with:Healthy People 2000 was concerned with: only special populationsonly special populations at particularly high risk for death, disease or disabilityat particularly high risk for death, disease or disability Healthy People 2010 is concerned with:Healthy People 2010 is concerned with: all subpopulations all subpopulations some worse off and some are better off than the totalsome worse off and some are better off than the total

9. Ratio of percent change compares change over time but not inequality at a given point in time Percent change = 0.66 2 2 4 NOTE: Imaginary data

10. Healthy People 2010 2 nd goal Eliminate Health DisparitiesEliminate Health Disparities Policy and statistical questions specific to Healthy People 2010Policy and statistical questions specific to Healthy People 2010

11. Situations for measuring disparity in Healthy People 2010 Single group across a set of objectivesSingle group across a set of objectives Race/ethnicityRace/ethnicity Socioeconomic statusSocioeconomic status (eg. How are Hispanics doing compared to the total population on diabetes objectives)(eg. How are Hispanics doing compared to the total population on diabetes objectives) Two groupsTwo groups SexSex Urban compared to ruralUrban compared to rural Multiple groupsMultiple groups Race/ethnicityRace/ethnicity Socioeconomic statusSocioeconomic status

12. Two groups

13. Questions common to each of the three situations What are the contexts for measuring disparity?What are the contexts for measuring disparity? Cross sectionalCross sectional Over timeOver time Across objectivesAcross objectives Between types of subpopulationsBetween types of subpopulations Across geographic areasAcross geographic areas

14. Questions common to each of the three situations Measure progress and disparity separately?Measure progress and disparity separately? What is the reference point?What is the reference point? Is an absolute or relative comparison of interest?Is an absolute or relative comparison of interest? Which statistic should be used?Which statistic should be used? Measure positive or negative outcomes?Measure positive or negative outcomes?

15. Should progress toward targets and elimination of disparity be measured separately? Measuring the two dimensions together introduces confoundingMeasuring the two dimensions together introduces confounding The two goals are listed separately; each dimension is of interest on its ownThe two goals are listed separately; each dimension is of interest on its own Measuring the two dimensions allows each of the goals to be tracked separatelyMeasuring the two dimensions allows each of the goals to be tracked separately

20. A three part approach to measuring progress in Healthy People 2010 is suggested Measure progress towards targetsMeasure progress towards targets OverallOverall Particular groupsParticular groups Measure disparityMeasure disparity OverallOverall Particular groupsParticular groups Explore and indicate any particular issuesExplore and indicate any particular issues Particular groupsParticular groups

22. “Best” rate- may change“Best” rate- may change Average rate- does not consider population distributionAverage rate- does not consider population distribution Total rate- is relatively stableTotal rate- is relatively stable Target rate- is a constant reference over timeTarget rate- is a constant reference over time Not all objectives use “better than best” as target setting methodNot all objectives use “better than best” as target setting method Is there a particular reference group suggested by HP2010?

23. Healthy People 2000 used total populationHealthy People 2000 used total population NIH minority health disparity charge seems to compare disparate race/ethnicity subpopulations to the total populationNIH minority health disparity charge seems to compare disparate race/ethnicity subpopulations to the total population Does Healthy People 2010 stated goals of eliminating health disparities and improving health for all segments of the population suggest using the “best” or target when it is set as “better than the best”?Does Healthy People 2010 stated goals of eliminating health disparities and improving health for all segments of the population suggest using the “best” or target when it is set as “better than the best”?

24. Absolute or relative measure? Absolute measures provide information about the number of excess eventsAbsolute measures provide information about the number of excess events Relative measures allow comparisons without regard to magnitudeRelative measures allow comparisons without regard to magnitude Absolute and relative measures may lead to the same conclusions when applied to the same objective at a given timeAbsolute and relative measures may lead to the same conclusions when applied to the same objective at a given time Absolute and relative measures may lead to different conclusions in comparisons over time or between objectivesAbsolute and relative measures may lead to different conclusions in comparisons over time or between objectives

25. Which statistic should be used? Particular group or Two groups Multiple groups Simple difference (A)Range (A) Percent difference (R)Mean deviation (A) Ratio (R)Mean deviation/ reference pt. (R) Simple difference/ target (H)Average of ratios (R) Mean deviation/ target (H)

26. Objectives measure positive or negative outcomes? Positive (success)Positive (success) Increase health insurance coverageIncrease health insurance coverage Negative (failure)Negative (failure) Reduce deaths caused by motor vehicle crashesReduce deaths caused by motor vehicle crashes Measuring all disparities in same terms allows comparison of relative measures of disparity across objectivesMeasuring all disparities in same terms allows comparison of relative measures of disparity across objectives

27. 80 20 75 25 Percent with health insurancePercent without health insurance 0 20 40 60 80 100 Percent Group one Group two Health insurance coverage in two groups NOTE: Imaginary data |80-75| = 5% |20-25|=5% |80-75/75| = 6.7% |20-25/25|=20%

28. Objectives measure positive or negative outcomes? Some objectives cannot usefully be measured as successesSome objectives cannot usefully be measured as successes NIH Strategic Plan to Reduce and Ultimately Eliminate Health Disparities defines disparity in terms of adverse health conditions, failuresNIH Strategic Plan to Reduce and Ultimately Eliminate Health Disparities defines disparity in terms of adverse health conditions, failures The HP2000 Health Status Indicators all used negative outcomes to be reduced (failures) so they could be comparedThe HP2000 Health Status Indicators all used negative outcomes to be reduced (failures) so they could be compared

29. Several common questions for each of these situations Measure progress and disparity separately?Measure progress and disparity separately? What is the reference point?What is the reference point? Is an absolute or relative comparison of interest?Is an absolute or relative comparison of interest? Which statistic should be used?Which statistic should be used? Measure positive or negative outcomes?Measure positive or negative outcomes? What is the context for measuring disparity?What is the context for measuring disparity? Cross sectionalCross sectional Over timeOver time Across objectivesAcross objectives Between types of subpopulationsBetween types of subpopulations Across geographic areasAcross geographic areas

30. Resources DHHS Healthy People: www.health.gov/healthypeople www.health.gov/healthypeople NCHS Healthy People: www.cdc.gov/nchs/healthypeople www.cdc.gov/nchs/healthypeople DATA2010: www.wonder.cdc.gov/data2010 www.wonder.cdc.gov/data2010