Eliminating Health Disparities: Healthy People Methods & Findings

1. Eliminating Health Disparities: Healthy People Methods & Findings LT David T. Huang, PhD, MPH, CPH Health Promotion Statistics Branch USPHS Scientific and Training Symposium College Park, MD June 20, 2012 Office of Analysis and Epidemiology National Center for Health Statistics

2. Outline • Background • HP2010 Methods • Choice of reference point • Absolute vs. relative statistics • Favorable and adverse outcomes • Summary Index • Changes in disparity over time • HP2010 Findings, Issues, and Limitations • Conclusions and Next Steps 2

3. Outline • Background • HP2010 Methods • Choice of reference point • Absolute vs. relative statistics • Favorable and adverse outcomes • Summary Index • Changes in disparity over time • HP2010 Findings, Issues, and Limitations • Conclusions and Next Steps 3

4. What is Healthy People? • A national agenda that communicates a vision for improving health and achieving health equity • A framework for public health priorities and actions • Overarching goals and a set of specific, measurable objectives with targets to be achieved over the decade. 4

5. Aligns Strategic Public Health Goals and Efforts Across the U.S. Healthy People: Strengths Non-Aligned Effort Aligned Effort Healthy People 5

6. Federally Led, Stakeholder-Driven HHS Secretary’s Advisory Committee HHS ODPHP Federal Interagency Workgroup (28 Federal Agencies) State and Local Governments (50 State Coordinators) National-Level Stakeholders, Including Members of the Healthy People Consortium (2,200+ Volunteers) Community-Based Organizations, Community Health Clinics, Social Service Organizations, etc. Individuals, Families, and Neighborhoods Across America 6

7. Role of NCHS in Healthy People • Statistical advisor to HHS and the Healthy People topic area Workgroups on health promotion data • Maintains comprehensive database for all the Healthy People objectives • Develops research on measuring the overarching goals of Healthy People • Develops analytic and graphical presentations to display progress towards reaching HP goals and objectives 7

8. Evolution of Healthy People 8

9. Healthy People 2010 Goals • Goal 1: Increase the quality and years of healthy life • Goal 2: Eliminate health disparities “Disparity is the quantity that separates a group from a reference point for an indicator of health that is measured in terms of a rate, proportion, mean, or some other quantitative measure.” Keppel KG, Pearcy JN, Klein RJ. Healthy People 2010 Statistical Note No. 25. Hyattsville, MD. 2004. 9

10. Healthy People 2010 Disparity Definition “Disparity is the quantity that separates a group from a reference point for an indicator of health that is measured in terms of a rate, proportion, mean, or some other quantitative measure.” Keppel KG, Pearcy JN, Klein RJ. Healthy People 2010 Statistical Note No. 25. Hyattsville, MD. 2004. 10

11. Outline • Background • HP2010 Methods • Choice of reference point • Absolute vs. relative statistics • Favorable and adverse outcomes • Summary Index • Changes in disparity over time • HP2010 Findings, Issues, and Limitations • Conclusions and Next Steps 11

12. HP2010 Final ReviewHealth Disparities Table • Summary of disparities for each population-based objective (n=469) • Disparities at most recent time • Changes in disparities over time • Characteristics • Race and ethnicity • Sex • Education level • Family income • Geographic location • Disability status 12

13. HP2010 Final Review Health Disparities Table Extract 13

14. HP2010 Final Review Health Disparities Table Legend 14

15. Choice of Reference Point • The “best” (most favorable) group rate was chosen as the reference point for measuring disparities • Potential for improvement among comparison groups • Best rate is theoretically achievable by all groups • More stringent reliability criterion (vs. data suppression): RSE < 10% 15

16. Choice of Reference Point 16

17. Absolute vs. Relative Statistics • Disparities measured relative to group with best rate • Used to compare objectives measured by different units • Unlike absolute measures, relative measures are unit free • Pairwise comparisons between group with the best rate and all other groups Percent difference (PD) Statistical significance of simple difference: , where Rb= best group rate Ri= rate of group i SEb= standard error of best group rate SEi = standard error of group i rate • If Z ≥ 1.645, statistically significant at the 0.05 level 17

18. Size of Relative Disparity Percent difference from the best group rate Less than 10%, or not statistically significant (when estimates of variability are available) 10%–49% 50%–99% 100% or more 18

19. Favorable and Adverse Outcomes • Disparity measured in terms of adverse events • About 25% of HP2010 objectives expressed in terms of favorable events that are to be increased • For comparability, all objectives were re-expressed using corresponding adverse events solely when evaluating disparities 3-13. Women receiving a mammogram within past 2 years (age adjusted, 40+ years) 19

20. Summary Index • Summary Index (Index of Disparity): Measure to summarize relative disparities for characteristics with 3 or more groups Summary Index , where • Bootstrap method used to obtain standard errors Reference: Pearcy JN, Keppel KG. A summary measure of health disparity. Public Health Rep 117, 273 80. May June 2002. n = number of groups 20

21. Changes in Disparities over Time • Pairwise: PDfinal – PDbaseline • Summary Index: SIfinal – SIbaseline • Changes in disparity are measured in percentage points • Statistical significance is assessed by: • Estimating an RSE for the percent difference • Calculating an approximate standard error for the percent difference • Using a Z-statistic for a simple percentage-point difference 21

22. Changes in Disparities over Time • Changes in disparities over time are only shown when: • (a) disparities data are available at both baseline and most recent time points; • (b) data are not for the group(s) indicated by "B" or "b" at either time point; and • (c) the change is: • greater than or equal to 10 percentage points and statistically significant • greater than or equal to 10 percentage points and estimates of variability were not available • Healthy People 2010 Final Review Technical Appendix provides details 22

23. Outline • Background • HP2010 Methods • Choice of reference point • Absolute vs. relative statistics • Favorable and adverse outcomes • Summary Index • Changes in disparity over time • HP2010 Findings, Issues, and Limitations • Conclusions and Next Steps 23

24. Healthy People 2010 Final Review • End of decade assessment of progress toward goals and objectives • Summary of Findings • Visuals • Progress • Disparities • Maps • Technical Appendix • Crosswalk to HP2020 24

25. Disparities at Most Recent Time Point by Race and Ethnicity Number of objectives (157) (98) (38) (66) (96) (311) (345) (354) Percent difference from the best group rate NOTES: Disparity from the best group rate is defined as the percent difference between the best group rate and each of the other group rates. “Less than 10%” includes changes that are not statistically significant (when estimates of variability are available). 25

26. Disparities by Race and Ethnicity 26

27. Disparities by Race and Ethnicity 27

28. Changes in Disparity over the Decade by Characteristic Number of objectives Disparity decrease Disparity increase No change Total Race and ethnicity* 117 169 Sex 167 216 Education* 107 132 Income* 64 75 Geographic location 23 33 Disability status 47 51 30 25 20 15 10 5 0 5 10 15 20 25 30 Disparity decrease Disparity increase 10-49 percentage points 10-49 percentage points 50-99 percentage points 50-99 percentage points 100 percentage points or more 100 percentage points or more NOTES: Changes in disparity from the baseline to the most recent time point are only shown when they can be assessed. No change includes changes of less than 10 percentage points, regardless of statistical significance, and all changes that are not statistically significant, when estimates of variability are available. FOOTNOTE: * Number of objectives with changes in the summary index as a measure of disparity. 28

29. Issues and Limitations • Availability of subgroup data • Availability of standard errors • Different time periods of analysis • Complexity of measuring health disparities 29

30. Outline • Background • HP2010 Methods • Choice of reference point • Absolute vs. relative statistics • Favorable and adverse outcomes • Summary Index • Changes in disparity over time • HP2010 Findings, Issues, and Limitations • Conclusions and Next Steps 30

31. HP 2010 Findings • Substantial health disparities between populations were observed for many objectives • Most objectives had no change in disparities • Health disparities persist in the U.S. • Disparities measurement continues to be a challenge 31

32. Transitioning to 2020 32

33. HP2010 Population Template Race and ethnicity Sex Education level Less than high school High school graduate At least some college OR Family income level Poor Near poor Middle/high income Optional Age Geographic location Urban/metropolitan Rural/non-metropolitan Disability status Persons with disabilities Persons without disabilities 33

34. HP2020 Population Template Race and ethnicity Age Sex Education level Less than high school High school graduate At least some college Associates degree 4 year college degree Advanced degree Family income level (% Federal Poverty Limit) <100 100-199 200-399 400-599 600+ Family type Single Married couple or partners Two parent family with children Single parent with children Other Country of birth US Outside US Disability status Persons with disabilities Persons without disabilities Geographic location Metropolitan Non-metropolitan Health insurance status Insured Any private Public only Uninsured Select Populations Sexual orientation People with chronic conditions People in nursing homes People in active military service People in prisons Marital status Veteran status Obesity status 34

35. Disparities: Looking Ahead 35

36. Lesley Dobrzynski Bob Francis Leda Gurley Elizabeth Jackson Bruce Jonas Deepthi Kandi Insun Kim Jeff Pearcy Cheryl Rose Kimberly Rosendorf Asel Ryskulova Makram Talih Ritu Tuteja Jean Williams Acknowledgements – NCHS Team Rebecca Hines, Chief, Health Promotion Statistics Branch Special Thanks to Richard Klein, NCHS, Chief, Health Promotion Statistics Branch (retired) 36

37. Online • Healthy People: http://www.healthypeople.gov • Healthy People 2010 Final Review: http://www.cdc.gov/nchs/healthy_people/hp2010/hp2010_final_review.htm • DATA 2010 (HP2010 Data): http://wonder.cdc.gov/data2010 • Health Indicators Warehouse (HP2020 data): http://www.healthindicators.gov 37

38. Contact David T. Huang, PhD, MPH, CPH LT, US Public Health Service Research Support Scientist CDC/National Center for Health Statistics 3311 Toledo Road, Room 6311 Hyattsville, MD 20782 Office: 301.458.4213 Email: dhuang@cdc.gov National Center for Health Statistics Office of Analysis and Epidemiology • The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the National Center for Health Statistics, Centers for Disease Control and Prevention. 38