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Are Local Health Department Expenditures Related to Racial Disparities in Mortality?

Are Local Health Department Expenditures Related to Racial Disparities in Mortality?. David Grembowski Douglas Conrad Betty Bekemeier William Kreuter University of Washington Funded by the Robert Wood Johnson Foundation & Changes in Health Care Financing and Organization.

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Are Local Health Department Expenditures Related to Racial Disparities in Mortality?

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  1. Are Local Health Department Expenditures Related to Racial Disparities in Mortality? David Grembowski Douglas Conrad Betty Bekemeier William Kreuter University of Washington Funded by the Robert Wood Johnson Foundation & Changes in Health Care Financing and Organization

  2. Healthy People 2010 • Goal 1: Increase quality and years of healthy life • Goal 2: Eliminate health disparities • Gender, race/ethnicity, education/income, disability, rural/urban, sexual orientation

  3. Population Health Paradox • Population health has increased in many developed countries • Disparities in population health have increased in many developed countries

  4. Absolute Change vs. Relative Disparityin Infant Mortality by Racial/Ethnic Group 2002- Absolute 19502004Change Black 44 14 30 White27 621 B/W Rate Ratio* 1.63 2.33 .70 bigger gap * 1950 Black/White Rate Ratio = 44/27 = 1.63 Infant mortality rate: rate of deaths in children less than 1 year old per 1,000 live births Health, United States, 2007

  5. Absolute Change vs. Relative Disparityin All-Cause, Age-Adjusted Mortality by Racial/Ethnic Group Absolute 19502004 Change Black 1,722 1,027 695 White1,411 786625 B/W Rate Ratio* 1.22 1.31.09 bigger gap * Black-White rate ratio in 1950 is 1,722/1,411 = 1.22 Rates are per 100,000 population Health, United States, 2007

  6. Race & Gender Health, United States

  7. Determinants of Population Health & Health Disparities Physical & Social Environment Behavior PopulationHealth & Disparities Human Biology Medical Care

  8. Determinants of Population Health & Health Disparities Physical & Social Environment Behavior PopulationHealth & Disparities Human Biology Medical Care Public Health

  9. Health Policy To reduce racial/ethnic disparities in mortality, How much of society’s resources should be invested in local public health systems vs. other determinants of population health and health disparities? What is the evidence that local public health funding reduces racial/ethnic disparities in mortality?

  10. Can Local Public Health Reduce Racial/Ethnic Disparities? • Yes! • Population-based interventions that influence everyone have the potential to reduce health disparities • Water fluoridation reduces disparities in oral health • Raising the health of the worst off fastest • No! • Policies to improve overall population health may increase disparities because people with more resources are more likely to take advantage of them • Goal of improving population health may conflict with goal of reducing health disparities Link & Phelan 2005; Mechanic 2002

  11. Few Studies • Medical Care • 10% increase in medical expenditures per capita associated with 1-2% reduction in mortality rates (Hadley, 1982) • Public Health • 10% increase in local health department spending per capita associated with 1-7% decline in mortality rates (Mays & Smith 2007) • In 1907-1910, 1 standard deviation increase in city health expenditures associated with decline in infant mortality from 14.9 to 11.5 deaths per 100 children under age 1 (Costa & Kahn 2006)

  12. What Matters for Policy? For local health departments (LHDs): Is it the amount of LHD spending per capita - or - Is it the share of total public revenue in a local area that goes to a LHD that matters in reducing racial/ethnic disparities in mortality rates?

  13. Methods Time-Trend Ecologic Study Design Test whether 1990-1997 changes in LHD funding are associated with 1990-1997 changes in Black/White mortality rates

  14. Data Sources • LHD expenditures: 1990 & 1997 National Profiles of Local Health Departments from the National Association of County and City Health Officials (NACCHO) • 1990 & 1997 Black and White mortality rates from the CDC Compressed Mortality File • 1989-91 & 1996-98 Black and White infant mortality rates

  15. Data Sources • U.S. Census of Government Organizations • U.S. Population Census, 1990 county • Area Resource File (Bureau of the Health Professions), county • Medicare county expenditures per capita (Centers for Medicare and Medicaid Services) • Rural/urban county commuting codes (Department of Agriculture)

  16. Number of Local Areas • Population: 3,256 LHDs in 1990 (NACCHO) • 857 local areas with Black & White all-cause mortality rates • 562 local areas (66%) have 1990 & 1997 Profile Surveys • 187 local areas with Black & White infant mortality rates in 1989-1991 & 1996-98 • 133 local areas (71%) have 1990 & 1997 Profile Surveys

  17. All-Cause, Age-Adjusted Mortality Variables • Absolute change for each race • Change = (1997MR - 1990MR) • Males & Females • Males • Females • Change in Black/White Rate Ratio • Change = (1997 B/W Ratio - 1990 B/W Ratio)

  18. Policy Variables • Change in LHD Expenditures per capita • Change = (1997 LHD$ - 1990 LHD$) • Change in percentage share of total local public revenue going to LHD • Percentage = LHD expenditures/(total revenue from county govt + cities & towns + school districts + special districts) • Change = (1997% - 1990%)

  19. Local Area Control Variables Social Environment Area Characteristics Female Rural/Urban Education Home value Income Rent amount Income inequality White collar occupation Unemployment Medical Care Household size Medicare expenditures Single female household Percent Black Health Care System Foreign residents Hospital beds English speaking Physicians Veterans Drive to work People in mental institutions People in correctional institutions

  20. Data Analysis • Descriptive statistics • General Estimating Equations (GEE) • 40 binary (0,1) State variables to control for State-level influences on local areas • Standard errors adjusted for clustering of local areas by Federal Region • Test for 2-way causation between LHD funding and mortality

  21. ResultsLHD Funding (Medians) 1997-1990 1990 1997 Change LHD expenditures $22* $30 $7 per capita % share of public 0.99% 1.17% 0.17 revenue to LHD * Adjusted 1997 dollars

  22. Average Mortality Rates 1997-1990 1990 1997 Change Black Mortality Total 1,235 1,152 -83 Female 969 932 -37 Male 1,646 1,479 -167 White Mortality Total 956 914 -41 Female 754 743 -11 Male 1,244 1,150 -94 ___________________________________________________________________________________ Rates are per 100,000 population

  23. Absolute Change in Black Mortality Rates(1997 – 1990)

  24. Mortality Rates & 1990 + 1997 Profile Surveys Areas Areas with without Profile Profile Surveys Surveys Both Yrs Both Yrs p-value 1997-1990 Change Black mortality -83 -34 .004 White mortality -41 -40 .868 Black infant mortality -3.0 -1.8 .070 White infant mortality -1.5 -1.2 .060 ___________________________________________________________________________________

  25. 1997 - 1990 Absolute Change in Black Mortality Rates 1997-1990 change in LHD expenditures per capita are not associated with 1997-1990 change in Black total mortality, Black female mortality and Black male mortality

  26. Change in LHD Share of Public Revenue & Change in Mortality Rates A 1-percent increase in share of public revenue to LHD associated with small declines in Black and White mortality rates: Avg Change 1997-1990 Mortality Decline Black Total Mortality -83 -1.24# White Total Mortality -41 -1.65# Black Female Mortality -37 -0.98 White Female Mortality -11 -1.35# Black Male Mortality -167 -2.23 White Male Mortality -94 -1.41# ___________________________________________________________________________________ Rates are per 100,000 population # Statistical test for 2-way causation significant

  27. 1990 & 1997 Black/White Rate Ratios (Averages) 1997-1990 1990 1997 Change Total 1.30 1.27 -.03 Female 1.30 1.28 -.02 Male 1.34 1.30 -.04 ____________________________________________________________________________

  28. Change in Black/White Rate Ratios(1997 – 1990)

  29. 1997 - 1990 Change inBlack/White Mortality Rate Ratios 1997-1990 changes in LHD expenditures per capita or changes in share of public revenue for LHD are not associated with 1997-1990 changes in Black/White rate ratios

  30. Average Infant Mortality Rates 1997-1990 1990 1997 Change Absolute Change Black 18 15 -3 White 8 6 -2 B/W Rate Ratio 2.35 2.43 +.08 _________________________________________________________________________ Rates are deaths in children less than 1 year old per 1,000 live births

  31. 1997 - 1990 Change inWhite Infant Mortality Rates 1997-1990 changes in LHD expenditures per capita or share of public revenue for LHD are not associated with 1997-1990 changes in White infant mortality rates

  32. 1997 – 1990 Change in Black Infant Mortality Rates • A 1-percent increase in share of public revenue to LHD associated with: • 0.36 increase in Black infant mortality rate (p =.002) • 0.07 increase in B/W rate ratio (p<.001) • A $1 increase in LHD expenditures per capita associated with: • 0.01 increase in Black infant mortality rate (p=.009)

  33. Conclusions • Per capita LHD expenditures and share of public revenue going to LHD generally not related to disparities in Black and White mortality rates • A greater share of public revenue for LHDs related to small decline in Black male mortality

  34. Conclusions • Per capita LHD expenditures and share of public revenue going to LHD related to greater Black infant mortality • We also are analyzing whether LHD services are related to Black/White disparities in mortality

  35. Limitations • Correlation or causation • Omitted variables (population-level smoking, medical care rates) • No data for LHDs without Profile Surveys • No data for how LHDs spent funds in 1990/97 Profile Surveys • No data for public health spending by other community agencies • Black county populations often too small to calculate cause of death mortality rates (by gender) • Only 2 racial/ethnic groups

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