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James P. Scanlan Washington, DC jps@jpscanlan

7 th International Conference on Health Policy Statistics, Philadelphia, PA, January 17-18, 2008 Can We Actually Measure Health Disparities?. James P. Scanlan Washington, DC jps@jpscanlan.com. Four Binary Indicators of Difference.

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James P. Scanlan Washington, DC jps@jpscanlan

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  1. 7th International Conference on Health Policy Statistics, Philadelphia, PA, January 17-18, 2008Can We Actually Measure Health Disparities? James P. Scanlan Washington, DC jps@jpscanlan.com

  2. Four Binary Indicators of Difference 1 Relative differences between rates of experiencing an outcome 2 Relative differences between rates of avoiding an outcome 3 Odds ratios 4 Absolute differences between rates

  3. References • Health Disparities Measurement tab on jpscanlan.com • Can We Actually Measure Health Disparities? Chance (Spring 2006) (A12) • Race and Mortality, Society (Jan-Feb 2000) (A10) • The Misinterpretation of Health Inequalities in the United Kingdom, British Society for Population Studies Conference 2006 (B7) • Measurement Problems in the National Healthcare Disparities Report, American Public Health Association 135th Annual Meeting & Exposition, Washington, DC, Nov. 3-7, 2007 (B12)

  4. Fig 1: Ratio of (1) DG Failure Rate to AG Failure Rate (AOR)

  5. Fig. 2: Ratios of (1) DG Fail Rate to AG Fail Rate (AOR) and (2) AG Pass Rate to DG Pass Rate (FOR) ZoneA ZoneB Point X Oin xPt

  6. Fig. 3: Ratios of (1) DG Fail Rate to AG Fail Rate (AOR), (2) AG Pass Rate to DG Pass Rate (FOR), and (3) DG Fail Odds to AG Fail Odds ZoneA ZoneB Oin xPt Point X

  7. Fig. 4: Ratios of (1) DG Fail Rate to AG Fail Rate (AOR), (2) AG Pass Rate to DG Pass Rate (FOR), (3) DG Fail Odds to AG Fail Odds; and (4) Absolute Difference Between Rates Zone A Zone B Zone A Point X ● Zone A Zone B Point X

  8. Fig 5: Ratios of (1) DG Fail Rate to AG Fail Rate (AOR), (2) AG Pass Rate to DG Pass Rate (FOR), (3) DG Fail Odds to AG Fail Odds; and (4) Absolute Difference Between Rates – for Range Defined by AG Fail Rate from 31 to 50 Point X ● Point X

  9. Fig. 6. Ratios of (1) Bl to Wh Rate of Falling Below Percentages of the Poverty Line (AOV), (2) Wh to Bl Rate of Falling Above the Percentage (FOV), (3) Bl to Wh Odds of Falling Below the Percentage: and (4)Absolute Difference Between Rates ZoneA Zone B Point X ● Zone A Zone B Point X

  10. Fig. 7. Ratio of (1) Bl to Wh Rate of Falling Above Various SBP Levels, (2) Wh to Bl Rate of Falling below the Level, (3) Bl to Wh Odds of Falling Above the Level; and (4) Absolute Difference Between Rates (NHANES 1999-2000, 2001-2002, Men 45-64) ZoneA Zone B Point X ● Zone A Zone B Point X

  11. Patterns of Black and White Rates of Adequate Hemodialysis Sehgal AR. Impact of quality improvement efforts on race and sex disparities in hemodialysis. JAMA 2003;289:996-1000 Rates of adequate hemodialysis: Year White Black 1993 46% 36% 2000 87% 84% Summary of changes in rate differences: Absolute diff: decreased from 10 to 3 percentage points Rel diff in adequate dialysis: decreased from 28% to 4% (cor. 3/08) Rel diff in inadequate dialysis: increased from 19% to 23% See B12, D23, D23a, D42 Difference between means of hypothetical underlying distributions: 1993: .26 standard deviations 2000: .14 standard deviation See D43

  12. Two Contrasting Studies • Trivedi et al. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353:692-700: found (mainly) declining absolute differences during periods of increasing prevalence of appropriate care • Jha et al. Racial trends in the use of major procedures among the elderly. N Engl J Med 2005;353:683-691: found (mainly) increasing absolute differences during periods of increasing prevalence of procedures • See D23, D23a, D40, D40a, D41, D41a, B11

  13. Fig 8: Ratios (1) DG Fail Rate to AG Fail Rate, (2) AG Pass Rate to DG Pass Rate, (3) DG Fail Odds to AG Fail Odds: and Absolute Differences within Subpopulation Falling Below Point Defined by 30 Percent Fail Rate for AG ZoneA Zone B ● Zone B Zone A

  14. Fig.9: Absolute Difference Between Rates within the Total Population, and with Population Below the 30 Percent Fail Rate for the AG, according to AG Fail Rate Within Each Population. ZoneA Zone B ● Zone B Zone A

  15. Fig. 10. Ratio of (1) Bl to Wh Rate of Falling Above Various SBP Levels, (2) Wh to Bl Rate of Falling below the Level, (3) Bl to Wh Odds of Falling Above the Level; and (4) Absolute Difference Between Rates (NHANES 1999-2000, 2001-2002, Men 45-64), Limited to Population with SBP Above 139 ZoneA Zone B ● Zone A Zone B

  16. Figure 11: Absolute Differences Between Rates of Falling Above Certain SBP Levels for Overall Population and Population with SBP above 139 ZoneA Zone B ● Zone A Zone B

  17. Measurement Possibilities on a Seemingly Continuous Scales • Longevity – no (see B7, B11) • SF 36 scores – no (see B11) • Metabolic syndrome measures – no (see B11) • Cardio risk indexes – no (see B11) • Allostatic load – possibly (see B11) • Components of allostatic load – possibly (see B9, B11) • Cortisol level – possibly (see B11) • Self rated health on a continuous scale - possibly (see B7, B11) • Gini coefficient, concentration Index etc (see A12, D43)

  18. Measurement Possibilities Using Outcome Rates • Approach 1 – departures from standard patterns (A12, B7, D41, D43) • Approach 2 – identifying the difference between means of hypothetical underlying distributions based on group rates in settings being compared (D43)

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