Is there progress toward eliminating racial/ethnic disparities in the leading causes of death?

OBJECTIVES: We examined changes in relative disparities between racial/ethnic populations for the five leading causes of death in the United States from 1990 to 2006. METHODS: The study was based on age-adjusted death rates for four racial/ethnic populations from 1990-1998 and 1999-2006. We compared the percent change in death rates over time between racial/ethnic populations to assess changes in relative differences. We also computed an index of disparity to assess changes in disparities relative to the most favorable group rate. RESULTS: Except for stroke deaths from 1990 to 1998, relative disparities among racial/ethnic populations did not decline between 1990 and 2006. Disparities among racial/ethnic populations increased for heart disease deaths from 1999 to 2006, for chronic obstructive pulmonary disease deaths from 1990 to 1998, and for chronic lower respiratory disease deaths from 1999 to 2006. CONCLUSIONS: Deaths rates for the leading causes of death are generally declining; however, relative differences between racial/ethnic groups are not declining. The lack of reduction in relative differences indicates that little progress is being made toward the elimination of racial/ethnic disparities.

Comparing racial and ethnic populations based on Healthy People 2010 objectives.

Objective - The Healthy People 2010 initiative (HP2010) specified objectives for improving the health of the nation, established baseline values, and set specific targets to be achieved by 2010. HP2010 objectives are based on two overarching goals: First, to increase years and quality of life, and second, to eliminate disparities among subgroups of the population. In this report racial and ethnic populations are compared based on progress toward targets, the size of disparities, and changes in disparity for specific sets of objectives. Methods - Progress is measured in terms of movement toward or away from the target between the HP2010 baseline and the most recent data point. Disparities are measured as the percent difference between the rate for the racial and ethnic population with the best or most favorable rate and the rates for the other racial and ethnic populations. Changes in disparity are measured in terms of the percentage point change in the percent difference from the best group rate between the baseline and the most recent data point. Some comparisons can be made based on objectives with data for five populations (American Indian or Alaska Native, Asian, Hispanic or Latino, non-Hispanic black, and non-Hispanic white). Additional comparisons can be made for objectives with data for the three larger populations (Hispanic or Latino, non-Hispanic black, and non-Hispanic white). Results - Differences between populations in progress toward the targets for HP2010 objectives are observed; however, the majority of objectives was moving toward or had reached their targets for each population. Greater differences between racial and ethnic populations are evident in the size of disparities. Disparities for the American Indian or Alaska Native, the Hispanic or Latino and non-Hispanic black populations are greater than those for the Asian and non-Hispanic white populations. Between the baseline and the most recent data point, the number of objectives with increasing disparities was similar to the number of objectives with decreasing disparities and there was no change in disparity for most objectives. In order to achieve the two goals of HP2010, rates must improve and relative differences between populations must be reduced.

Measuring disparities in the incidence of sexually transmitted diseases.

The Centers for Disease Control and Prevention (CDC) defines a health disparity as a "[health] difference that occurs by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation." Health equity is achieved by eliminating health disparities or inequalities. Measuring health disparities is a critical first step toward reducing differences in health outcomes. To determine the methods to be used in measuring a health disparity, several decisions must be made, which include: (1) selecting a reference group for the comparison of 2 or more groups; (2) determining whether a disparity should be measured in absolute or in relative terms; (3) opting to measure health outcomes or health indicators expressed as adverse or favorable events; (4) selecting a method to monitor a disparity over time; and (5) choosing to measure a disparity as a pair-wise comparison between 2 groups or in terms of a summary measure of disparity among all groups for a particular characteristic. Different choices may lead to different conclusions about the size and direction of health disparities at a point in time and changes in disparities over time.The objective of this article is to review the methods for measuring health disparities, provide examples of their use, and make specific recommendations for measuring disparities in the incidence of sexually transmitted diseases (STDs).

Monitoring change in health disparity.

Agencies and programs tasked to reduce and eliminate disparity need the best available methods to assess the success of their efforts. When monitoring disparity it is vital to be aware of how absolute and relative measures of disparity, and when changes are measured, can lead to different conclusions regarding progress. Absolute and relative disparities for homicide rates between Hispanics and non-Hispanic Whites were calculated on an annual basis for 1989 through 2003. A joinpoint regression of rates was used to identify where significant changes occurred over the 15-year period. Absolute and relative changes in disparity were measured for each interval identified. The annualized percent changes in homicide rates for each interval were used to evaluate how relative rates of change in homicide affect disparity. Three distinct change points were found for homicide rates and changes in disparity between Hispanics and non-Hispanic Whites for the period 1989-2003. Intervals 2 (1991-1994) and 3 (1994-1999) had declines in both absolute and relative disparity. Only interval 3 had disparity reductions sufficient, if they had continued, to suggest any elimination of disparity within the next 5 years. Reduction in the relative difference between groups is the best evidence of progress toward eliminating disparity. The relative rate of improvement for the group with less favorable rate must be greater than that of the group with the more favorable rate. It is just as important to be aware of when disparity is being assessed in a longer overall trend.

Improving population health and reducing health care disparities.

The first goal of Healthy People 2010, to increase quality and years of healthy life, does not necessarily coincide with the second goal, to eliminate disparities among population groups. Improvement in the health of the total population without any reduction in relative disparities among racial and ethnic groups was the most frequent outcome at mid-decade for population-based Healthy People objectives. Strategies to maximize improvement in overall population health may have little or no impact on relative disparities or, indeed, may cause them to increase. An independent commitment to eliminating disparities may be necessary.

Ten largest racial and ethnic health disparities in the United States based on Healthy People 2010 Objectives.

A consistent framework has been developed for measuring health disparities and making comparisons across indicators with regard to the public health goals of Healthy People 2010. Disparities are measured as the percent difference from the best group rate, with all indicators being expressed in terms of adverse events. The 10 largest health disparities for each of five US racial and ethnic groups are identified here. There are both similarities and differences in the largest health disparities. New cases of tuberculosis and drug-induced death rates are among the largest health disparities for four of the five racial and ethnic groups. However, drug-induced death is the only indicator among the 10 largest disparities that is shared by both Black and White non-Hispanic populations.

Measuring relative disparities in terms of adverse events.

OBJECTIVES: To compare relative measures of disparity in rates of favorable events with those in rates of adverse events. METHODS: Relative measures of disparity are applied to four health indicators to demonstrate how the size of a disparity between groups, and changes in disparity over time, depend on whether indicators are expressed in terms of favorable or adverse events. RESULTS: The size of an absolute measure of disparity is the same whether favorable or adverse events are studied. The size of a relative measure of disparity depends on the rate for each group and the reference point from which the disparity is measured. The rates for each group and for the reference point depend on whether the indicator is expressed in terms of favorable or adverse events. Relative measures of disparity, and conclusions about changes in relative measures of disparity, depend on whether indicators are expressed in terms of favorable or adverse events. CONCLUSIONS: When relative measures of disparity are used to monitor changes in disparity over time or to compare disparities across different indicators, disparities should be measured in terms of adverse events.

Methodological issues in measuring health disparities

This report discusses issues that affect the measurement of disparities in health between groups in a population, published on National Center for Health Statistics. Vital Health Stat 2(141). 2005. Document on PDF format, Acrobat Reader required.

Methodological issues in measuring health disparities.

OBJECTIVES: This report discusses six issues that affect the measurement of disparities in health between groups in a population: Selecting a reference point from which to measure disparity. Measuring disparity in absolute or in relative terms. Measuring in terms of favorable or adverse events. Measuring in pair-wise or in summary fashion. Choosing whether to weight groups according to group size. Deciding whether to consider any inherent ordering of the groups. These issues represent choices that are made when disparities are measured. METHODS: Examples are used to highlight how these choices affect specific measures of disparity. RESULTS: These choices can affect the size and direction of disparities measured at a point in time and conclusions about the size and direction of changes in disparity over time. Eleven guidelines for measuring disparities are presented. CONCLUSIONS: Choices concerning the measurement of disparity should be made deliberately, recognizing that each choice will affect the results. When results are presented, the choices on which the measurements are based should be described clearly and justified appropriately.

Measuring progress in Healthy People 2010.

Background--Healthy People 2010 (HP2010) objectives are based on two overarching goals: 1) to increase years and quality of healthy life, and 2) to eliminate disparities among subgroups of the population. Four hundred and sixty-seven specific objectives consistent with these goals were outlined, baseline data were identified when available, and specific targets were set for the year 2010. This report discusses the techniques that are being used to measure progress toward these two goals. Process--In order to promote consistency in monitoring across different objectives, a minimum template of subgroups was adopted for the population-based objectives in HP2010. A workgroup of individuals representing the U.S. Department of Health and Human Services agencies involved in HP2010 was convened to consider the issues related to monitoring progress toward the two goals of HP2010. The workgroup concurred with the recommendations in this report. Recommendations--Progress toward target attainment can be monitored for all objectives with at least one data point beyond the baseline. For those objectives that are based on data for a population, progress toward target attainment can also be measured for subgroups of the population. Progress toward the elimination of disparity for individual population subgroups can be measured in terms of the percent difference between each subgroup rate and the most favorable or "best" subgroup rate in each domain. For purposes of measuring disparity relative to the "best" subgroup rate, all measures are expressed in terms of adverse events.

A summary measure of health disparity.

OBJECTIVES: Eliminating health disparities is a goal of Healthy People 2010. In order to track progress toward this goal, we need improved methods for measuring disparity. The authors present the Index of Disparity (ID) as a summary measure of disparity. METHODS: The ID, a modified coefficient of variation, was used to measure disparity across populations defined on the basis of race/ethnicity, income, education, and gender. Disparity was also assessed for a diverse range of health indicators and over time to monitor trends. RESULTS: Disparity in cardiovascular disease deaths decreased based on gender from 1989 to 1998 but was largely unchanged based on race/ethnicity. The magnitude of disparities in cervical cancer and cholesterol screening, smoking, exercise, and health insurance ranged from 1.9% to 78.6%. The largest disparities for health indicators were not associated with any particular population classification, whether defined on the basis of race/ethnicity, education, or income. CONCLUSIONS: To eliminate disparities, we need a means to assess disparities across many types of health indicators. Furthermore, for a given health indicator, disparities may differ for populations defined on the basis of race/ethnicity, education, income, and so on. The ID is a simple method for summarizing disparities across groups within a population that can be applied across health indicators regardless of magnitude, over time to monitor trends, and across different populations.

Trends in racial and ethnic-specific rates for the health status indicators: United States, 1990-98.

The Health Status Indicators (HSIs) were developed as part of the Healthy People 2000 process to facilitate the comparison of health status measures at national, State,and local levels. In this report national trends in racial and ethnic-specific rates for 17 HSIs are examined for the period from 1990-8. One of three overarching goals of Healthy People 2000 was to reduce health disparities. Examination of trends in the HSIs indicates that rates for most racial/ethnic groups improved. Rates for American Indian or Alaska Natives did not improve for six of the HSIs. An index of disparity, a summary measure of disparity among race/ethnic-specific rates, was used to measure changes in disparity between 1990 and 1998. The index of disparity decreased for 12 of the HSIs. Based on this index, racial/ethnic disparity in the percent of low birthweight infants declined by 19 percent, disparity in the percent of children under 18 years of age in poverty and in the syphilis case rate declined by 13 percent, and disparity in the stroke death rate declined by 11 percent. The index declined by less than 10 percent for eight other indicators. The index of disparity increased between 1990 and 1998 for the other five HSIs examined here. The index of disparity increased by more than 10 percent for work-related injury death rates, motor vehicle crash death rates, and suicide death rates. While rates for the HSIs have improved, not all groups have benefited equally and substantial differences among racial/ethnic groups persist.