Are Local Health Department Expenditures Related to Racial Disparities in Mortality? David...
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Transcript of Are Local Health Department Expenditures Related to Racial Disparities in Mortality? David...
Are Local Health Department Expenditures Related to Racial
Disparities in Mortality?
David GrembowskiDouglas ConradBetty BekemeierWilliam Kreuter
University of Washington
Funded by the Robert Wood Johnson Foundation &Changes in Health Care Financing and Organization
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
Population Health Paradox
Population health has increased in many developed countries
Disparities in population health have increased in many developed countries
Absolute Change vs. Relative Disparity
in Infant Mortality by Racial/Ethnic Group
2002- Absolute 1950 2004 Change
Black 44 14 30 White 27 6 21 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
Absolute Change vs. Relative Disparityin All-Cause, Age-Adjusted Mortality by
Racial/Ethnic Group
Absolute1950 2004
ChangeBlack 1,722 1,027 695White 1,411 786 625B/WRate 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
Race & Gender
Health, United States
Determinants of Population Health& Health Disparities
Physical & SocialEnvironment
Behavior
Human Biology
PopulationHealth &Disparities
Medical Care
Determinants of Population Health& Health Disparities
Physical & SocialEnvironment
Behavior
Human Biology
PopulationHealth &Disparities
Medical Care
Public Health
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?
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
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)
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?
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
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
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)
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
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)
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%)
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
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
ResultsLHD Funding (Medians)
1997-1990 1990 1997 Change
LHD expenditures $22* $30 $7 per capita
% share of public0.99% 1.17% 0.17 revenue to LHD * Adjusted 1997 dollars
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 MortalityTotal 956 914 -41
Female 754 743 -11 Male 1,244 1,150 -94___________________________________________________________________________________
Rates are per 100,000 population
Absolute Change in Black Mortality Rates
(1997 – 1990)
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
___________________________________________________________________________________
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
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 Change1997-1990
Mortality Decline
Black Total Mortality -83 -1.24#White Total Mortality -41 -1.65#
Black Female Mortality -37 -0.98White Female Mortality -11 -1.35#
Black Male Mortality -167 -2.23White Male Mortality -94 -1.41#___________________________________________________________________________________
Rates are per 100,000 population
# Statistical test for 2-way causation significant
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
____________________________________________________________________________
Change in Black/White Rate Ratios
(1997 – 1990)
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
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
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
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)
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
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
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