Disparity Measurement in Healthy People 2010

John Aberle-Grasse, MPHNational Center for Health Statistics

Healthy People 2010 goalsIncrease quality and years of healthy life

2. Eliminate health disparities

No method for measuring disparity initially specified

Healthy People 2000 goalsIncrease the span of healthy lifeReduce health disparity in special populationsAddress the problems that represent the greatest needSeparate targets set for special and total populationsAchieve access to preventive services

Chose: Percent change over time or Ratio of percent change(RPl-RPb)/RPb (SPl-SPb)/SPb

special population reference populationBaseline (b)Last data point (l)NOTE: Imaginary data

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50150

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Special pop

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Reference pop10050

Special pop200150

Reference target4040

Special target6060

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Reference target

Special target

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0000

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Special target

Healthy People 2010 2nd goalEliminate Health Disparities

The second goal of Healthy People 2010 is to eliminate health disparities among segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.

Healthy People 2010 2nd goalEliminate Health Disparities

Implement a vision for the nations healthA single target for all population groupsStandard set of population subgroupsApplies to all population-based objectives (389 of 467 objectives)

Is ratio of percent change a good option for measuring disparity in Healthy People 2010?Healthy People 2000 was concerned with:only special populations at particularly high risk for death, disease or disabilityHealthy People 2010 is concerned with: all subpopulationssome worse off and some are better off than the total

Ratio of percent change compares change over time but not inequality at a given point in timePercent change = 0.66Percent change = 0.66

Healthy People 2010 2nd goalEliminate Health Disparities

Policy and statistical questions specific to Healthy People 2010

Situations for measuring disparity in Healthy People 2010Single group across a set of objectivesRace/ethnicity Socioeconomic status(eg. How are Hispanics doing compared to the total population on diabetes objectives)Two groupsSexUrban compared to ruralMultiple groups Race/ethnicitySocioeconomic status

Two groups

Sheet1

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between females and males

AbsoluteRelative

Simple differencePercent differenceRatioSimple dif./ target

Gender

TotalFemaleMaleF-M(F-M)/M*100F/M(F-M)/T

1997404336719.41.1940.35

1998404337616.21.1620.30

1999394237513.51.1350.25

2000394135617.11.1710.30

Percent change 1997-2000-2.5-4.7-2.8-14.3-11.8-11.8-14.3

2010202020

This percent has been changed for illustrative purposes. The correct estimate

is 36 percent.

Sheet1 (10)

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Black non-Hispanics and the White non-Hispanics

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

BnHWnHF-M(F-M)/M*100F/M(F-M)/T

199752361644.41.4440.80

199852361644.41.4440.80

199951351645.71.4570.80

200052351748.61.4860.85

Percent change 1997-20000.0-2.86.39.39.36.2

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Hispanics and White non-Hispanics

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

HWnHF-M(F-M)/M*100F/M(F-M)/T

199754361850.01.5000.90

199855361952.81.5280.95

199956352160.01.6001.05

200054351954.31.5430.95

Percent change 1997-20000.0-2.85.68.68.65.6

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between American Indians or Alaska Natives and White non-Hispanics

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

AIANWnHF-M(F-M)/M*100F/M(F-M)/T

199746361027.81.2780.50

199848361233.31.3330.60

19994335822.91.2290.40

200048351337.11.3710.65

Percent change 1997-20004.3-2.830.033.733.730.0

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Asian or Pacific Islanders and White non-Hispanics

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

APIWnHF-M(F-M)/M*100F/M(F-M)/T

19974236616.71.1670.30

19984036411.11.1110.20

1999373525.71.0570.10

2000353500.01.0000.00

Percent change 1997-2000-16.7-2.8-100.0-100.0-100.0-100.0

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20102020

Sheet1 (6)

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Black non-Hispanics and the "best" group (White non-Hispanics)

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

BnH"best" WnHF-M(F-M)/M*100F/M(F-M)/T

199752361644.41.4440.80

199852361644.41.4440.80

199951351645.71.4570.80

200052351748.61.4860.85

Percent change 1997-20000.0-2.86.39.39.36.2

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Hispanics and the "best" group (White non-Hispanics)

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

H"best" WnHF-M(F-M)/M*100F/M(F-M)/T

199754361850.01.5000.90

199855361952.81.5280.95

199956352160.01.6001.05

200054351954.31.5430.95

Percent change 1997-20000.0-2.85.68.68.65.6

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.

20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between American Indians or Alaska Natives and the "best" group (White non-Hispanics)

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

AIAN"best" WnHF-M(F-M)/M*100F/M(F-M)/T

199746361027.81.2780.50

199848361233.31.3330.60

19994335822.91.2290.40

200048351337.11.3710.65

Percent change 1997-20004.3-2.830.033.733.730.0

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.

.

20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Asian or Pacific Islanders and the "best" group (White non-Hispanics)

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

API"best" WnHF-M(F-M)/M*100F/M(F-M)/T

19974236616.71.1670.30

19984036411.11.1110.20

1999373525.71.0570.10

2000353500.01.0000.00

Percent change 1997-2000-16.7-2.8-100.0-100.0-100.0-100.0

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.

20102020

Sheet1 (7)

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Black non-Hispanics and the Average of the race/origin group rates

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

BnHAvg.F-M(F-M)/M*100F/M(F-M)/T

19975246613.01.1300.30

19985246.25.812.61.1260.29

19995144.46.614.91.1490.33

20005244.87.216.11.1610.36

Percent change 1997-20000.0-2.620.023.223.220.0

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201020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between White non-Hispanics and the Average of the race/origin group rates

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

WnHAvg.F-M(F-M)/M*100F/M(F-M)/T

19973646-10-21.70.783-0.50

19983646.2-10.2-22.10.779-0.51

19993544.4-9.4-21.20.788-0.47

20003544.8-9.8-21.90.781-0.49

Percent change 1997-2000-2.8-2.6-2.00.60.6-2.0

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201020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Hispanics and the Average of the race/origin group rates

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

HAvg.F-M(F-M)/M*100F/M(F-M)/T

19975446817.41.1740.40

19985546.28.819.01.1900.44

19995644.411.626.11.2610.58

20005444.89.220.51.2050.46

Percent change 1997-20000.0-2.615.018.118.115.0

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201020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between American Indians or Alaska Natives and the Average of the race/origin group rates

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

AIANAvg.F-M(F-M)/M*100F/M(F-M)/T

1997464600.01.0000.00

19984846.21.83.91.0390.09

19994344.4-1.4-3.20.968-0.07

20004844.83.27.11.0710.16

Percent change 1997-20004.3-2.60.00.00.00.0

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201020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Asian or Pacific Islanders and the Average of the race/origin group rates

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

APIAvg.F-M(F-M)/M*100F/M(F-M)/T

19974246-4-8.70.913-0.20

19984046.2-6.2-13.40.866-0.31

19993744.4-7.4-16.70.833-0.37

20003544.8-9.8-21.90.781-0.49

Percent change 1997-2000-16.7-2.6145.0151.6151.6145.0

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201020

Sheet1 (8)

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Black non-Hispanics and the Total population rate

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

BnHTotalF-M(F-M)/M*100F/M(F-M)/T

199752401230.01.3000.60

199852401230.01.3000.60

199951391230.81.3080.60

200052391333.31.3330.65

Percent change 1997-20000.0-2.58.311.111.18.3

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between White non-Hispanics and the Total population rate

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

WnHTotalF-M(F-M)/M*100F/M(F-M)/T

19973640-4-10.00.900-0.20

19983640-4-10.00.900-0.20

19993539-4-10.30.897-0.20

20003539-4-10.30.897-0.20

Percent change 1997-2000-2.8-2.50.02.62.60.0

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Hispanics and the Total population rate

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

HTotalF-M(F-M)/M*100F/M(F-M)/T

199754401435.01.3500.70

199855401537.51.3750.75

199956391743.61.4360.85

200054391538.51.3850.75

Percent change 1997-20000.0-2.57.19.99.97.1

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between American Indians or Alaska Natives and the Total population rate

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

BnHTotalF-M(F-M)/M*100F/M(F-M)/T

19974640615.01.1500.30

19984840820.01.2000.40

19994339410.31.1030.20

20004839923.11.2310.45

Percent change 1997-20004.3-2.550.053.853.850.0

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Asian or Pacific Islanders and the Total population rate

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

APITotalF-M(F-M)/M*100F/M(F-M)/T

1997424025.01.0500.10

1998404000.01.0000.00

19993739-2-5.10.949-0.10

20003539-4-10.30.897-0.20

Percent change 1997-2000-16.7-2.5100.0105.1105.1100.0

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20102020

Sheet1 (9)

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Black non-Hispanics and the Healthy People 2010 target

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

BnHTargetF-M(F-M)/M*100F/M(F-M)/T

1997522032160.02.6001.60

1998522032160.02.6001.60

1999512031155.02.5501.55

2000522032160.02.6001.60

Percent change 1997-20000.00.00.00.00.00.0

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between White non-Hispanics and the Healthy People 2010 target

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

WnHTargetF-M(F-M)/M*100F/M(F-M)/T

199736201680.01.8000.80

199836201680.01.8000.80

199935201575.01.7500.75

200035201575.01.7500.75

Percent change 1997-2000-2.80.0-6.3-6.3-6.3-6.3

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Hispanics and the Healthy People 2010 target

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

HTargetF-M(F-M)/M*100F/M(F-M)/T

1997542034170.02.7001.70

1998552035175.02.7501.75

1999562036180.02.8001.80

2000542034170.02.7001.70

Percent change 1997-20000.00.00.00.00.00.0

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between American Indian or Alaska Native and the Healthy People 2010 target

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

AIANTargetF-M(F-M)/M*100F/M(F-M)/T

1997462026130.02.3001.30

1998482028140.02.4001.40

1999432023115.02.1501.15

2000482028140.02.4001.40

Percent change 1997-20004.30.07.77.77.77.7

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20102020

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Measures of disparity between Asian or Pacific Islanders and the Healthy People 2010 target

AbsoluteRelative

SimplePercentRatioSimple dif.

Race/origindifferencedifferencetarget

APITargetF-M(F-M)/M*100F/M(F-M)/T

1997422022110.02.1001.10

1998402020100.02.0001.00

199937201785.01.8500.85

200035201575.01.7500.75

Percent change 1997-2000-16.70.0-31.8-31.8-31.8-31.8

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20102020

Sheet1 (2)

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Absolute measures of disparity among race and Hispanic origin groups

Absolute

RangeMean deviation

Race and Hispanic originfromfromfromfromfrom

TotalWnHBnHHAIANAPIHi-LoWnH"best" (WnH)Avg.TotalTarget

19974036525446421812.512.55.6467.626.0

19984036525548401912.812.86.646.27.826.2

19993935515643372111.811.87.344.47.824.4

20003935525448351912.312.37.844.89.024.8

Percent change 1997-2000-2.5-2.80.00.04.3-16.75.6-2.0-2.040.0-2.618.4-4.6

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2010202020202020

Sheet1 (3)

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Disparity among race and Hispanic origin groups, Mean deviation/reference point

Relative

Mean deviation/reference point

Race and Hispanic originfromfromfromfromfrom

TotalWnHBnHHAIANAPIWnH"best" WnHAvg.TotalTarget

19974036525446420.350.350.12460.191.30

19984036525548400.350.350.1446.20.201.31

19993935515643370.340.340.1644.40.201.22

20003935525448350.350.350.1844.80.231.24

Percent change 1997-2000-2.5-2.80.00.04.3-16.70.80.843.8-2.621.5-4.6

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2010202020202020

Sheet1 (4)

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Disparity among race and Hispanic origin groups, Mean deviation/target

Relative

Mean deviation/target

Race and Hispanic originfromfromfromfromfrom

TotalWnHBnHHAIANAPIWnH"best" WnHAvg.TotalTarget

19974036525446420.630.630.28460.381.30

19984036525548400.640.640.3346.20.391.31

19993935515643370.590.590.3644.40.391.22

20003935525448350.610.610.3944.80.451.24

Percent change 1997-2000-2.5-2.80.00.04.3-16.7-2.0-2.040.0-2.618.4-4.6

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2010202020202020

Sheet1 (5)

Healthy People 2010 objective 22-01: Percent with no leisure-time physical activity, (age adjusted, ages 18 and over) Disparity among race and Hispanic origin groups, Average of ratios

Relative

Average of ratios

Race and Hispanic origintoto

TotalWnHBnHHAIANAPI"best" WnHTarget

19974036525446421.352.30

19984036525548401.352.31

19993935515643371.342.22

20003935525448351.352.24

Percent change 1997-2000-2.5-2.80.00.04.3-16.70.8-4.6

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2010202020202020

Sheet2

Sheet3

Questions common to each of the three situationsWhat are the contexts for measuring disparity?Cross sectionalOver timeAcross objectivesBetween types of subpopulationsAcross geographic areas

Questions common to each of the three situationsMeasure progress and disparity separately?What is the reference point?Is an absolute or relative comparison of interest?Which statistic should be used?Measure positive or negative outcomes?

Should progress toward targets and elimination of disparity be measured separately?Measuring the two dimensions together introduces confounding The two goals are listed separately; each dimension is of interest on its ownMeasuring the two dimensions allows each of the goals to be tracked separately

Log scale

Target not attained, disparities persist

NOTE: Imaginary dataSOURCE: CDC/NCHS

Target = 5

Log scale

Target attained, disparities persist

Target = 5

NOTE: Imaginary dataSOURCE: CDC/NCHS

Log scale

Target not attained, disparities eliminated

Target = 5

NOTE: Imaginary dataSOURCE: CDC/NCHS

Log scale

Target attained, disparities eliminated

Target = 5

NOTE: Imaginary dataSOURCE: CDC/NCHS

A three part approach to measuring progress in Healthy People 2010 is suggestedMeasure progress towards targetsOverallParticular groupsMeasure disparityOverallParticular groupsExplore and indicate any particular issuesParticular groups

Log scale

Target not attained, disparities persist

Target = 5

NOTE: Imaginary dataSOURCE: CDC/NCHS

Best rate- may change Average rate- does not consider population distributionTotal rate- is relatively stable Target rate- is a constant reference over timeNot all objectives use better than best as target setting method

Is there a particular reference group suggested by HP2010?

Is there a particular reference group suggested by HP2010?Healthy People 2000 used total populationNIH minority health disparity charge seems to compare disparate race/ethnicity subpopulations to the total populationDoes Healthy People 2010 stated goals of eliminating health disparities and improving health for all segments of the population suggest using the best or target when it is set as better than the best?

Absolute or relative measure?Absolute measures provide information about the number of excess eventsRelative measures allow comparisons without regard to magnitudeAbsolute and relative measures may lead to the same conclusions when applied to the same objective at a given timeAbsolute and relative measures may lead to different conclusions in comparisons over time or between objectives

Which statistic should be used?

Objectives measure positive or negative outcomes?Positive (success) Increase health insurance coverageNegative (failure)Reduce deaths caused by motor vehicle crashesMeasuring all disparities in same terms allows comparison of relative measures of disparity across objectives

80207525Percent with health insurancePercent without health insurance020406080100Percent Health insurance coverage in two groupsNOTE: Imaginary data

Objectives measure positive or negative outcomes?Some objectives cannot usefully be measured as successesNIH Strategic Plan to Reduce and Ultimately Eliminate Health Disparities defines disparity in terms of adverse health conditions, failuresThe HP2000 Health Status Indicators all used negative outcomes to be reduced (failures) so they could be compared

Several common questions for each of these situationsMeasure progress and disparity separately?What is the reference point?Is an absolute or relative comparison of interest?Which statistic should be used?Measure positive or negative outcomes?What is the context for measuring disparity?Cross sectionalOver timeAcross objectivesBetween types of subpopulationsAcross geographic areas

ResourcesDHHS Healthy People: www.health.gov/healthypeople

NCHS Healthy People: www.cdc.gov/nchs/healthypeople

DATA2010: www.wonder.cdc.gov/data2010