Local Health Department
Changes in Service:
Relationships
p to Mortality
y
Disparities
June 29, 2010
AcademyHealth, Boston, MA
Betty Bekemeier PhD, MPH, RN
School of Nursing
University of Washington, Seattle
David Grembowski PhD, MA
School of Public Health
University of Washington
Young Ran Yang MPH, RN
School of Nursing
University of Washington
Background
• “…not
ot o
only
ya
are
e we
e ge
generally
e a y not
ot e
eliminating
at g
disparities, …we are not even [significantly]
reducing them
them.” (Orsi et al, 2009)
• “Dramatic shifts” in funding (Lenaway et al., 2006)
• Trends toward more population-level service
(Keene, 2003)
• Little evidence of impact of service changes
Research Question
Are LHD services associated with
reductions in Black-White
Black White
mortality disparities?
Funded by: Pfizer Scholars
Grant in Public Health
Methods
• Time-trend ecologic study design
• Data
D t S
Sources
– LHD Services ((NACCHO Profile 1993,, 2005))
– U.S. Census
– CDC Wonder Database
– Area Resource File
– Rural/Urban Commuting Codes (RUCA)
Outcome Variables
Absolute, age-adjusted mortality
change (2005
(2005-1993)
1993)
– Black, White, & Black-White “Gap”
for:
• Total population
• Age 15-44
LHD Services by Category (1993, 2005)
Independent Variables
SERVICE DOMAIN
Screening
Treatment
Sample
S
l A
Activity
ti it Items
It
in
i Domain
D
i
HIV, TB, STDs, Cardiovascular disease
HIV, STDs
Maternal/Child Health
Family
F
il Planning,
Pl
i
WIC,
WIC Early
E l Periodic
P i di Screening
S
i &
Developmental Testing (EPSDT)
Health Services
Comprehensive primary care, Oral health, Home health
care Mental Health
care,
Epidemiology and Surveillance Infectious disease, Injury, EH, Chronic Disease
p
Primary
y
Population-based
Prevention
Injury control, Tobacco
Regulation, Inspection,
and/or Licensing
Daycares, Solid waste disposal, Private drinking water,
Restaurant inspection
Other Environmental Health
Other Activities
Indoor air, Food safety education, Vector control,
Groundwater protection
EMS, Animal Control, Lab, School Health
Assessment & Planning
Community Health Assessment (in last 3 yrs); Health
improvement planning (in last 3 yrs)
Regression Model
10 LHD Service
Domains
Change of Mortality
Gap
► All ages
► 15-44 ages
Clustered
by State
Covariates
Change in
Community
Socioeconomic
Disadvantage
Index
(2005-1990)*
LPHA
Characteristics
Change of
Staff FTEs
► (2005-1993)
► BOH
► Change in
type of
Leadership
►
►
(* Robert & Reither, 2001)
Change of
Community
Ch
Characteristics
t i ti
(2000-1990)
Change of
Health care
Resource
(2005-1990)
Region
Urban to
rural
► Federal
region
►
Sample Characteristics
• 558 “Common Local
Areas”
Areas
• 66% Urban
• Disadvantaged(1990)
– Ave
Ave. % Black=18
Black=18.3
3
– Ave. % Families on
Public Assistance=9
Assistance 9.1
1
– Ave. % HS diploma or
>=69.1
69.1
Mostly South
• So
South
th East = 46%
(258)
• Midwest=12% (69)
• South West=12% (68)
• North East=9% (52)
• NJ, NY=6.5% (36)
• Other (New Eng
Eng., West
West,
etc)=13% (75)
Average Age-adjusted
Age adjusted Mortality
Rates (Age 15-44)…& the “Gap”
for Sample
Black Mortality 1993 = 327
186
Whit M
White
Mortality
t lit 1993 = 141
Gap
’05
05-’93
93
-99
Black Mortality 2005 = 224
White Mortality 2005 =137
Rates per 100,000 population
87
Changes in Breadth of Service
between 1993 & 2005
100%
90%
80%
70%
60%
50%
40%
30%
Maintained
20%
Decreased
10%
Increased
0%
Differences in Breadth of
Service 1993 & 2005
Significant* decreases in…
– MCH
– Health Services
– Regulation
– EH
– Other Activities
* p<0.001
Significant* increases in…
– Epidemiology &
Surveillance
– Population-based
Prevention
– Assessment
Summary Regression Findings
• No significant effects for all-age mortality gap
• Services related to a decreasing mortality gap (1544 year olds)
– MCH (coef. -10.51; p<0.1)
– Other Activities (coef. -7.85; p<0.05)
– Health Services (coef. -7.96; p = 0.13…approaching signific.)
• Services related to an increasing
mortality gap (15-44 year olds)
-- Screening (coef. 5.97; p<0.05)
p 0.05)
….Significant
Significant differences in
Other Activities 1993 & 2005?
•
•
•
•
•
•
EMS (ns)
L b t
Laboratory
((ns))
Animal Control***
Control
Occupational Health & Safety***
School-based Clinics***
School Health***
Health
*** p<0.001
Discussion
MCH
• Supports
S
t other
th MCH fifindings
di
ffor iimproving
i
disparities (Khanani, et al., 2010)
• Comprehensive preventive services as
“markers”
markers for broader community focus on
early childhood development
• Prevention in very early childhood is closer
to outcomes in the causal pathway
p
y
Di
Discussion
i
Health Services & MCH
(& “Other Services”?)
• Importance of intensive preventive
services
se
ces for
o vulnerable
u e ab e populations
popu a o s
Screening
• IIncreases in
i b
breadth
dth off services
i
responding to disparities
Population-based services
• Harder to detect related outcomes
Conclusions & Implications
• Certain direct services appear to
particularly impact Black
Black-White
White mortality
disparities in a positive way
– Make shifts in direct service with caution
– Determine what mechanisms in these LHD services
appear to impact disparities
• Hasty
y changes
g ((cuts?)) to services could
negatively impact disparities
– Longitudinal monitoring of changes to services &
relationships to disparities needs to occur
A functional LHD…
• “….addresses health disparities”
• “uses and contributes to”…the evidencebase for PH practice
p
• “provides expertise” in communities
regarding PH issues
NACCHO, 2005