Department of Global Health Lecture Series Leo Morales December 16, 2008 'Perspectives and Research on Minority Health and Health Disparities'

1. Perspectives and Research on Minority Health and Health Disparities Leo S. Morales, MD, PhD Associate Professor Division of General Internal Medicine and Health Services Research, UCLA

5. The Changing Demographics of United States: Population Projections 2000-2100 Source: US Census Bureau Projections, Middle Series, 2000

6. Population Trends in California (2005) Source: American Community Survey, 2004

7. Immigration Trends, 1850-2000

8. Origins of Immigrants to United States (1900)

9. Origins of Immigrants to United States (2000) Latin America 51.7%

10. Hispanics Are Younger than Whites Aging Labor

11. Age Distribution of Mexican-American Population by Generational Status FIGURE 1. Age-sex composition of Mexican-origin population by generation, 1998-2002. Note. Males on the right and females on the left. First generation are immigrants; second generation are US-born with at least one foreign-born parent; third generation and higher are US-born with US-Born parents. Source: Hispanics and the Future of America , National Research Council, 2006. Females Males Aging Immigrants Patterns of Assimilation – 2 nd Generation

16. Results from a study using the National CAHPS Benchmarking Database 1.0 (NCBD 1.0) Racial and Ethnic Differences in Patents’ Assessments of Pediatric Care in Medicaid Managed Care (Weech-Maldonado et al., HSR, 2001) Disparities in Healthcare

18. Linking Patients’ Experiences of Health Care to Health Outcomes Health Care Delivery System Patients’ Experiences of Care Patients Seek Care Patients’ Assessments of Care Health Outcomes Adherence & Utilization

22. Example Global Rating Item 0 Worst Possible Health Care 1 2 3 4 5 6 7 8 9 10 Best Possible Health Care How Would You Rate Your Child’s Health Care?

26. Selected Sample Characteristics

27. Regression Results: Minority Patients Report Worse Experiences with Care  Indicate significantly differences compared with whites at p<0.05 level. Models control for parents’ age, gender, education and child’s health status.

28. Regression Results w/Home Language  Indicate significantly differences compared with whites at p<0.05 level. Models control for parents’ age, gender, education and child’s health status.

29. Regression Results w/Home Language  Indicate significantly differences compared with whites at p<0.05 level. Models control for parents’ age, gender, education and child’s health status.

31. Impact of interpreters on parents' experiences with ambulatory care for their children. Morales LS, Elliott M, Weech-Maldonado R, Hays RD. Med Care Res Rev. 2006 Feb;63(1):110-28. Disparities in Healthcare

35. Main Explanatory Variable

38. Sample Characteristics 8 2207 Other 18 4639 Asian/Pacific Islander 9 2623 White % (weighted) N (unweighted) 7 1,926 <25 years 44 11,469 25-34 years 41 10,680 35-44 years 9 2,199 ≥ 45 year Parents’ Education 20 5,206 0-8 Grade 15 3,941 9-11 Grade 30 7,811 12 Grade 34 9,103 >12 Grade Parents’ Race/Ethnicity 63 16729 Hispanic 2 473 African American Parents’ Age

39. Sample Characteristics 24 6,268 Good 37 9,697 Excellent % (weighted) N (unweighted) 41 11,231 English 47 12,458 Spanish 6 1,374 Cantonese 4 979 Korean 3 629 Vietnamese Child Age 34 9,006 0-5 Years 41 10,921 6-9 Years 25 6,744 10-13 Years Child Health Status 7 1,800 Fair/Poor 32 8,412 Very Good Survey Language

40. Access to Interpreters by Need Source: Morales et al., 2006 N=26,671

41. Effect of Interpreters on Reports About Care Source: Morales et al, 2006 * * * * * * * Note: OLS regressions controlling for respondent’s age, respondent’s education, child’s health status, child’s age, survey language, plan membership, year.

42. Effect of Interpreters on Ratings of Care Source: Morales et al., 2006 * * * * * * * Note: OLS regressions controlling for respondent’s age, respondent’s education, child’s health status, child’s age, survey language, plan membership, year.

43. Variation in Access to Interpreters by Health Plan Source: Morales et, 2006

46. Item and Scale Differential Functioning in the Mini Mental Status Examination Assessed Using the DFIT Framework Morales LS et al. Med Care. 2006 Nov;44(11 Suppl 3):S143-51. Patient-Reported Outcomes

47. Self-Reported Vision by Racial/Ethnic Group Among Persons Visual Acuity of 20/25 or Better

53. MMSE Items 1-11 Categories Content Item 4 Name 3 objects MMSE11 2 Name of type of place MMSE10 2 Name floor of building MMSE9 2 Name 2 nearby streets MMSE8 2 Name city MMSE7 2 Name state MMSE6 2 Name month MMSE5 2 State day of week MMSE4 2 State day of month MMSE3 2 State season MMSE2 2 State year MMSE1

54. MMSE Items 12-21 2 Copy design MMSE21 2 Write sentence MMSE20 4 Instructions w/paper MMSE19 2 Close eyes MMSE18 2 Repeat phrase MMSE17 2 Name wristwatch MMSE16 2 Name pencil MMSE15 4 Recall 3 objects MMSE14 6 Spell WORLD MMSE13 6 Serial 7s MMSE12 Categories Content Item

55. Sample Characteristics (n=1,578) 1 6 Asian 18 82 1 <1 98 17 39 44 76 Spanish (n=665) 54 46 32 62 5 31 42 28 75 English (n=913) 9+ years 0 – 8 years <0.001 Education White African American Latino <0.001 Race/Ethnicity 85+ years 75 – 84 years <0.001 <75 years Age 0.82 Female P-Value Gender

58. Item-Scale Correlation and Alpha 0.87 0.89 Alpha 0.43-0.68 0.48-0.72 Range 0.62 0.67 Median 0.58 0.63 Mean Item-Test Correlations Spanish English MMSE

59. Results from CFA 1-Factor Solution 0.06 0.99 0.97 English 0.06 0.99 0.97 Spanish Root Mean Square Error of Approximation Rec: <0.05 Tucker-Lewis Index Rec >0.90 Comparative Fit Index Rec >0.90 MMSE

60. Evaluating Differential Item and Test Functioning

62. 2-Parameter Models I am unhappy some of the time I don’t care what happens to me I cry easily Severe Happy True  b = 0.25 b = 1.33 b = -0.23 a = 2.83 a = 1.11 a = 2.20

63. MMSE 2: Name Season NCDIF: 0.060 Cutoff: 0.006

64. MMSE 17: Repeat Phrase NCDIF: 0.098 Cutoff: 0.006

65. MMSE 8: Name 2 Nearby Streets NCDIF: 0.005* Cutoff: 0.006

66. MMSE 14: Recall 3 Objects NCDIF: 0.106 Cutoff: 0.054

67. MMSE 19: Instructions with Paper NCDIF: 0.087 Cutoff: 0.054

68. MMSE Scale Response Functions Spanish English DTF: 0.215 Cutoff: 0.558

69. Differential Test Functioning

70. Impact of DIF on MMSE Scale Scoring 0.09 DIF-Adjusted IRT Scores Constrained: 1,4-5,8-16,20-21 Unconstrained: 2-3,6-7,17-19 0.05 Change in Group Mean Difference 0.04 Fully Constrained IRT Scores Group Mean Score Difference: English-Spanish Model Assumptions

78. 2-Parameter Model (Dichotomous Outcomes)