Mapping and Measuring Social Disparities in Premature Mortality: The Impact of Census Tract Poverty within and across Boston Neighborhoods, 1999–2001

Abstract

The identification and documentation of health disparities are important functions of public health surveillance. These disparities, typically falling along lines defined by gender, race/ethnicity, and social class, are often made visible in urban settings as geographic disparities in health between neighborhoods. Recognizing that premature mortality is a powerful indicator of disparities in both health status and access to health care that can readily be monitored using routinely available public health surveillance data, we undertook a systematic analysis of spatial variation in premature mortality in Boston (1999Boston ( -2001 across neighborhoods and sub-neighborhoods in relation to census tract (CT) poverty. Using a multilevel model based framework, we estimated that the incidence of premature mortality was 1.39 times higher (95% credible interval 1.09-1.78) among persons living in the most economically deprived CTs (Q20% below poverty) compared to those in the least impoverished tracts (G5% below poverty). We present maps of model-based standardized mortality ratios that show substantial withinneighborhood variation in premature mortality and a sizeable decrease in spatial variation after adjustment for CT poverty. Additionally, we present maps of modelbased direct standardized rates that can more readily be compared to externally published rates and targets, as well as maps of the population attributable fraction that show that in some of Boston's poorest neighborhoods, the proportion of excess deaths associated with CT poverty reaches 25-30%. We recommend that these methods be incorporated into routine analyses of public health surveillance data to highlight continuing social disparities in premature mortality.

Disparities in TKA Outcomes: Census Tract Data Show Interactions Between Race and Poverty

“…In our model, disparities in 2-year WOMAC pain and function scores between blacks and whites are minimal when patients live in wealthy communities but are present in communities with high census tract poverty levels. Our study suggests an important association of community poverty on patient-reported outcomes after TKA, and that poverty has a disproportionately strong association with TKA outcomes among black patients than among white patients Our study is consistent with other studies [2,7,8,21], showing a strong interaction between community poverty and race on health outcomes. For example, in a study analyzing the interaction of neighborhood poverty and race as they affect mortality, the effect of increasing poverty was greater for blacks than for whites.…”

“…Census tract-level data are sensitive to gradients in health across communities [15] and capture variables that are missed at the individual level [18]. Resources linked to better health outcomes are less prevalent in neighborhoods where 20% or more of the population lives below the poverty level [7].…”

“…In the United States there are racial disparities in multiple health outcomes including the management and outcomes of cancer, diabetes, and life expectancy [7]. There also are persistent disparities in the use and outcomes of arthroplasty [23].…”

The Geography of Recreational Open Space: Influence of Neighborhood Racial Composition and Neighborhood Poverty

“…Specially, we excluded the Harbor Islands, consistent with past neighborhood research in Boston, 38,40,41 and we excluded a census tract that includes only the Massachusetts Bay. The Harbor Islands includes a small population of 535 individuals who are not typical of the rest of the city, e.g., there is a detoxification center there with permanent residents.…”

Health Through the Urban Lens

“…Poverty is a lethal condition: adjusted hazard ratios for all-cause mortality are more than 2 1/2 times higher among those with incomes less than $10,000 than among those earning $30,000 or more, 34 and a quarter or more of premature deaths before age 75 in one study of the urban poor would not have occurred had these individuals died at the same age-specific mortality rates as their affluent neighbors. 35 In addition, lack of health insurance is common among the urban poor, affecting an estimated 20% in 2002 in New York for example. 36 Being uninsured is associated with delays in care, lack of stable clinical relationships, foregone treatment, excessive use of emergency facilities, and high case fatality rates.…”