Part 1:
1. Choose a paper describing the development or validation of a measure of relevance in health disparities research (please give the full citation and/or upload the paper if that's possible).
a. Patino CM, Okelo SO, Rand CS, Riekert KA, Krishnan JA, Thompson K, Quartey RI, Perez-Williams D, Bilderback A, Merriman B, Paulin L, Hansel N, Diette GB. The Asthma Control and Communication Instrument: a clinical tool developed for ethnically diverse populations. The Journal of allergy and clinical immunology. 2008;122(5):936-43.e6. doi: 10.1016/j.jaci.2008.08.027.
2. What was the definition of the construct?
a. The construct is a global assessment of asthma control with a goal of applicability to both African Americans and Whites (the ACCI Asthma Control and Communication Instrument).
3. How did the authors provide evidence on the validity of the measure? Could you think of additional approaches to validating the measure?
a. The authors enrolled subjects (N=220) and administered the ACCI, which included self-reported symptoms as well as objective measures of flare rates requiring ER visits, medications, or hospital admissions. To validate the measure, the authors compared it to previous symptom assessment tools including the Asthma Control Test, quality of life measures - the Mini-Asthma Quality of Life Questionnaire (m-AQOL) , the St. George Respiratory Questionnaire, generic health survey SF-36, as well as spirometry and specialist rating of asthma disease status. They compared the scores using Pearson Correlations. They also calculated the % agreement between ACCI vs. specialist’s assessment of asthma control. To validate across race, they compared the results in using all of the data vs. using measures stratified by race. I think they could have used more sophisticated methods such as partitioning the data with a 9 vs. 1 training vs. validation set with cross-validation. Comparing the results between Whites and African Americans also appeared rudimentary to me, therefore I think they could have assessed the questionnaire in the both populations then determined how much it correlated with the prior “Gold standard” methods in the other race category.
4. How did the authors provide evidence on the reliability of the measure? Could you think of additional approaches to evaluating the reliability of the measure?
a. The authors only compared the measure to prior methods used to assess asthma control. They could have used cross-validation techniques and could have also applied the questionnaire to a separate clinical cohort. To assess if it was applicable to both African Americans and Whites, they could have compared the outcomes to other measures of disparity in the population (e.g. self-reported measures of discrimination) to determine if the questionnaire applied to those with higher reported values of experienced discrimination.
5. Describe the implications of a lack of measurement validity or reliability for future research applications.
a. The lack of measurement validity using this tool could result in using this tool to assess asthma control between African Americans and Whites and concluding that either they are equivalent, even though there could be other confounders that are contributing to African Americans’ perception of asthma severity that are not related to care-related to asthma, or could lead to systemic “correction” for race that impedes the ability to differentiate disparities in African Americans vs. Whites.
Part 2:
1. Find a paper describing a health disparity (please give the full citation or, even better, upload the paper so everyone else can look at it too)
a. Mirsaeidi M, Machado RF, Schraufnagel D, Sweiss NJ, Baughman RP. Racial difference in sarcoidosis mortality in the United States. Chest. 2015;147(2):438-49. doi: 10.1378/chest.14-1120.
2. Summarize the construct and measurement of the dimension of disparity (e.g., racial inequalities?, SES inequalities?) and the outcome measured (e.g., self-rated health).
a. This paper assessed the difference in mortality rates in Whites vs. African Americans with sarcoidosis. The construct was self-reported race and the outcome was mortality.
3. What is the evidence for the validity and reliability of the measures?
a. Since this paper focused only on self-identified race and mortality in one cohort (N = 10,348), they did not validate their findings in another cohort and since the measure was mortality, they did not validate this measure.
4. What is the reference category used for the disparity measure (ie, who is the comparison group)? Why does this reference category make sense (or not) for this research question?
a. The reference groups included pedestrians who died from traffic accidents (healthy population), and patients who died from sarcoidosis (a chronic inflammatory disease similar to sarcoidosis). African Americans where compared to Whites. Age-adjusted death rates were calculated by weighting averages of the age-specific rates and comparing with relative mortality risk among 2,000 US standard populations. Since they were comparing Whites vs. African Americans, the reference category of Whites was appropriate, but it made it more difficult to assess what features within African Americans increased their risk of mortality from sarcoidosis. The pedestrian and RA reference groups seemed like a good start to compare disease status, but there were several confounders and sources of bias that could affect the risk of death in pedestrians (including SES, neighborhood, access to transportation, and other medical co-morbidities). This poses risk of underestimating the potential intersectional effect of having a chronic disease such as sarcoidosis in African Americans.
5. How is the disparity quantified or measured? Is this an absolute or relative measure or are both provided? Describe which type of measure you would prefer for this research area, or, if both, why.
a. The disparity was quantified by age-adjusted mortality comparing African Americans to Whites. This was almost an absolute measure (it was adjusted for race, appropriately), but it was not controlled for other potential confounders such as SES. This study was appropriate in reporting the absolute difference in mortality rate between African Americans and Whites, but it lacked more detailed analysis to assess which populations among African Americans had the highest risk. It also did not assess how much of the difference in mortality was mediated by other factors, such as access to care (e.g. insurance), income, and geographic location, which could help assess how to address the difference – e.g. is the disparity because African Americans in general have poorer health outcomes compared to Whites in general, or are there specific aspects of the disease (e.g. time since diagnosis, access to specialists, etc.) that particularly affect African Americans with sarcoidosis?
Part 3:
1. Read someone else's response to part 1 above (identifying a construct) and comment, specifically noting whether you can see any additional implications of measurement quality for future research or whether you agree with those noted by your classmate.
a. Response to Hunter Holt’s Post:
The Health Literacy paper to me did not come across as a validation study - it compared how well a three question tool compared to the s-TOFHLA. While it seems that this is an important step to determine if this three question tool can help identify those who have decreased health literacy, a true validation study would have used cross-validation (training and test sets) and/or compared to other populations. It seems like it would be a simple three question test to identify those who need more assistance with forms, but how reproducible it is is unclear to me.
For the mental health paper, it seemed like a positive step forward in further assessing how much rural vs. urban populations actually used mental health services, but it did not seem to advance the question of how to address it - was it all due to income and barriers to traveling to appointments or is it because of the paucity of providers? Answering these questions would help assess how to better serve rural patients.