1. The Impact of Racial and Ethnic Disparities in Influenza Vaccination on Minority Deaths Kevin Fiscella, MD, MPH Departments of Family Medicine Community & Preventive Medicine University of Rochester School of Medicine & Dentistry

2. Goals of Study Estimate the impact of racial and ethnic disparity in flu shots on elderly, minority deaths and lives saved by achievement of HP 2010 vaccination rates. Illustrate a method for quantifying the impact of health care disparities on disparities in health.

3. Annual All-Cause Deaths among Elderly from Influenza 46,000 (range 23,000-64,000) –CDC, 2003 Racial and ethnic disparities in influenza vaccination are striking (W 67%, B 46%, H 55%) Impact of disparities in vaccination on elderly minority deaths is not known

4. Methods Estimate the number of influenza associated all-cause deaths attributable to influenza among elderly minority patients (both vaccinated and unvaccinated). Simulate the number of influenza associated all-cause deaths assuming equivalence between white, non-Hispanic and minority rates.

5. Influenza Vaccination Rates (MCBS, 2002) Percent Vaccinated Sex/race/ethnicity65-74 ys75-84 yrs> 85 yrs White Male6578 White Female677475 Black Male535970 Black Female545160 Hispanic Male606656 Hispanic Female445565

6. Estimate of Reduction in All- Cause Mortality from Flu Shots Meta-analysis of cohort studies show a 68% reduction in all-cause mortality (not just flu related!) among elderly vaccinated patients. Estimate is improbably high – vastly exceeds the number of deaths CDC attributes to influenza. Selection bias confounds estimates.

7. Comparison of Deaths During Influenza and Non-influenza Season among Vaccinated and Unvaccinated (Armstrong et al 2004) Minimizes selection bias Vaccination reduces influenza attributable risk percent from 13.4% to 2.2%

8. Estimating deaths deaths in age, gender, race/ethnicity subgroup = annual deaths x PAR x number in subgroup x #months flu/12 Estimating deaths under varying flu shot rates

9. Validation in U.S. Applying these estimates to 1998-1999 US data approximates CDC estimates of elderly flu deaths (60,230 v. 58,820)

10. Total and influenza associated deaths among elderly minorities, 2002 Minority Group Total deathsFlu-Associated deaths African Americans 162,5005,890 Hispanics64,6002,220

11. Minority lives saved from increases in vaccination rates v. deaths from 10 th leading cause Minority Group Lives saved under vaccination equity Lives saved with HP 2010 objective Deaths from 10 th leading cause of death African Americans 1,5203,0502,960 Hispanics6101,2001,070

12. Minority Years of Life Saved Minority Group YLS under vaccination equity YLS with HP 2010 objective African Americans 12,60027,100 Hispanics5,69011,630 Total18,29038,730

13. Limitations of findings Uncertainty regarding impact of influenza vaccination on mortality Uncertainty as comparable attributable risk of influenza among different groups or comparable benefit of vaccine.

14. Conclusions Racial and ethnic disparities in flu shot contribute appreciably to minority deaths. Achievement of 90% vaccination coverage for minorities would save more minority lives than elimination of the 10 th leading cause of deaths. Deaths resulting from disparities in health care represent one means for quantifying the impact of health care disparities on minority health.

15. Acknowledgments Richard Dressler, MD, MPH Kathleen Holt, PhD RWJF for support