Title: Equity and Efficiency Tradeoffs in the Prevention of Heart Disease – Concepts and Evidence
Description: Heart disease, including principally coronary heart disease (CHD) remains the top cause of mortality in the United States among adults ages 35 and older. Disparities in CHD mortality between socially advantaged and disadvantaged groups, such as whites and blacks have persisted for decades. These social gaps persist despite advances in treatments, preventive measures, and decreases in population prevalence of smoking that have done much to reduce the burden of CHD overall. While these differences in disease burden have been well documented, there is a poor understanding of what interventions might narrow these differences. An equity-efficiency tradeoffs (EET) framework is a useful lens through which to consider this problem. Tradeoffs between equity of intervention efforts and efficiency of the returns on such efforts arise when public health interventions are deployed across groups of unequal socioeconomic position. While such interventions may achieve overall and intra-group improvement, this improvement may come at the expense of stable or widening inter-group differences.

Aiming to add to this literature, we took three approaches. First, we critically assessed the literature in order to identify and summarize prior work on EETs across cardiovascular outcomes. We aimed to identify the questions that empirical studies should answer for a given policy, from an EET perspective. Second, recognizing both that tobacco taxation is an effective policy intervention on CHD, and that we have little evidence from United States based studies that it influences racial gaps in CHD we used as an example this policy intervention to examine the treatment efficiency inherent in raising tobacco taxes from an equity lens. We conducted an empirical study to estimate the treatment effectiveness of US tobacco taxation on smoking and CHD mortality. Third, we simulated the equity and treatment efficiency effects of pharmaceutical (Statins), taxation (tobacco) and early education interventions on CHD mortality, and racial gaps in CHD mortality. Our scoping review of EETs in cardiovascular disease (Chapter 2) yielded a very small number of studies (n=6), that explicitly engaged equity and efficiency, and provided information on their trade-offs in the context of CVDs.

Despite a paucity of evidence, we identified 2 important lessons: (1) movement toward equity in the context of interventions on those with a high burden of CHD risk factors may be achieved by targeting deprived populations. Second, pairing these “high risk” with structural interventions can provide substantial movement toward not only efficiency, but also equity. Our nationally representative observational, state-level study of the effects of tobacco taxation on smoking prevalence and CHD mortality by race and gender (Chapter 3) showed that between 2005 and 2016, tobacco taxes were associated with reductions in both outcomes. The strongest reductions in smoking prevalence were observed among black non-Hispanic women, while an increase was observed among black non-Hispanic men. Our simulation study (Chapter 4) showed that the equity and efficiency effects of population health interventions in the context of reducing racial disparities in CHD may vary by gender. Among men, compared to no intervention, an education intervention was associated with the greatest reduction in racial disparities in CHD mortality, while among women, a $3 tobacco tax intervention was associated with the greatest reduction in racial disparities in CHD mortality.

Additionally, among men, tobacco taxes were an equity lose intervention, while for women, in contrast, tobacco taxes were nearly always a win-win intervention. Conversely, compared to tobacco taxes, statins are in some cases a win-win intervention for men, and in all cases a lose-lose intervention for women. Our findings support the utility of an EET lens in the reduction of racial disparities in health, and point to the need for more scholarship and broader integration of this lens into public health practice. Consideration of the interplay between equity and efficiency in population health interventions offers a deeper understanding of intervention effects than the consideration of either dimension alone. In some cases, we need not trade equity for efficiency in the reduction of racial inequities in health.