Evaluating Effects of Multilevel Interventions on Disparity in Health and Healthcare Decisions

In this paper, we introduce an analytic approach for assessing effects of multilevel interventions on disparity in health outcomes and health-related decision outcomes (i.e., a treatment decision made by a healthcare provider). We outline common challenges that are encountered in interventional health disparity research, including issues of effect scale and interpretation, choice of covariates for adjustment and its impact on effect magnitude, and the methodological challenges involved with studying decision-based outcomes. To address these challenges, we introduce total effects of interventions on disparity for the entire sample and the treated sample, and corresponding direct effects that are relevant for decision-based outcomes. We provide weighting and g-computation estimators in the presence of study attrition and sketch a simulation-based procedure for sample size determinations based on precision (e.g., confidence interval width). We validate our proposed methods through a brief simulation study and apply our approach to evaluate the RICH LIFE intervention, a multilevel healthcare intervention designed to reduce racial and ethnic disparities in hypertension control.