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Mani K, Kleinbart E, Schlumprecht A, Golding R, Akioyamen N, Song H, De La Garza Ramos R, Eleswarapu A, Yang R, Geller D, Hoang B, Yassari R, Fourman MS. Area Socioeconomic Status is Associated with Refusal of Recommended Surgery in Patients with Metastatic Bone and Joint Disease. Ann Surg Oncol 2024; 31:4882-4893. [PMID: 38861205 PMCID: PMC11236857 DOI: 10.1245/s10434-024-15299-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/01/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND This study sought to identify associations between the Yost Index, a geocoded area neighborhood socioeconomic status (nSES) score, and race/ethnicity with patient refusal of recommended surgery for metastatic bone disease. METHODS Patients with metastatic bone disease were extracted from the Surveillance, Epidemiology, and End Results database. The Yost Index was geocoded using factor analysis and categorized into quintiles using census tract-level American Community Service (ACS) 5-year estimates and seven nSES measures. Multivariable logistic regression models calculated odds ratios (ORs) of refusal of recommended surgery and 95% confidence intervals (CIs), adjusting for clinical covariates. RESULTS A total of 138,257 patients were included, of which 14,943 (10.8%) were recommended for surgical resection. Patients in the lowest nSES quintile had 57% higher odds of refusing surgical treatment than those in the highest quintile (aOR = 1.57, 95% CI 1.30-1.91, p < 0.001). Patients in the lowest nSES quintile also had a 31.2% higher age-adjusted incidence rate of not being recommended for surgery compared with those in the highest quintile (186.4 vs. 142.1 per 1 million, p < 0.001). Black patients had 34% higher odds of refusing treatment compared with White patients (aOR = 1.34, 95% CI 1.14-1.58, p = 0.003). Advanced age, unmarried status, and patients with aggressive cancer subtypes were associated with higher odds of refusing surgery (p < 0.001). CONCLUSIONS nSES and race/ethnicity are independent predictors of a patient refusing surgery for metastatic cancer to bone, even after adjusting for various clinical covariates. Effective strategies for addressing these inequalities and improving the access and quality of care of patients with a lower nSES and minority backgrounds are needed.
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Affiliation(s)
- Kyle Mani
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Anne Schlumprecht
- Department of Neurological Surgery, Montefiore Einstein, Bronx, NY, USA
| | | | - Noel Akioyamen
- Department of Orthopedic Surgery, Montefiore Einstein, Montefiore Medical Center, Bronx, NY, USA
| | - Hyun Song
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Ananth Eleswarapu
- Department of Orthopedic Surgery, Montefiore Einstein, Montefiore Medical Center, Bronx, NY, USA
| | - Rui Yang
- Department of Orthopedic Surgery, Montefiore Einstein, Montefiore Medical Center, Bronx, NY, USA
| | - David Geller
- Department of Orthopedic Surgery, Montefiore Einstein, Montefiore Medical Center, Bronx, NY, USA
| | - Bang Hoang
- Department of Orthopedic Surgery, Montefiore Einstein, Montefiore Medical Center, Bronx, NY, USA
| | - Reza Yassari
- Department of Neurological Surgery, Montefiore Einstein, Bronx, NY, USA
| | - Mitchell S Fourman
- Department of Orthopedic Surgery, Montefiore Einstein, Montefiore Medical Center, Bronx, NY, USA.
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Marcotte LM, Deeds S, Wheat C, Gunnink E, Gray K, Rojas J, Finch C, Nelson K, Reddy A. Automated Opt-Out vs Opt-In Patient Outreach Strategies for Breast Cancer Screening: A Randomized Clinical Trial. JAMA Intern Med 2023; 183:1187-1194. [PMID: 37695621 PMCID: PMC10495926 DOI: 10.1001/jamainternmed.2023.4321] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/12/2023] [Indexed: 09/12/2023]
Abstract
Importance Optimal strategies for population-based outreach for breast cancer screening remain unknown. Objective To evaluate the effect on breast cancer screening of an opt-out automatic mammography referral strategy compared with an opt-in automated telephone message strategy. Design, Setting, and Participants This pragmatic randomized clinical trial was conducted from April 2022 to January 2023 at a single Veterans Affairs (VA) medical center. Participants were female veterans aged 45 to 75 years who were eligible for breast cancer screening and enrolled in VA primary care. Intervention Veterans were randomized 1:1 to receive either an automatic mammography referral (opt-out arm) or an automated telephone call with an option for mammography referral (opt-in arm). Main Outcomes and Measures The primary outcome was completed mammography 100 days after outreach. Secondary outcomes were scheduled or completed mammography by 100 days after outreach and referrals canceled if mammography was not scheduled within 90 days. Both intention-to-treat analyses and a restricted analysis were conducted. The restricted analysis excluded veterans who were unable to be reached by telephone (eg, a nonworking number) or who were found to be ineligible after randomization (eg, medical record documentation of recent mammography). Results Of 883 veterans due for mammography (mean [SD] age, 59.13 [8.24] years; 656 [74.3%] had received prior mammography), 442 were randomized to the opt-in group and 441 to the opt-out group. In the intention-to-treat analysis, there was no significant difference in the primary outcome of completed mammography at 100 days between the opt-out and opt-in groups (67 [15.2%] vs 66 [14.9%]; P = .90) or the secondary outcome of completed or scheduled mammography (84 [19%] vs 106 [24.0%]; P = .07). A higher number of referrals were canceled in the opt-out group compared with the opt-in group (104 [23.6%] vs 24 [5.4%]; P < .001). The restricted analysis demonstrated similar results except more veterans completed or scheduled mammography within 100 days in the opt-out group compared with the opt-in group (102 of 388 [26.3%] vs 80 of 415 [19.3%]; P = .02). Conclusions and Relevance In this randomized clinical trial, an opt-out population-based breast cancer screening outreach approach compared with an opt-in approach did not result in a significant difference in mammography completion but did lead to substantially more canceled mammography referrals, increasing staff burden. Trial Registration ClinicalTrials.gov Identifier: NCT05313737.
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Affiliation(s)
- Leah M. Marcotte
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle
| | - Stefanie Deeds
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle
- VA Puget Sound Health Care System, Seattle, Washington
| | - Chelle Wheat
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Eric Gunnink
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Kristen Gray
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Jorge Rojas
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Carolyn Finch
- VA Puget Sound Health Care System, Seattle, Washington
| | - Karin Nelson
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle
- VA Puget Sound Health Care System, Seattle, Washington
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Ashok Reddy
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle
- VA Puget Sound Health Care System, Seattle, Washington
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
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McDermott A, Kim N, Hausmann LRM, Magnani JW, Good CB, Litam TMA, Mor MK, Omole TD, Gellad WF, Fine MJ, Essien UR. Association of Neighborhood Disadvantage and Anticoagulation for Patients with Atrial Fibrillation in the Veterans Health Administration: the REACH-AF Study. J Gen Intern Med 2023; 38:848-856. [PMID: 36151447 PMCID: PMC10039185 DOI: 10.1007/s11606-022-07810-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common arrhythmia, the management of which includes anticoagulation for stroke prevention. Although disparities in anticoagulant prescribing have been well documented for individual socioeconomic factors, less is known about the association of neighborhood-level disadvantage and anticoagulation for AF. OBJECTIVE To assess the association between neighborhood disadvantage and anticoagulant initiation for patients with incident AF. DESIGN Retrospective cohort study. PARTICIPANTS A cohort of patients enrolled in the Veterans Health Administration (VA) with incident AF from January 2014 through December 2020 from the Race, Ethnicity, and Anticoagulant CHoice in Atrial Fibrillation (REACH-AF) Study. MAIN MEASURES The primary exposure was neighborhood disadvantage quantified using area deprivation index (ADI), classified by quintiles (Q). The outcomes were initiation of any anticoagulant therapy (warfarin or direct oral anticoagulant, DOAC) within 90 days of AF diagnosis and DOAC use among initiators. We used mixed effects logistic regression to assess the association between ADI and anticoagulant therapy, incorporating a fixed effect for treatment site and baseline patient, provider, and facility covariates. KEY RESULTS Among 161,089 patients, 105,489 (65.5%) initiated any anticoagulant therapy, and 78,903 (74.8%) used DOACs. Any anticoagulant therapy increased 3.2 percentage points (63.0% to 66.2%; p<.001) from Q1 to Q5, whereas DOAC use decreased 8.2 percentage points (79.4% to 71.2%; p<.0001) across quintiles. The adjusted odd ratios of any anticoagulant therapy were non-significantly different for Q2-Q5 than Q1. The adjusted odds of DOAC use decreased progressively from 0.89 (95% CI, 0.84-0.94) in Q2 to 0.77 (95% CI, 0.73-0.83) in Q5 compared to Q1 (p<.0001). CONCLUSIONS Among Veterans with incident AF, we observed similar initiation of any anticoagulant, though neighborhood deprivation was associated with decreased DOAC use among anticoagulant initiators. Future interventions to improve pharmacoequity in anticoagulant prescribing for AF should consider the role of neighborhood-level determinants of health inequities.
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Affiliation(s)
- Annie McDermott
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, PA, USA
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Toluwa D Omole
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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India-Aldana S, Rundle AG, Zeleniuch-Jacquotte A, Quinn JW, Kim B, Afanasyeva Y, Clendenen TV, Koenig KL, Liu M, Neckerman KM, Thorpe LE, Chen Y. Neighborhood Walkability and Mortality in a Prospective Cohort of Women. Epidemiology 2021; 32:763-772. [PMID: 34347687 PMCID: PMC8969891 DOI: 10.1097/ede.0000000000001406] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is a paucity of prospective cohort studies evaluating neighborhood walkability in relation to the risk of death. METHODS We geocoded baseline residential addresses of 13,832 women in the New York University Women's Health Study (NYUWHS) and estimated the Built Environment and Health Neighborhood Walkability Index (BEH-NWI) for each participant circa 1990. The participants were recruited from 1985 to 1991 in New York City and followed for an average of 27 years. We conducted survival analyses using Cox proportional hazards models to assess the association between neighborhood walkability and risk of death from any cause, obesity-related diseases, cardiometabolic diseases, and obesity-related cancers. RESULTS Residing in a neighborhood with a higher neighborhood walkability score was associated with a lower mortality rate. Comparing women in the top versus the lowest walkability tertile, the hazards ratios (and 95% CIs) were 0.96 (0.93, 0.99) for all-cause, 0.91 (0.86, 0.97) for obesity-related disease, and 0.72 (0.62, 0.85) for obesity-related cancer mortality, respectively, adjusting for potential confounders at both the individual and neighborhood level. We found no association between neighborhood walkability and risk of death from cardiometabolic diseases. Results were similar in analyses censoring participants who moved during follow-up, using multiple imputation for missing covariates, and using propensity scores matching women with high and low neighborhood walkability on potential confounders. Exploratory analyses indicate that outdoor walking and average BMI mediated the association between neighborhood walkability and mortality. CONCLUSION Our findings are consistent with a protective role of neighborhood walkability in obesity-related mortality in women, particularly obesity-related cancer mortality.
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Affiliation(s)
- Sandra India-Aldana
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 5 Fl., New York, NY, 10016, USA
| | - Andrew G. Rundle
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 USA
| | - Anne Zeleniuch-Jacquotte
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 5 Fl., New York, NY, 10016, USA
| | - James W. Quinn
- Columbia Population Research Center, Columbia University
| | - Byoungjun Kim
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 USA
| | - Yelena Afanasyeva
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 5 Fl., New York, NY, 10016, USA
| | - Tess V. Clendenen
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 5 Fl., New York, NY, 10016, USA
| | - Karen L. Koenig
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 5 Fl., New York, NY, 10016, USA
| | - Mengling Liu
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 5 Fl., New York, NY, 10016, USA
- Department of Environmental Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Lorna E. Thorpe
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 5 Fl., New York, NY, 10016, USA
| | - Yu Chen
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 5 Fl., New York, NY, 10016, USA
- Department of Environmental Medicine, NYU Grossman School of Medicine, New York, NY, USA
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Zhang K, Lovasi GS, Odden MC, Michael YL, Newman AB, Arnold AM, Kim DH, Wu C. Association of Retail Environment and Neighborhood Socioeconomic Status with Mortality among Community-dwelling Older Adults in the US: Cardiovascular Health Study. J Gerontol A Biol Sci Med Sci 2021; 77:2240-2247. [PMID: 34669918 DOI: 10.1093/gerona/glab319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Few studies have examined the association of neighborhood environment and mortality among community-dwelling older populations. Geographic Information Systems (GIS)-based measures of neighborhood physical environment may provide new insights on the health effects of the social and built environment. METHODS We studied 4,379 community-dwelling older adults in the US aged ≥65 years from the Cardiovascular Health Study. Principal component analysis was used to identify neighborhood components from 48 variables assessing facilities and establishments, demographic composition, socio-economic status, and economic prosperity. We used a Cox model to evaluate the association of neighborhood components with five-year mortality. Age, sex, race, education, income, marital status, body mass index, smoking status, disability, coronary heart disease, and diabetes were included as covariates. We also examined the interactions between neighborhood components and sex and race (Black vs. white or other). RESULTS We identified five neighborhood components, representing facilities and resources, immigrant communities, community-level economic deprivation, resident-level socio-economic status and residents' age. Communities' economic deprivation and residents' socio-economic status were significantly associated with five-year mortality. We did not find interactions between sex or race and any of the five neighborhood components. The results were similar in a sensitivity analysis where we used ten-year mortality as the outcome. CONCLUSIONS We found that communities' economic status but not facilities in communities was associated with mortality among older adults. These findings revealed the importance and benefits living in a socio-economically advantaged neighborhood could have on health among older residents with different demographic backgrounds.
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Affiliation(s)
- Kehan Zhang
- Global Health Research Center, Duke Kunshan University, Kunshan, Jiangsu, China
| | - Gina S Lovasi
- Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Yvonne L Michael
- Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Anne B Newman
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Alice M Arnold
- School of Public Health, University of Washington, Seattle, WA
| | - Dae Hyun Kim
- Hebrew Rehabilitation Center, Harvard University, Cambridge, MA
| | - Chenkai Wu
- Global Health Research Center, Duke Kunshan University, Kunshan, Jiangsu, China
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Social determinants do not affect access to specialized epilepsy care in veterans. Epilepsy Behav 2021; 121:108071. [PMID: 34052631 DOI: 10.1016/j.yebeh.2021.108071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/09/2021] [Accepted: 05/09/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION It is well established that sociodemographic and neighborhood determinants impact access to healthcare. Veterans with epilepsy (VWE) face unique challenges that may limit access to specialized epilepsy care, though institutional initiatives have aimed to minimize disparities. We assessed the extent to which surrogate markers of access to quality care in VWE were impacted by sociodemographic and neighborhood determinants. METHODS The sample included 180 VWE. Surrogate markers included time between initial diagnosis and admission to epilepsy monitoring unit (EMU) (time to referral, TTR), and the number of CT, MRI, and EEGs conducted prior to initial EMU evaluation. Sociodemographic and neighborhood determinants included age, sex, race, education, neighborhood advantage, rural status, distance from home to the nearest VAMC, and number of service connection (SC) conditions. Significant correlations across variables of interest were entered into a linear regression. Group differences between social factors were assessed for early and late TTR groups (based on 1st and 4th quartiles). RESULTS The mean TTR was 12 years (SD ± 13.18). Longer TTR was correlated to older age (p < 0.001) and fewer SC conditions (p = 0.03). None of the other factors were significantly correlated to TTR. Older age significantly predicted longer TTR on regression. The earlier TTR group was younger, had more SC conditions, lived closer to a VAMC, and was more likely to be female. Greater geographic distance was correlated with fewer CT scans (p = 0.01). A greater number of MRIs was correlated with older age (p = 0.04). Younger age (p < 0.01) and greater education (p = 0.01) were correlated with more SC. CONCLUSION Access to epilepsy care among VWE was largely unimpacted by social determinants, with the exception of older age leading to longer TTR. The TTR in VWE was considerably shorter than has been reported in the literature for civilian patients. The Veterans Health Administration model of care may harbor certain advantages in epilepsy treatment.
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Trinh-Shevrin C. Applying a Population Health Equity Framework in the Clinical Setting-Incorporating Social and Behavioral Determinants of Health Into Estimations of Risk. JAMA Netw Open 2020; 3:e2021771. [PMID: 33079193 PMCID: PMC8628362 DOI: 10.1001/jamanetworkopen.2020.21771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Chau Trinh-Shevrin
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
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Bowe B, Xie Y, Yan Y, Al-Aly Z. Burden of Cause-Specific Mortality Associated With PM2.5 Air Pollution in the United States. JAMA Netw Open 2019; 2:e1915834. [PMID: 31747037 PMCID: PMC6902821 DOI: 10.1001/jamanetworkopen.2019.15834] [Citation(s) in RCA: 165] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Ambient fine particulate matter (PM2.5) air pollution is associated with increased risk of several causes of death. However, epidemiologic evidence suggests that current knowledge does not comprehensively capture all causes of death associated with PM2.5 exposure. OBJECTIVE To systematically identify causes of death associated with PM2.5 pollution and estimate the burden of death for each cause in the United States. DESIGN, SETTING, AND PARTICIPANTS In a cohort study of US veterans followed up between 2006 and 2016, ensemble modeling was used to identify and characterize morphology of the association between PM2.5 and causes of death. Burden of death associated with PM2.5 exposure in the contiguous United States and for each state was then estimated by application of estimated risk functions to county-level PM2.5 estimates from the US Environmental Protection Agency and cause-specific death rate data from the Centers for Disease Control and Prevention. MAIN OUTCOMES AND MEASURES Nonlinear exposure-response functions of the association between PM2.5 and causes of death and burden of death associated with PM2.5. EXPOSURES Annual mean PM2.5 levels. RESULTS A cohort of 4 522 160 US veterans (4 243 462 [93.8%] male; median [interquartile range] age, 64.1 [55.7-75.5] years; 3 702 942 [82.0%] white, 667 550 [14.8%] black, and 145 593 [3.2%] other race) was followed up for a median (interquartile range) of 10.0 (6.8-10.2) years. In the contiguous United States, PM2.5 exposure was associated with excess burden of death due to cardiovascular disease (56 070.1 deaths [95% uncertainty interval {UI}, 51 940.2-60 318.3 deaths]), cerebrovascular disease (40 466.1 deaths [95% UI, 21 770.1-46 487.9 deaths]), chronic kidney disease (7175.2 deaths [95% UI, 5910.2-8371.9 deaths]), chronic obstructive pulmonary disease (645.7 deaths [95% UI, 300.2-2490.9 deaths]), dementia (19 851.5 deaths [95% UI, 14 420.6-31 621.4 deaths]), type 2 diabetes (501.3 deaths [95% UI, 447.5-561.1 deaths]), hypertension (30 696.9 deaths [95% UI, 27 518.1-33 881.9 deaths]), lung cancer (17 545.3 deaths [95% UI, 15 055.3-20 464.5 deaths]), and pneumonia (8854.9 deaths [95% UI, 7696.2-10 710.6 deaths]). Burden exhibited substantial geographic variation. Estimated burden of death due to nonaccidental causes was 197 905.1 deaths (95% UI, 183 463.3-213 644.9 deaths); mean age-standardized death rates (per 100 000) due to nonaccidental causes were higher among black individuals (55.2 [95% UI, 50.5-60.6]) than nonblack individuals (51.0 [95% UI, 46.4-56.1]) and higher among those living in counties with high (65.3 [95% UI, 56.2-75.4]) vs low (46.1 [95% UI, 42.3-50.4]) socioeconomic deprivation; 99.0% of the burden of death due to nonaccidental causes was associated with PM2.5 levels below standards set by the US Environmental Protection Agency. CONCLUSIONS AND RELEVANCE In this study, 9 causes of death were associated with PM2.5 exposure. The burden of death associated with PM2.5 was disproportionally borne by black individuals and socioeconomically disadvantaged communities. Effort toward cleaner air might reduce the burden of PM2.5-associated deaths.
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Affiliation(s)
- Benjamin Bowe
- Research and Education Service, Clinical Epidemiology Center, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- College for Public Health and Social Justice, Department of Epidemiology and Biostatistics, St Louis University, St Louis, Missouri
| | - Yan Xie
- Research and Education Service, Clinical Epidemiology Center, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- College for Public Health and Social Justice, Department of Epidemiology and Biostatistics, St Louis University, St Louis, Missouri
- Veterans Research & Education Foundation of St Louis, St Louis, Missouri
| | - Yan Yan
- Research and Education Service, Clinical Epidemiology Center, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ziyad Al-Aly
- Research and Education Service, Clinical Epidemiology Center, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Veterans Research & Education Foundation of St Louis, St Louis, Missouri
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
- Nephrology Section, Medicine Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Institute for Public Health, Washington University School of Medicine in St Louis, St Louis, Missouri
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The Association Between Neighborhood Environment and Mortality: Results from a National Study of Veterans. J Gen Intern Med 2017; 32:416-422. [PMID: 27815763 PMCID: PMC5377878 DOI: 10.1007/s11606-016-3905-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 09/23/2016] [Accepted: 10/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND As the largest integrated US health system, the Veterans Health Administration (VHA) provides unique national data to expand knowledge about the association between neighborhood socioeconomic status (NSES) and health. Although living in areas of lower NSES has been associated with higher mortality, previous studies have been limited to higher-income, less diverse populations than those who receive VHA care. OBJECTIVE To describe the association between NSES and all-cause mortality in a national sample of veterans enrolled in VHA primary care. DESIGN One-year observational cohort of veterans who were alive on December 31, 2011. Data on individual veterans (vital status, and clinical and demographic characteristics) were abstracted from the VHA Corporate Data Warehouse. Census tract information was obtained from the US Census Bureau American Community Survey. Logistic regression was used to model the association between NSES deciles and all-cause mortality during 2012, adjusting for individual-level income and demographics, and accounting for spatial autocorrelation. PARTICIPANTS Veterans who had vital status, demographic, and NSES data, and who were both assigned a primary care physician and alive on December 31, 2011 (n = 4,814,631). MAIN MEASURES Census tracts were used as proxies for neighborhoods. A summary score based on census tract data characterized NSES. Veteran addresses were geocoded and linked to census tract NSES scores. Census tracts were divided into NSES deciles. KEY RESULTS In adjusted analysis, veterans living in the lowest-decile NSES tract were 10 % (OR 1.10, 95 % CI 1.07, 1.14) more likely to die than those living in the highest-decile NSES tract. CONCLUSIONS Lower neighborhood SES is associated with all-cause mortality among veterans after adjusting for individual-level socioeconomic characteristics. NSES should be considered in risk adjustment models for veteran mortality, and may need to be incorporated into strategies aimed at improving veteran health.
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Bethea TN, Palmer JR, Rosenberg L, Cozier YC. Neighborhood Socioeconomic Status in Relation to All-Cause, Cancer, and Cardiovascular Mortality in the Black Women's Health Study. Ethn Dis 2016; 26:157-64. [PMID: 27103765 DOI: 10.18865/ed.26.2.157] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Neighborhood socioeconomic status (SES) is associated with adverse health outcomes, but longitudinal data among Black Americans, who tend to live in more deprived neighborhoods, is lacking. OBJECTIVE We prospectively assessed the relation of neighborhood SES to mortality in the Black Women's Health Study. DESIGN A prospective cohort of 59,000 Black women was followed from 1995-2011. Participant addresses were geocoded and US Census block group was identified. Neighborhood SES was measured by a score based on US Census block group data for six indicators of income, education and wealth. MAIN OUTCOME MEASURES Deaths were identified through the National Death Index. Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% CIs with control for covariates. RESULTS Based on 2,598 deaths during 1995-2011, lower neighborhood SES was associated with increased all-cause and cancer mortality irrespective of individual education: among those with 16 or more years of education, HRs for lowest relative to highest neighborhood SES quartile were 1.42 (95% CI 1.18-1.71) for all-cause and 1.54 (95% CI 1.14-2.07) for cancer mortality. Neighborhood SES was associated with cardiovascular mortality among less-educated women. CONCLUSIONS Lower neighborhood SES is associated with greater risk of mortality among Black women. The presence of the association even among women with high levels of education suggests that individual SES may not overcome the unfavorable influence of neighborhood deprivation.
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Bihan H, Backholer K, Peeters A, Stevenson CE, Shaw JE, Magliano DJ. Socioeconomic Position and Premature Mortality in the AusDiab Cohort of Australian Adults. Am J Public Health 2016; 106:470-7. [PMID: 26794164 DOI: 10.2105/ajph.2015.302984] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine the association of socioeconomic position indicators with mortality, without and with adjustment for modifiable risk factors. METHODS We examined the relationships of 2 area-based indices and educational level with mortality among 9338 people (including 8094 younger than 70 years at baseline) of the Australian Diabetes Obesity and Lifestyle (AusDiab) from 1999-2000 until November 30, 2012. RESULTS Age- and gender-adjusted premature mortality (death before age 70 years) was more likely among those living in the most disadvantaged areas versus least disadvantaged (hazard ratio [HR] = 1.48; 95% confidence interval [CI] = 1.08, 2.01), living in inner regional versus major urban areas (HR = 1.36; 95% CI = 1.07, 1.73), or having the lowest educational level versus the highest (HR = 1.64; 95% CI = 1.17, 2.30). The contribution of modifiable risk factors (smoking status, diet quality, physical activity, stress, cardiovascular risk factors) in the relationship between 1 area-based index or educational level and mortality was more apparent as age of death decreased. CONCLUSIONS The relation of area-based socioeconomic position to premature mortality is partly mediated by behavioral and cardiovascular risk factors. Such results could influence public health policies.
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Affiliation(s)
- Hélène Bihan
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Kathrin Backholer
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Anna Peeters
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Christopher E Stevenson
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Jonathan E Shaw
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Dianna J Magliano
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
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August KJ, Billimek J. A theoretical model of how neighborhood factors contribute to medication nonadherence among disadvantaged chronically ill adults. J Health Psychol 2015; 21:2923-2933. [PMID: 26089191 DOI: 10.1177/1359105315589391] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In addition to individual-level socioeconomic and psychological factors, the neighborhood environment has been found to be related to medication nonadherence, particularly among low-income, minority populations managing a chronic disease. In this article, we synthesize the relevant literature on how neighborhood factors contribute to engagement in health behaviors and reasons for medication nonadherence among this population. We propose a theoretical framework for understanding the mediating and moderating mechanisms whereby the neighborhood environment may impact medication nonadherence among individuals most at risk for adverse disease outcomes. Guided by this model, we provide recommendations for future research, practice, and policy.
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Billimek J, Sorkin DH. Self-reported neighborhood safety and nonadherence to treatment regimens among patients with type 2 diabetes. J Gen Intern Med 2012; 27:292-6. [PMID: 21935749 PMCID: PMC3286552 DOI: 10.1007/s11606-011-1882-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 08/24/2011] [Accepted: 09/01/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Few studies have explored the association between neighborhood characteristics and adherence to diabetes self-management behaviors, and none have examined the influence of neighborhood safety on adherence to treatment regimens among patients with diabetes. OBJECTIVE To assess whether neighborhood safety is associated with self-reports of technical quality of care and with nonadherence to diabetes treatment regimens. DESIGN A cross-sectional analysis of a population-based sample of California adults responding to the 2007 California Health Interview Survey. Multivariable logistic regression models were used to examine the association of self-reported neighborhood safety with technical quality of care and treatment nonadherence, adjusted for sociodemographic characteristics, barriers to access to care, and health status. PARTICIPANTS Adults with type 2 diabetes currently receiving medical treatment. MAIN MEASURES Patient-reported neighborhood safety, performance of recommended processes of care by provider, treatment nonadherence (patient delays in filling prescriptions and obtaining needed medical care). KEY RESULTS Self-reported neighborhood safety was not associated with process measures of technical quality of care, but was associated with treatment nonadherence. Specifically, compared to those who report living in a safe neighborhood, a higher proportion of patients living in unsafe neighborhoods reported delays in filling a prescription for any reason (21.9% vs. 12.8%, aOR = 1.69, 95%CI 1.19, 2.40) and delays in filling a prescription due to cost (12.2% vs. 6.8%, aOR = 1.63, 95%CI 1.02, 2.62). CONCLUSIONS Contextual factors, such as neighborhood safety, may contribute to treatment nonadherence in daily life, even when the technical quality of care delivered in the clinic is not diminished.
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Affiliation(s)
- John Billimek
- Health Policy Research Institute, Department of Medicine, University of California, Irvine, 100 Theory, Suite 110, Irvine, CA 92697-5800, USA.
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Williams EC, McFarland LV, Nelson KM. Alcohol consumption among urban, suburban, and rural Veterans Affairs outpatients. J Rural Health 2011; 28:202-10. [PMID: 22458321 DOI: 10.1111/j.1748-0361.2011.00389.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE United States rural residents tend toward poorer health than urban residents. Although alcohol use is associated with multiple medical conditions and can be reduced via brief primary care-based interventions, it is unknown whether alcohol consumption differs by rurality among primary care patients. We sought to describe alcohol consumption among urban, suburban, and rural Veterans Affairs (VA) outpatients. METHODS Outpatients from 7 VA facilities responded to mailed surveys that included the validated Alcohol Use Disorders Identification Test Consumption (AUDIT-C) screening questionnaire. The ZIP code approximation of the US Department of Agriculture's rural-urban commuting area (RUCA) codes classified participants into urban, suburban, and rural areas. For each area, adjusted logistic regression models estimated the prevalence of past-year abstinence among all participants and unhealthy alcohol use (AUDIT-C ≥ 3 for women and ≥ 4 for men) among drinkers. FINDINGS Among 33,883 outpatients, 14,967 (44%) reported abstinence. Among 18,916 drinkers, 8,524 (45%) screened positive for unhealthy alcohol use. The adjusted prevalence of abstinence was lowest in urban residents (43%, 95% CI 42%-43%) with significantly higher rates in both suburban and rural residents [45% (44%-46%) and 46% (45%-47%), respectively]. No significant differences were observed in the adjusted prevalence of unhealthy alcohol use among drinkers. CONCLUSIONS Abstinence is slightly more common among rural and suburban than urban VA outpatients, but unhealthy alcohol use does not vary by rurality. As the VA and other health systems implement evidence-based care for unhealthy alcohol use, more research is needed to identify whether preventive strategies targeted to high-risk areas are needed.
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Affiliation(s)
- Emily C Williams
- Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington 98101, USA.
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