Race, socioeconomic status, and cause-specific mortality

Disparities in prevalence and treatment of diabetes, cardiovascular and chronic kidney diseases - Recommendations from the taskforce of the guideline workshop

There is a mounting clinical, psychosocial, and socioeconomic burden worldwide as the prevalence of diabetes, cardiovascular disease (CVD), and chronic kidney disease (CKD) continues to rise. Despite the introduction of therapeutic interventions with demonstrated efficacy to prevent the development or progression of these common chronic diseases, many individuals have limited access to these innovations due to their race/ethnicity, and/or socioeconomic status (SES). However, practical guidance to providers and healthcare systems for addressing these disparities is often lacking. In this article, we review the prevalence and impact of healthcare disparities derived from the above-mentioned chronic conditions and present broad-based recommendations for improving access to quality care and health outcomes within the most vulnerable populations.

Health Care Disparities and the Emergency Management of Postpartum Patients with Cardiovascular Complaints

OBJECTIVE

 This study aimed to determine health care disparities in evaluation and admission among underserved racial and ethnic minority groups presenting with cardiovascular complaints during the first postpartum year according to patient and provider demographics.

STUDY DESIGN

 A retrospective cohort study was performed on all postpartum patients who sought emergency care between February 2012 and October 2020 in a large urban care center in Southeastern Texas. Patient information was collected according to International Classification of Diseases 10th Revision codes and individual chart analysis. Race, ethnicity, and gender information were self-reported for both patients on hospital enrollment forms and emergency department (ED) providers on their employment records. Statistical analysis was performed with logistic regression and Pearson's chi-square test.

RESULTS

 Of 47,976 patients who delivered during the study period, 41,237 (85.9%) were black, Hispanic, or Latina and 490 (1.1%) presented to the ED with cardiovascular complaints. Baseline characteristics were similar between groups; however, Hispanic or Latina patients were more likely to have had gestational diabetes mellitus during the index pregnancy (6.2 vs. 18.3%). There was no difference in hospital admission between groups (17.9% black vs. 16.2% Latina or Hispanic patients). There was no difference in the hospital admission rate by provider race or ethnicity overall (p = 0.82). There was no difference in the hospital admission rate when a patient was evaluated by a provider of a different race or ethnicity (relative risk [RR] = 1.08, CI: 0.6-1.97). There was no difference in the rate of admission according to the self-reported gender of the provider (RR = 0.97, CI: 0.66-1.44).

CONCLUSION

 This study illustrates that disparities did not exist in the management of racial and ethnic minority groups who presented to the ED with cardiovascular complaints during the first postpartum year. Patient-provider discordance in race or gender was not a significant source of bias or discrimination during the evaluation and treatment of these patients.

KEY POINTS

· Adverse postpartum outcomes disproportionately affect minorities.. · There was no difference in admissions between minority groups.. · There was no difference in admissions by provider race and ethnicity..

Association of Preoperative Lung Function with Complications after Lobectomy Using Race-Neutral and Race-Specific Normative Equations

Rationale: Pulmonary function testing (PFT) is performed to aid patient selection before surgical resection for non-small cell lung cancer (NSCLC). The interpretation of PFT data relies on normative equations, which vary by race, but the relative strength of association of lung function using race-specific or race-neutral normative equations with postoperative pulmonary complications is unknown. Objectives: To compare the strength of association of lung function, using race-neutral or race-specific equations, with surgical complications after lobectomy for NSCLC. Methods: We studied 3,311 patients who underwent lobectomy for NSCLC and underwent preoperative PFT from 2001 to 2021. We used Global Lung Function Initiative equations to generate race-specific and race-neutral normative equations to calculate percentage predicted forced expiratory volume in 1 second (FEV1%). The primary outcome of interest was the occurrence of postoperative pulmonary complications within 30 days of surgery. We used unadjusted and race-adjusted logistic regression models and least absolute shrinkage and selection operator analyses adjusted for relevant comorbidities to measure the association of race-specific and race-neutral FEV1% with pulmonary complications. Results: Thirty-one percent of patients who underwent surgery experienced pulmonary complications. Higher FEV1, whether measured with race-neutral (odds ratio [OR], 0.98 per 1% change in FEV1% [95% confidence interval (CI), 0.98-0.99]; P < 0.001) or race-specific (OR, 0.98 per 1% change in FEV1% [95% CI, 0.98-0.98]; P < 0.001) normative equations, was associated with fewer postoperative pulmonary complications. The area under the receiver operator curve for pulmonary complications was similar for race-adjusted race-neutral (0.60) and race-specific (0.60) models. Using least absolute shrinkage and selection operator regression, higher FEV1% was similarly associated with a lower rate of pulmonary complications in race-neutral (OR, 0.99 per 1% [95% CI, 0.98-0.99]) and race-specific (OR, 0.99 per 1%; 95% CI, 0.98-0.99) models. The marginal effect of race on pulmonary complications was attenuated in all race-specific models compared with all race-neutral models. Conclusions: The choice of race-specific or race-neutral normative PFT equations does not meaningfully affect the association of lung function with pulmonary complications after lobectomy for NSCLC, but the use of race-neutral equations unmasks additional effects of self-identified race on pulmonary complications.

Impact of Community Socioeconomic Characteristics on Emergency Medical Service Delays in Responding to Fatal Vehicle Crashes

Introduction

This study aimed to determine the impact of community socioeconomic status on emergency medical services' response time for fatal vehicle crashes.

Methods

Authors used the 2019 National Highway Traffic Safety Administration Fatality Analysis Reporting System and 2019-2020 Area Health Resource Files to obtain emergency medical services' time intervals and county socioeconomic characteristics (e.g., median household income, availability of trauma centers, and rurality), generating a study sample of 18,540 individuals involved in fatal vehicle crashes between January and December 2019. Generalized linear models with log-link and Gamma-family were used to obtain estimates, and other variables were adjusted in the model.

Results

Both the mean time of the emergency medical service arrival to the site of the crash and the mean transport time from the crash site to hospital varied by county SES. Counties with a higher mean household income had 12% shorter emergency medical services' arrival times and up to 7% shorter emergency medical services' hospital transport times than counties with lower SES. The emergency medical services' hospital transport times by emergency medical services also varied by proximity to trauma centers and were 15% shorter in counties that had ≥2 trauma centers than in counties without trauma centers.

Conclusions

This study shows socioeconomic disparities in emergency medical service rescue time for fatal vehicle crashes. Community characteristics play a major role in emergency medical services' arrival time intervals. Prior research demonstrated a strong link between the timeliness of emergency medical service response and the likelihood of survival in fatal motor vehicle accidents. These findings showing that socioeconomically disadvantaged areas and those lacking trauma facilities had slower emergency medical service rescue times, suggest that socioeconomic status may be a predictor of mortality in fatal motor vehicle accidents. Effective emergency medical services are essential to reduce the morbidity and mortality among motor vehicle crash victims; however, disparities exist in the timeliness of these services by geographic and socioeconomic county characteristics. Further research is urgently needed to inform policy interventions.

Relationships between neighborhood disadvantage and cardiovascular findings at autopsy in subjects with sudden death

BACKGROUND

Neighborhood disadvantage is associated with a higher risk of sudden cardiac death. However, autopsy findings have never been investigated in this context. Here, we sought to explore associations between neighborhood disadvantage and cardiovascular findings at autopsy in cases of sudden death in the State of Maryland.

METHODS

State of Maryland investigation reports from 2,278 subjects within the CVPath Sudden Death Registry were screened for street addresses and 9-digit zip codes. Area deprivation index (ADI), used as metric for neighborhood disadvantage, was available for 1,464 subjects; 650 of whom self-identified as Black and 814 as White. The primary study outcome measurements were causes of death and gross and histopathologic findings of the heart.

RESULTS

Subjects from most disadvantaged neighborhoods (i.e., ADI ≥ 8; n = 607) died at younger age compared with subjects from less disadvantaged neighborhoods (i.e., ADI ≤ 7; n = 857; 46.07 ± 14.10 vs 47.78 ± 13.86 years; P = 0.02) and were more likely Black or women. They were less likely to die from cardiac causes of death (61.8% vs 67.7%; P = 0.02) and had less severe atherosclerotic plaque features, including plaque burden, calcification, intraplaque hemorrhage, and thin-cap fibroatheromas. In addition, subjects from most disadvantaged neighborhoods had lower frequencies of plaque rupture (18.8% vs 25.1%, P = 0.004). However, these associations were omitted after adjustment for traditional risk factors and race.

CONCLUSION

Neighborhood disadvantage did not associate with cause of death or coronary histopathology after adjustment for cardiovascular risk factors and race, implying that social determinants of health other than neighborhood disadvantage play a more prominent role in sudden cardiac death.

Bearing allostatic load: insights into a more equitable future within cardio-oncology

Chronic stress is often regarded as a significant cause of morbidity and mortality; however, the mechanistic link between stress and various disease states has not yet been fully characterized. We explore the concept of allostatic load, a measurement of the physiological burden of chronic stress, as well as its potential role in disease pathogenesis as it relates to cardiovascular disease, cancer, and health-related disparities. Building from this framework, we then posit the potential implications of allostatic load on patient care and research in cardio-oncology. We identify allostatic load as a potential clinically actionable tool to improve health equity in cardio-oncology.

Long-Term Effects of Cognitive Training on All-Cause Mortality in US Older Adults

Objectives: Cognitive abilities have been implicated as predictors of mortality in older adults. This study examines the effects of cognitive training on mortality 20 years post-intervention. Methods: Data come from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) randomized control trial (N = 2802). Participants were cognitively and physically healthy, community-dwelling adults aged 65 and older. Cox proportional hazard models were used to investigate (1) the association between baseline cognition and mortality risk and (2) the effect of ACTIVE cognitive training (memory, reasoning, and speed of processing) on mortality risk 20 years post-intervention. Results: Higher baseline cognition predicted lower mortality risk 20 years post-intervention. No significant effects of ACTIVE cognitive training in memory, reasoning, or speed of processing on mortality risk were observed. Discussion: More work is needed to identify cognitive training interventions that may lead to lower mortality risks in later adulthood.

Leisure but Not Occupational Physical Activity and Sedentary Behavior Associated With Better Health

OBJECTIVE

This study explores relations between occupational and leisure-time physical activity (OPA, LTPA) and sedentary behavior (OSB, LTSB) and several health outcomes.

METHODS

A total 114 full-time workers had their body composition, waist circumference, height, weight, resting heart rate, and resting blood pressure measured. ActivPal monitor measured physical activity behaviors. Stress, mood, and pain were measured with ecological momentary assessment. General linear models were used to examine the relationship between high and low OPA, LTPA, OSB, and LTSB with each health outcome while controlling for covariates.

RESULTS

The high LTPA group had lower body mass index (BMI) (P = 0.04) and better mood (P = 0.007) than the low LTPA group. The high LTSB group had higher systolic blood pressure (P = 0.001), higher diastolic blood pressure (P = 0.01), higher BMI (P = 0.027), higher body fat percentage (P = 0.003), higher waist circumference (P = 0.01), and worse mood (P = 0.032) than the low LTSB group. No differences were found between OPA and OSB groups.

CONCLUSIONS

These findings suggest there may be differential relations between PA and SB accumulated during leisure versus occupational time.

Health Care Disparities in Use of Continuous Glucose Monitoring

Numerous studies have demonstrated that use of continuous glucose monitoring (CGM) improves glycemic control and reduces diabetes-related hospitalizations and emergency room service utilization in individuals with diabetes who are treated with intensive insulin regimens. Recent studies have revealed disparities in use of CGM within racially and ethnically diverse and lower socioeconomic populations, leading to underutilization of CGM in these populations. This article reviews the scope and impact of these disparities on utilization of CGM and explores the factors that may be contributing to this issue.

Race, Flourishing, and All-Cause Mortality in the United States, 1995-2016

We assessed whether race moderates the association between flourishing and all-cause mortality. We used panel data from the Midlife in the United States Study (MIDUS) (1995-2016; n = 2,851). Approximately 19% of White respondents and 23% of Black respondents in the baseline sample died over the course of the 21-year study period (n = 564). Cox proportional hazard models showed that Blacks had a higher mortality rate relative to Whites and higher levels of flourishing were associated with a lower mortality rate. Furthermore, a significant interaction between flourishing and race in predicting death was observed. Blacks with higher levels of flourishing had a mortality rate that was not significantly different from that of Whites. However, Blacks, but not Whites, with low flourishing scores had a higher mortality rate. As such, health-promotion efforts focused on enhancing flourishing among Black populations may reduce the Black-White gap in mortalityrate.

No effect of the Penalty Point System on road traffic accident mortality among men with a high socioeconomic status in Spain

The purpose of this study was to assess the effect of the Penalty Point System (PPS) on road traffic accident mortality by gender and socioeconomic status. We conducted a nationwide prospective study covering adult people living in Spain on November 2001. They were followed up until 30 Nov 2007 to determine vital status and cause of death. An interrupted time-series analysis was used to assess whether PPS (explanatory variable) had both immediate and long-term effect on the rates of road traffic accident mortality (RTAMs) separately by gender. Subjects were classified by socioeconomic status (low and high) using two indicators: educational attainment (up to lower secondary education; upper secondary education or more) and occupation (manual and non-manual workers). We performed several segmented Poisson regression models, controlling for trend, seasonality, 2004 road safety measures and fuel consumption as proxy for traffic exposure. Among men, we found a decrease on the RTAMs immediately after PPS in those with low educational level (16.2 %, IC95 %: 6.1 %-25.2 %) and manual workers (16.3 %, IC95 %: 2.8 %-27.8 %), and a non-significant increase among those with high education level and non-manual workers (6.2 % and 1.8 %). Among women, there were no significant differences in the immediate effect of PPS by socioeconomic status. We did not identify significant trend changes between pre-PPS and post-PPS periods in any socioeconomic group. In a context of downward trend of traffic mortality, the PPS implementation led to an immediate reduction on death rates only among men with a low socioeconomic status.

Area deprivation amplifies racial inequities in premature mortality: Analysis of 242,667 deaths in Washington State, USA 2011-15

Racial and socioeconomic inequalities in health are consistently reported, but less is known about the interplay between racial and deprivation-related inequities. We used geographically-localized data on all deaths recorded in Washington state 2011 to 2015 (n = 242,667 decedents) and multi-level regression models to examine premature (<65 years) mortality by race and neighborhood deprivation separately and in combination. White versus non-white inequities in premature mortality did not vary substantially with increasing levels of deprivation. However, most non-white races from deprived neighborhoods had odds of premature mortality between three and eight times that of more-affluent whites. These findings may reflect the compounding of disadvantage stemming from social and environmental risk factors.

Educational inequalities in traffic deaths during fluctuations of the economy in four Argentinian provinces, 1999-2013

OBJECTIVES

The objective of this study is to analyse how educational differentials in traffic mortality changed during economic fluctuations in four Argentinian provinces.

STUDY DESIGN

Retrospective quantitative analysis of secondary data.

METHODS

Data on fatalities due to traffic injuries (all traffic injuries, pedestrians/cyclists, motorcyclists, car users and unspecified road users) in four Argentinian provinces between 1999 and 2013 were linked to population data and information on the educational level of the deceased to compute mortality rates by educational level. Negative binomial models were estimated using age, sex, year, province of residence, year of economic expansion or recession and educational level as explanatory variables.

RESULTS

Annual traffic mortality differentials by educational level were lower during the period of economic crisis. An absolute increase in traffic mortality was observed in individuals of low educational level during economic expansions, but here, there were no traffic mortality differences for individuals of medium to high educational level. The educational gap in motorcyclist mortality widened during the period of quick economic expansion between 2005 and 2013.

CONCLUSIONS

We found less educational inequality in traffic mortality during an economic crisis in a developing country. However, the educational inequalities for different subtypes of traffic mortality show different patterns of evolution during the cycle of economic expansion and recession. Considering deaths due to traffic injuries, economic growth seems to be riskier for individuals of lower educational level compared with those of medium-high educational level.

The distribution and socioeconomic burden of Hepatitis C virus in South Australia: a cross-sectional study 2010-2016

Background

Hepatitis C virus infection (HCV) is a communicable disease of increasing global importance with 1.75 million new infections and 400,000 related deaths annually. Until recently, treatment options have had low uptake and most infected people remain untreated. New Direct Acting Antiviral medications can clear the virus in around 95% of cases, with few side-effects. These medications are restricted in most countries but freely accessible in Australia, yet most people still remain untreated. This study applies a cross-sectional research design to investigate the socio-spatial distribution of HCV in South Australia, to identify vulnerable populations, and examine epidemiological factors to potentially inform future targeted strategies for improved treatment uptake.

Method

HCV surveillance data were sourced from South Australia’s Communicable Diseases Control Branch and socio-economic population data from the Australian Bureau of Statistics from January 2010 to December 2016 inclusive. HCV cases were spatially mapped at postcode level. Multivariate logistic regression identified independent predictors of demographic risks for HCV notification and notification source.

Results

HCV notifications (n = 3356) were seven times more likely to be from people residing in the poorest areas with high rates of non-employment (75%; n = 1876) and injecting drug use (74%; n = 1862) reported. Notifications among Aboriginal and Torres Strait Islander people were around six times that of non-Indigenous people. HCV notifications negatively correlated (Spearman’s rho − 0.426; p < 0.001) with socio-economic status (residential postcode socio-economic resources Index). History of imprisonment independently predicted HCV diagnoses in lesser economically-resourced areas (RR1.5; p < 0.001). Independent predictors of diagnosis elsewhere than in general practices were non-employment (RR 4.6; p = 0.028), being male (RR 2.5; p < 0.001), and younger than mean age at diagnosis (RR 2.1; p = 0.006).

Conclusions

Most people diagnosed with HCV were from marginalised sub-populations. Given general practitioners are pivotal to providing effective HCV treatment for many people in Australia a most concerning finding was that non-employed people were statistically less likely to be diagnosed by general practitioners. These findings highlight a need for further action aimed at improving healthcare access and treatment uptake to help reduce the burden of HCV for marginalised people, and progress the vision of eliminating HCV as a major public health threat.

"Just too busy living in the moment and surviving": barriers to accessing health care for structurally vulnerable populations at end-of-life

BACKGROUND

Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous 'normative' populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL.

METHODS

Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently.

RESULTS

Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a 'silo-ed' care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the 'normative' palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers.

CONCLUSIONS

Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.

Implicit Physician Biases in Periviability Counseling

OBJECTIVE

To assess whether neonatologists show implicit racial and/or socioeconomic biases and whether these are predictive of recommendations at extreme periviability.

STUDY DESIGN

A nationwide survey using a clinical vignette of a woman in labor at 23^2/7 weeks of gestation asked physicians how likely they were to recommend intensive vs comfort care. Participants were randomized to 1 of 4 versions of the vignette in which racial and socioeconomic stimuli were varied, followed by 2 implicit association tests (IATs).

RESULTS

IATs revealed implicit preferences favoring white (mean IAT score = 0.48, P < .001) and greater socioeconomic status (mean IAT score = 0.73, P < .001). Multivariable linear regression analysis showed that physicians with implicit bias toward greater socioeconomic status were more likely than those without bias to recommend comfort care when presented with a patient of high socioeconomic status (P = .037). No significant effect was seen for implicit racial bias.

CONCLUSIONS

Building on previous demonstrations of unconscious racial and socioeconomic biases among physicians and their predictive validity, our results suggest that unconscious socioeconomic bias influences recommendations when counseling at the limits of viability. Physicians who display a negative socioeconomic bias are less likely to recommend resuscitation when counseling women of high socioeconomic status. The influence of implicit socioeconomic bias on recommendations at periviability may influence neonatal healthcare disparities and should be explored in future studies.

Relative Roles of Race Versus Socioeconomic Position in Studies of Health Inequalities: A Matter of Interpretation

An abundance of research has documented health inequalities by race and socioeconomic position (SEP) in the United States. However, conceptual and methodological challenges complicate the interpretation of study findings, thereby limiting progress in understanding health inequalities and in achieving health equity. Fundamental to these challenges is a lack of clarity about what race is and the implications of that ambiguity for scientific inquiry. Additionally, there is wide variability in how SEP is conceptualized and measured, resulting in a lack of comparability across studies and significant misclassification of risk. The objectives of this review are to synthesize the literature regarding common approaches to examining race and SEP health inequalities and to discuss the conceptual and methodological challenges associated with how race and SEP have been employed in public health research. Addressing health inequalities has become increasingly important as the United States trends toward becoming a majority-minority nation. Recommendations for future research are presented.

Death Is a Social Justice Issue: Perspectives on Equity-Informed Palliative Care

All too often, palliative care services are not responsive to the needs of those who are doubly vulnerable, being that they are both in need of palliative care services and experiencing deficits in the social determinants of health that result in complex, intersecting health and social concerns. In this article, we argue for a reorientation of palliative care to explicitly integrate the premises of health equity. We articulate the philosophical, theoretical, and empirical scaffolding required for equity-informed palliative care and draw on a current study to illustrate such an approach to the care of people who experience structural vulnerabilities.

The association of posttraumatic stress disorder and chronic medical conditions by ethnicity

Our study extends the literature on associations between posttraumatic stress disorder (PTSD) and chronic medical conditions by assessing differences in the magnitude of these relations by ethnicity. We examined group differences in the magnitude of the relation between PTSD and chronic medical conditions (cardiovascular disease [CVD], hypertension, obesity, diabetes). We obtained data from Latino (n = 3,224) and non-Latino white (n = 4,180) respondents from the Collaborative Psychiatric Epidemiology Surveys. Logistic regression models were constructed to test for the modification of the effect of PTSD on chronic medical conditions by ethnicity, and then by nativity. Unadjusted models revealed significant interactions between Latino ethnicity and PTSD for odds of diabetes (OR = 2.18 [Latino] v. 0.81 [non-Latino white]), CVD (OR = 3.23 [Latino] v. 1.28 [non-Latino white]), and hypertension (OR = 1.61 [Latino] v. 0.98 [non-Latino white]). Among U.S.-born Latinos, we found a significant interaction between ethnicity and PTSD for odds of CVD (OR = 4.18 [Latino] v. 1.28 [non-Latino white]) and diabetes (OR = 2.27 [Latino] v. 0.81 [non-Latino white]). These findings attenuated in adjusted models with the exception of differences in PTSD and odds of diabetes among Latinos (including aggregated group & U.S.-born) compared to non-Latino whites. Our findings support the need for further research on the complex relations between PTSD and chronic conditions, including the investigation of conditional risk by Latino sub-groups.

US Mortality: Influence of Race, Geography and Cardiovascular Risk Among Participants in the Population-Based REGARDS Cohort

OBJECTIVES

We evaluated whether differences in cardiovascular risk factors, as assessed by the Framingham risk scores for stroke and cardiovascular disease (FSRS and FCRS), contributed to disparities in all-cause mortality across race and regional strata of USA.

DESIGN

Race-region-specific FSRS and FCRS scores were computed for 30,086 REGARDS participants who were recruited between January 2003 and October 2007. They were divided across six regions of the "Eight Americas" and then compared after adjusting for race and sex. Kaplan-Meier curves and hazard ratios for all-cause mortality were estimated between regions, first adjusted for age and sex, and then for the risk scores.

RESULTS

After adjustment for age, sex, FCRS, and FSRS, there was no difference in mortality among Middle-America Whites versus Low-Income White. However, mortality was lower among Middle-America Blacks (-23 %; p = 0.06) and High-Risk Urban Blacks (-24 %; p = 0.01) compared to Southern Low-Income Rural Blacks. Compared to Middle-American Whites, mortality was higher among Middle-America Blacks (+39 %; p < 0.001), High-Risk Urban Blacks (+35 %; p < 0.001) and Southern Low-Income Rural Blacks (+85 %; p < 0.001).

CONCLUSION

Accounting for cardiovascular risk unmasked a greater disparity in mortality between Blacks and Whites and among Southern Rural Blacks compared to Middle-America Blacks and High-Risk Urban Blacks.

Epidemiology of Prostate and Testicular Cancer

Prostate and testicular cancers account for a large percentage of cancer morbidity in men in the United States and worldwide due to high prevalence rates that continue to grow. Patterns of incidence and mortality vary greatly in both cancers among men of different age groups, ethnicities, and geographic locations. This article summarizes the incidence, prognosis, and risk factors of both prostate and testicular cancers, globally and in the United States.

Neighborhood-Level Interventions to Improve Childhood Opportunity and Lift Children Out of Poverty

Population health is associated with the socioeconomic characteristics of neighborhoods. There is considerable scientific and policy interest in community-level interventions to alleviate child poverty. Intergenerational poverty is associated with inequitable access to opportunities. Improving opportunity structures within neighborhoods may contribute to improved child health and development. Neighborhood-level efforts to alleviate poverty for all children require alignment of cross-sector efforts, community engagement, and multifactorial approaches that consider the role of people as well as place. We highlight several accessible tools and strategies that health practitioners can engage to improve regional and local systems that influence child opportunity. The Child Opportunity Index is a population-level surveillance tool to describe community-level resources and inequities in US metropolitan areas. The case studies reviewed outline strategies for creating higher opportunity neighborhoods for pediatricians interested in working across sectors to address the impact of neighborhood opportunity on child health and well-being.

Cumulative social risk exposure and risk of cancer mortality in adulthood

Background

Adults in the United States (U.S) can be simultaneously exposed to more than one social risk factor over their lifetime. However, cancer epidemiology tends to focus on single social risk factors at a time. We examined the prospective association between cumulative social risk exposure and deaths from cancer in a nationally representative sample of U.S. adults.

Methods

The study included 8745 adults (aged ≥ 40 years) in the NHANES Survey III Mortality Study over a median follow-up of 13.5 years (1988-1994 enrollment dates and 1988 through 2006 for mortality data). Social risk factors (low family income, low education level, minority race, and single-living status) were summed to create a cumulative social risk score (0 to ≥3). We used Cox proportional hazard models to estimate age- and sex-adjusted hazard ratios (HRs) and 95 % confidence intervals (95 % CI) for the association between cumulative social risk with deaths from all-cancers combined, tobacco-related cancers, and screening-detectable cancers.

Results

Deaths from all-cancers combined (P for trend = 0.001), tobacco-related cancers (P for trend = <0.001), and lung cancer (P for trend = 0.01) increased with an increasing number of social risk factors. As compared with adults with no social risk factors, those exposed to ≥3 social risk factors were at increased risk of deaths from all-cancers combined (HR = 1.8, 95 % CI = 1.3-2.4), tobacco-related cancers (HR = 2.6, 95 % CI: 1.6-4.0), and lung cancer (HR = 2.3, 95 % CI = 1.3-4.1).

Conclusions

U.S. adults confronted by higher amounts of cumulative social risk appear to have increased mortality from all-cancers combined, tobacco-related cancers, and lung cancer. An enhanced understanding of the cumulative effect of social risk factors may be important for targeting interventions to address social disparities in cancer mortality.

Epidemiology and Regional Distribution of Pediatric Unintentional Emergency Injury in Korea from 2010 to 2011

Injury is a leading cause of death and disability in children and adolescents worldwide. The purpose of the current study was to investigate the epidemiologic characteristics of the pediatric unintentional injuries presenting to the Korean emergency department (ED). We included unintentional injuries in patients aged < 20 yr. Data collected from January 2010 to December 2011 was extracted from the National Emergency Department Information System (NEDIS) of Korea. The NEDIS data included information on patient's age and gender, geographic location of the ED visits, mechanism of injuries; and clinical outcomes. Most (94.1%) injuries were unintentional while 5.9% were intentional. The rate of ED visit for pediatric unintentional injury was 6,097 per 100,000 and critical injury was 59.8 per 100,000 (< 20 yr habitants). The mortality rate was 5.4 per 100,000. The mortality rate of pediatric unintentional injuries was 0.1% including the prehospital death and ED death. Unintentional pediatric injuries occurred most commonly in those age 0-4 boys and girls and were predominantly caused by collisions. Male motorcyclists aged 15-19 yr formed a critical injury high-risk group. The rates of critical injury and mortality were highest in Jeju, Gangwon, Gwangju, and Jeonbuk than those in other regions. High-risk groups by age, gender, mechanism and region should be targeted to prevent pediatric injuries in Korea.

Body Mass Index and Mortality in the General Population and in Subjects with Chronic Disease in Korea: A Nationwide Cohort Study (2002-2010)

BACKGROUND

The association between body mass index (BMI) and mortality is not conclusive, especially in East Asian populations. Furthermore, the association has been neither supported by recent data, nor assessed after controlling for weight changes.

METHODS

We evaluated the relationship between BMI and all-cause or cause-specific mortality, using prospective cohort data by the National Health Insurance Service in Korea, which consisted of more than one million subjects. A total of 153,484 Korean adults over 30 years of age without pre-existing cardiovascular disease or cancer at baseline were followed-up until 2010 (mean follow-up period = 7.91 ± 0.59 years). Study subjects repeatedly measured body weight 3.99 times, on average.

RESULTS

During follow-up, 3,937 total deaths occurred; 557 deaths from cardiovascular disease, and 1,224 from cancer. In multiple-adjusted analyses, U-shaped associations were found between BMI and mortality from any cause, cardiovascular disease, and cancer after adjustment for age, sex, smoking status, alcohol consumption, physical activity, socioeconomic status, and weight change. Subjects with a BMI < 23 kg/m2 and ≥ 30 kg/m2 had higher risks of all-cause and cause-specific mortality compared with the reference group (BMI 23-24.9 kg/m2). The lowest risk of all-cause mortality was observed in subjects with a BMI of 25-26.4 kg/m2 (adjusted hazard ratio [HR] 0.86; 95% CI 0.77 to 0.97). In subgroup analyses, including the elderly and those with chronic diseases (diabetes mellitus, hypertension, and chronic kidney disease), subjects with a BMI of 25-29.9 kg/m2 (moderate obesity) had a lower risk of mortality compared with the reference. However, this association has been attenuated in younger individuals, in those with higher socioeconomic status, and those without chronic diseases.

CONCLUSION

Moderate obesity was associated more strongly with a lower risk of mortality than with normal, underweight, and overweight groups in the general population of South Korea. This obesity paradox was prominent in not only the elderly but also individuals with chronic disease.

Trends in Socioeconomic Inequalities in Motor Vehicle Accident Deaths in the United States, 1995-2010

Motor vehicle accident (MVA) mortality has been declining overall, but little is known about trends by socioeconomic position. We examined trends in education-related inequalities in US MVA death rates from 1995 to 2010. We used mortality data from the National Center for Health Statistics and population estimates from the Current Population Survey, and we calculated vehicle- and person-miles traveled using data from the National Household Travel Survey. We used negative binomial regression to estimate crude and age-, sex-, and race-adjusted mortality rates among adults aged 25 years or more. We found larger mortality decreases among the more highly educated and some evidence of mortality increases among the least educated. Adjusted death rates were 15.3 per 100,000 population (95% confidence interval (CI): 10.7, 19.9) higher at the bottom of the education distribution than at the top of the education distribution in 1995, increasing to 17.9 per 100,000 population (95% CI: 14.8, 21.0) by 2010. In relative terms, adjusted death rates were 2.4 (95% CI: 1.7, 3.0) times higher at the bottom of the education distribution than at the top in 1995, increasing to 4.3 times higher (95% CI: 3.4, 5.3) by 2010. Inequality increases were larger in terms of vehicle-miles traveled. Although overall MVA death rates declined during this period, socioeconomic differences in MVA mortality have persisted or worsened over time.

Childhood maltreatment predicts allostatic load in adulthood

Childhood maltreatment has been linked to numerous negative health outcomes. However, few studies have examined mediating processes using longitudinal designs or objectively measured biological data. This study sought to determine whether child abuse and neglect predicts allostatic load (a composite indicator of accumulated stress-induced biological risk) and to examine potential mediators. Using a prospective cohort design, children (ages 0-11) with documented cases of abuse and neglect were matched with non-maltreated children and followed up into adulthood with in-person interviews and a medical status exam (mean age 41). Allostatic load was assessed with nine physical health indicators. Child abuse and neglect predicted allostatic load, controlling for age, sex, and race. The direct effect of child abuse and neglect persisted despite the introduction of potential mediators of internalizing and externalizing problems in adolescence and social support and risky lifestyle in middle adulthood. These findings reveal the long-term impact of childhood abuse and neglect on physical health over 30 years later.

Sex differences in predictors of ischemic stroke: current perspectives

Globally, stroke is a significant public health concern affecting more than 33 million individuals. Of growing importance are the differences between males and females in the predictors and overall risk of stroke. Given that women have a higher lifetime risk for stoke and account for more than half of all stroke deaths, sex-specific stroke risk factors merit investigation and may help target public health interventions. This review aims to discuss the current body of knowledge regarding sex-specific predictors of ischemic stroke including both modifiable and non-modifiable risk factors, as well as specific pathologies known to increase stroke risk.

Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: a cohort study

BACKGROUND

Risk for violent victimization or crime perpetration after firearm-related hospitalization (FRH) must be determined to inform the need for future interventions.

OBJECTIVE

To compare the risk for subsequent violent injury, death, or crime perpetration among patients with an FRH, those hospitalized for noninjury reasons, and the general population.

DESIGN

Retrospective cohort study.

SETTING

All hospitals in Washington.

PATIENTS

Patients with an FRH and a random sample of those with a non-injury-related hospitalization in 2006 to 2007 (index hospitalization).

MEASUREMENTS

Primary outcomes included subsequent FRH, firearm-related death, and the combined outcome of firearm- or violence-related arrest ascertained through 2011.

RESULTS

Among patients with an index FRH (n = 613), rates of subsequent FRH, firearm-related death, and firearm- or violence-related arrest were 329 (95% CI, 142 to 649), 100 (CI, 21 to 293), and 4221 (CI, 3352 to 5246) per 100 000 person-years, respectively. Compared with the general population, standardized incidence ratios among patients with an index FRH were 30.1 (CI, 14.9 to 61.0) for a subsequent FRH and 7.3 (CI, 2.4 to 22.9) for firearm-related death. In survival analyses that accounted for competing risks, patients with an index FRH were at greater risk for subsequent FRH (subhazard ratio [sHR], 21.2 [CI, 7.0 to 64.0]), firearm-related death (sHR, 4.3 [CI, 1.3 to 14.1]), and firearm- or violence-related arrest (sHR, 2.7 [CI, 2.0 to 3.5]) than those with a non-injury-related index hospitalization.

LIMITATION

Lack of information on whether patients continued to reside in Washington during follow-up may have introduced outcome misclassification.

CONCLUSION

Hospitalization for a firearm-related injury is associated with a heightened risk for subsequent violent victimization or crime perpetration. Further research at the intersection of clinical care, the criminal justice system, and public health to evaluate the effectiveness of interventions delivered to survivors of firearm-related injury is warranted.

PRIMARY FUNDING SOURCE

Seattle City Council and University of Washington Royalty Research Fund.

The contribution of national disparities to international differences in mortality between the United States and 7 European countries

OBJECTIVES

This study examined to what extent the higher mortality in the United States compared to many European countries is explained by larger social disparities within the United States. We estimated the expected US mortality if educational disparities in the United States were similar to those in 7 European countries.

METHODS

Poisson models were used to quantify the association between education and mortality for men and women aged 30 to 74 years in the United States, Belgium, Denmark, Finland, France, Norway, Sweden, and Switzerland for the period 1989 to 2003. US data came from the National Health Interview Survey linked to the National Death Index and the European data came from censuses linked to national mortality registries.

RESULTS

If people in the United States had the same distribution of education as their European counterparts, the US mortality disadvantage would be larger. However, if educational disparities in mortality within the United States equaled those within Europe, mortality differences between the United States and Europe would be reduced by 20% to 100%.

CONCLUSIONS

Larger educational disparities in mortality in the United States than in Europe partly explain why US adults have higher mortality than their European counterparts. Policies to reduce mortality among the lower educated will be necessary to bridge the mortality gap between the United States and European countries.

Mortality in adult offspring of immigrants: a Swedish national cohort study

BACKGROUND

Higher risks of psychiatric disorders and lower-than-average subjective health in adulthood have been demonstrated in offspring of immigrants in Sweden compared with offspring of native Swedes, and linked to relative socioeconomic disadvantage. The present study investigated mortality rates in relation to this inequity from a gender perspective.

METHODS

We used data from national registers covering the entire Swedish population aged 18-65 years. Offspring of foreign-born parents who were either Swedish born or had received residency in Sweden before school age (<7 years) were defined as "offspring of immigrants." We used Cox regression models to examine the association between parental country of birth and mortality between 1990 and 2008, with adjustment for education, income, age and family type.

RESULTS

Male offspring of immigrants from the Middle East (HR:2.00, CI:1.66-2.26), other non-European countries (HR:1.80, CI:1.36-2.36) and Finland (HR:1.56, CI:1.48-1.65) showed an age-adjusted excess mortality risk from all causes of death when compared to offspring with Swedish-born parents. Income, but not education, greatly attenuated these increased mortality risks. No excess mortality rates were found among female offspring of immigrants, with the exception of external cause of death among offspring of Finnish immigrants.

CONCLUSION

The study demonstrates high mortality rates in male offspring of immigrants from Finland and non-European countries that are associated with economic, but not educational, disadvantage. No increased mortality rates were found among female offspring of immigrants. Future studies are needed to explain this gender differential and why income, but not education, predicts mortality in male offspring of immigrants.

Mortality differentials by immigrant groups in Sweden: the contribution of socioeconomic position

OBJECTIVES

We studied mortality differentials between specific groups of foreign-born immigrants in Sweden and whether socioeconomic position (SEP) could account for such differences.

METHODS

We conducted a follow-up study of 1 997 666 men and 1 964 965 women ages 30 to 65 years based on data from national Swedish total population registers. We examined mortality risks in the 12 largest immigrant groups in Sweden between 1998 and 2006 using Cox regression. We also investigated deaths from all causes, circulatory disease, neoplasms, and external causes.

RESULTS

We found higher all-cause mortality among many immigrant categories, although some groups had lower mortality. When studying cause-specific mortality, we found the largest differentials in deaths from circulatory disease, whereas disparities in mortality from neoplasms were smaller. SEP, especially income and occupational class, accounted for most of the mortality differentials by country of birth.

CONCLUSIONS

Our findings stressed that different aspects of SEP were not interchangeable in relation to immigrant health. Although policies aimed at improving immigrants' socioeconomic conditions might be beneficial for health and longevity, our findings indicated that such policies might have varying effects depending on the specific country of origin and cause of death.

Racial differences in mortality in older adults: factors beyond socioeconomic status

BACKGROUND

Little is known about the simultaneous effect of socioeconomic status (SES), psychosocial, and health-related factors on race differences in mortality in older adults.

PURPOSE

This study examined the association between race and mortality and the role of SES, health insurance, psychosocial factors, behavioral factors, and health-related factors in explaining these differences.

METHODS

Data consisted of 2,938 adults participating in the Health, Aging and Body Composition study. Mortality was assessed over 8 years.

RESULTS

SES differences accounted for 60% of the racial differences in all-cause mortality; behavioral factors and self-rated health further reduced the disparity. The racial differences in coronary heart disease mortality were completely explained by SES. Health insurance and behavioral factors accounted for some, but not all, of the race differences in cancer mortality.

CONCLUSIONS

Race-related risk factors for mortality may differ by the underlying cause of mortality.

The contribution of smoking to black-white differences in U.S. mortality

Smoking has significantly impacted American mortality and remains a major cause of morbidity and mortality. No previous study has systematically examined the contribution of smoking-attributable deaths to mortality trends among blacks or to black-white mortality differences at older ages over time in the United States. In this article, we employ multiple methods and data sources to provide a comprehensive assessment of this contribution. We find that smoking has contributed to the black-white gap in life expectancy at age 50 for males, accounting for 20 % to 48 % of the gap between 1980 and 2005, but not for females. The fraction of deaths attributable to smoking at ages above 50 is greater for black males than for white males; and among men, current smoking status explains about 20 % of the black excess relative risk in all-cause mortality at ages above 50 without adjustment for socioeconomic characteristics. These findings advance our understanding of the contribution of smoking to contemporary mortality trends and differences and reinforce the need for interventions that better address the needs of all groups.

Racial disparities in gastrointestinal cancers-related mortality in the U.S. population

BACKGROUND

Racial difference in cancer-related mortality has been described in epidemiological studies and evidence points towards higher mortalities in the minorities. To determine the magnitude of racial disparities and sex differences in GI cancer-related mortalities in the US population, we analyzed the data using the third National Health and Nutrition Examination Survey (NHANES III) and related mortality data files.

METHODS

NHANES III and its related public linked mortality files were used for this study. Our study cohort included subjects who were ≥18 years and were part of the longitudinal mortality follow-up database. The overall GI cancers related mortality was calculated using combined mortality from malignant neoplasm of esophagus, stomach, colon, liver and pancreas. The evaluation of independent predictors of overall GI cancer-related mortality and of each individual GI cancer was carried out using the Cox proportional hazards model.

RESULTS

A total of 13,221 individuals were included in the analyses with the average person year follow-up of 13.9 years. During the follow-up period, 4,146 subjects died. Of these, 199 were from GI-related cancers. Non-Hispanic black (NHB) had significantly higher overall GI-cancer related mortality compared to non-Hispanic white (NHW, adjusted hazard ratio, aHR: 2.31, 95% CI 1.57-3.38, p < 0.001). Subgroup analyses by sex demonstrated higher mortality from gastric, colorectal and primary liver cancer related mortality in NHB men compared to NHW men. Esophageal and pancreatic cancer mortalities were higher in NHB women compared to NHW women.

CONCLUSION

Overall GI cancer-related mortality is significantly higher among NHB compared to NHW in the U.S. population.

The prevalence of spirituality, optimism, depression, and fatalism in a bi-ethnic stroke population

To provide insight into the reduced post-stroke all-cause mortality among Mexican Americans, we explored ethnic differences in the pre-stroke prevalence of (1) spirituality, (2) optimism, (3) depression, and (4) fatalism in a Mexican American and non-Hispanic white stroke population. The Brain Attack Surveillance in Corpus Christi (BASIC) project is a population-based stroke surveillance study in Nueces County, Texas. Seven hundred ten stroke patients were queried. For fatalism, optimism, and depression scales, unadjusted ethnic comparisons were made using linear regression models. Regression models were also used to explore how age and gender modify the ethnic associations after adjustment for education. For the categorical spirituality variables, ethnic comparisons were made using Fisher's exact tests. Mexican Americans reported significantly more spirituality than non-Hispanic whites. Among women, age modified the ethnic associations with pre-stroke depression and fatalism but not optimism. Mexican American women had more optimism than non-Hispanic white women. With age, Mexican American women had less depression and fatalism, while non-Hispanic white women had more fatalism and similar depression. Among men, after adjustment for education and age, there was no ethnic association with fatalism, depression, and optimism. Spirituality requires further study as a potential mediator of increased survival following stroke among Mexican Americans. Among women, evaluation of the role of optimism, depression, and fatalism as they relate to ethnic differences in post-stroke mortality should be explored.

Examining the association between socioeconomic status and invasive colorectal cancer incidence and mortality in California

BACKGROUND

Colorectal cancer (CRC) incidence and mortality rates vary across race/ethnicity. Socioeconomic status (SES) also influences CRC rates; however, these associations might be inconsistent across racial/ethnic groups and tumor subsite. We examined associations between area-level SES and CRC incidence and mortality in a population-based registry study of non-Hispanic Whites, African Americans, Hispanics, and Asians/Pacific Islanders from California.

METHODS

Data on 52,608 incident CRC cases (1998-2002) and 14,515 CRC deaths (1999-2001) aged ≥50 years were obtained from the California Cancer Registry. Based on 2000 U.S. Census data, each cancer case and death was assigned a multidimensional census tract-level SES index. SES-specific quintiles of CRC incidence and mortality rates, incidence rate ratios (IRR) and mortality rate ratios, and 95% confidence intervals (CI) were estimated. Analyses were stratified by anatomical site, including left- versus right-sided tumors, race/ethnicity, and stage of disease.

RESULTS

Overall CRC incidence and SES did not show a clear association, yet patterns of associations varied across tumor subsite and race/ethnicity. Positive associations between SES and CRC incidence were found in Hispanics [SES Q5 v. Q1: IRR = 1.54, CI = 1.39-1.69], irrespective of the subsite. For Whites [SES Q5 v. Q1: IRR = 0.80, CI = 0.77-0.83], and African Americans [SES Q5 v. Q1: IRR = 0.83, CI = 0.70-0.97] inverse associations were observed, predominantly for left-sided tumors. Mortality rates declined with increasing SES in Whites, whereas in Hispanics mortality rates significantly increased with SES.

CONCLUSIONS

Our findings show that SES differences in CRC incidence and mortality vary considerably across anatomical subsite and race/ethnicity.

IMPACT

Studies combining area- and individual-level SES information are warranted.

Food polyamine and cardiovascular disease--an epidemiological study

The purpose of this study was to examine the contribution of dietary polyamines toward preventing cardiovascular disease (CVD). Age-standardized mortality rates as well as other relevant information regarding individuals with CVD were gathered from the World Health Organization and the International Monetary Fund in 48 different European and other Western countries. Food supply data were collected from the database of the United Nations, and the amount of dietary polyamines was estimated by using polyamine concentrations in foods from published sources. The association between CVD mortality and the amount of polyamines was investigated by performing a series of multiple linear regression analyses. Analyses using factors known to modulate the risk of CVD including: Gross Domestic Product (GDP) (standardized regression coefficient (r) = -0.786, p < 0.001) and the amount of fruits, vegetable, nuts, and beans (r = -0.183, p = 0.001) but not including polyamines, showed negative associations with CVD, while smoking rate (r = 0.139, p = 0.041) and whole milk amount (r = 0.131, p = 0.028) showed positive associations with CVD. When the amount of polyamines was added to the analyses as a covariate, GDP (r = -0.864, p < 0.001) and polyamines (r = -0.355, p = 0.007) showed negative associations with CVD, while smoking rate (r = 0.183, p = 0.006) and whole milk (r = 0.113, p = 0.041) showed positive associations with CVD. The inverse association between dietary polyamines and CVD mortality revealed by the present study merits further evaluation.

Does the African-American-white mortality gap persist after playing professional basketball? A 59-year historical cohort study

PURPOSE

The African-American-white mortality gap for males in the United States is 6 years in favor of whites. Participation in professional sport may moderate this ethnic disparity. The historical cohort of professional basketball players, with nearly equal numbers of African-American and white players, can provide a natural experiment that may control for the classic confounders of income, education, socioeconomic status (SES), and physical factors related to mortality. The objectives of this study are to assess mortality and calculate survival for the overall study population and within ethnicity.

METHODS

Data were combined from several publicly available sources. The cohort was analyzed to compare longevity among all players, and for players stratified by ethnicity, with the general U.S. population.

RESULTS

The final dataset included 3366 individuals, of whom 56.0% were African American. Results suggest white players live 18 months longer than their African-American colleagues. African-American players gained 9 years on their respective referent and live longer than white men in the general public. After controlling for covariates, we found that African-American players have a 75% increased risk of death compared with white players, a statistically significant gap (p < .0001, 95% confidence interval 1.41-2.44).

CONCLUSIONS

The African-American-white mortality gap for males is largely ameliorated (1.5 years vs. 6.1 years) in professional basketball but still persists.

Allostatic load burden and racial disparities in mortality

BACKGROUND

Black-white disparities in mortality persist after adjustment for socioeconomic status and health behaviors. We examined whether allostatic load, the physiological profile influenced by repeated or chronic life stressors, is associated with black-white mortality disparities independent of traditional sociobehavioral risk factors.

METHODS

We studied 4515 blacks and whites aged 35 to 64 years from the third National Health and Nutrition Examination Survey (1988-1994), using the linked mortality file, to ascertain participant deaths through 2006. We estimated unadjusted sex-specific black-white disparities in cardiovascular/diabetes-related mortality and noninjury mortality. We constructed baseline allostatic load scores based on 10 biomarkers and examined attenuation of mortality disparities in 4 sets of sex-stratified multivariate models, sequentially adding risk factors: (1) age/clinical conditions, (2) socioeconomic status (SES) variables, (3) health behaviors, and (4) allostatic load.

RESULTS

Blacks had higher allostatic load scores than whites; for men, 2.5 vs 2.1, p < .01; and women, 2.6 vs 1.9, p < .01. For cardiovascular/diabetes-related mortality among women, the magnitude of the disparity after adjustment for other risk factors (hazard ratio [HR], 1.63; 95% confidence interval [CI], 0.96-2.75) decreased after adjustment for allostatic load (HR, 1.15; 95% CI, 0.70-1.88). For noninjury mortality among women, the magnitude of the disparity after adjustment for other risk factors (HR, 1.43; 95% CI, 1.00-2.04) also decreased after adjustment for allostatic load (HR, 1.26; 95% CI, 0.90-1.78). For men, disparities were attenuated but persisted after adjustment for allostatic load.

CONCLUSIONS

Allostatic load burden partially explains higher mortality among blacks, independent of SES and health behaviors. These findings underscore the importance of chronic physiologic stressors as a negative influence on the health and lifespan of blacks in the United States.

Black-white disparities in life expectancy: how much can the standard SES variables explain?

This article quantifies the extent to which socioeconomic and demographic characteristics can account for black-white disparities in life expectancy in the United States. Although many studies have investigated the linkages between race, socioeconomic status, and mortality, this article is the first to measure how much of the life expectancy gap remains after differences in mortality are purged of the compositional differences in socioeconomic characteristics between blacks and whites. The decomposition is facilitated by a reweighting technique that creates counterfactual estimation samples in which the distribution of income, education, employment and occupation, marital status, and other theoretically relevant variables among blacks is made to match the distribution of these variables among whites. For males, 80% of the black-white gap in life expectancy at age 1 can be accounted for by differences in socioeconomic and demographic characteristics. For females, 70% percent of the gap is accounted for. Labor force participation, occupation, and (among women only) marital status have almost no additional power to explain the black-white disparity in life expectancy after precise measures for income and education are controlled for.

Patients living in impoverished areas have more severe ischemic strokes

BACKGROUND AND PURPOSE

Initial stroke severity is one of the strongest predictors of eventual stroke outcome. However, predictors of initial stroke severity have not been well-described within a population. We hypothesized that poorer patients would have a higher initial stroke severity on presentation to medical attention.

METHODS

We identified all cases of hospital-ascertained ischemic stroke occurring in 2005 within a biracial population of 1.3 million. "Community" socioecomic status was determined for each patient based on the percentage below poverty in the census tract in which the patient resided. Linear regression was used to model the effect of socioeconomic status on stroke severity. Models were adjusted for race, gender, age, prestroke disability, and history of medical comorbidities.

RESULTS

There were 1895 ischemic stroke events detected in 2005 included in this analysis; 22% were black, 52% were female, and the mean age was 71 years (range, 19-104). The median National Institutes of Health Stroke Scale was 3 (range, 0-40). The poorest community socioeconomic status was associated with a significantly increased initial National Institutes of Health Stroke Scale by 1.5 points (95% confidence interval, 0.5-2.6; P<0.001) compared with the richest category in the univariate analysis, which increased to 2.2 points after adjustment for demographics and comorbidities.

CONCLUSIONS

We found that increasing community poverty was associated with worse stroke severity at presentation, independent of other known factors associated with stroke outcomes. Socioeconomic status may impact stroke severity via medication compliance, access to care, and cultural factors, or may be a proxy measure for undiagnosed disease states.

Understanding the psychosocial issues of African American couples surviving prostate cancer

African Americans are disproportionately affected by prostate cancer, yet less is known about the most salient psychosocial dimensions of quality of life. The purpose of this study was to explore the perceptions of African American prostate cancer survivors and their spouses of psychosocial issues related to quality of life. Twelve African American couples were recruited from a National Cancer Institute Comprehensive Cancer Center registry and a state-based non-profit organization to participate in individual interviews. The study was theoretically based on Ferrell's Quality of Life Conceptual Model. Common themes emerged regarding the psychosocial needs of African American couples. These themes were categorized into behavioral, social, psychological, and spiritual domains. Divergent perspectives were identified between male prostate cancer survivors and their female spouses. This study delineated unmet needs and areas for future in-depth investigations into psychosocial issues. The differing perspectives between patients and their spouses highlight the need for couple-centered interventions.

The social patterning of deaths due to assault in Scotland, 1980-2005: population-based study

Objectives

The objectives of this study were to explore the extent of the social gradient for deaths due to assault and its impact on overall inequalities in mortality and to investigate the contribution to assault mortality of knives and other sharp weapons.

Design

An analysis of death records and contemporaneous population estimates was conducted.

Setting

The authors investigated the social patterning of homicide in Scotland.

Participants

This study included deaths between 1980 and 2005 due to assault.

Main measurements

Death rates were standardised to the European standard population. Time trends were analysed and inequalities were assessed, using rate ratios and the slope index of inequality, along axes defined by individual occupational socioeconomic status and area deprivation.

Results

An increase in mortality due to assault was most pronounced at ages 15–44 and was steeper among assaults involving knives. The death rate among men in routine occupations aged 20–59 was nearly 12 times that of those in higher managerial and professional occupations. Men under 65 living in the most deprived quintile of areas had a death rate due to assault 31.9 times (95% CI 13.1 to 77.9) that of those living in the least deprived quintile; for women, this ratio was 35.0 (4.8 to 256.2). Despite comprising just 3.2% of all male deaths between 15 and 44 years, assault accounted for 6.4% of the inequalities in mortality.

Conclusions

Inequalities in mortality due to assault in Scotland exceed those in other countries and are greater than for other causes of death in Scotland. Reducing mortality and inequalities depends on addressing the problems of deprivation as well as targeting known contributors, such as alcohol use, the carrying of knives and gang culture.

Socioeconomic factors impact colon cancer outcomes in diverse patient populations

PURPOSE

Cancer disparities among racial and ethnic groups are major public health concerns. Our objective was to examine the impact of socioeconomic status (SES) on survival of colon cancer patients within major racial and ethnic groups.

METHODS

Patients with colon adenocarcinoma from Los Angeles County (LAC) were assessed. SES was utilized as an indicator of healthcare access and categorized by tertiles (high, middle, and low). Patient characteristics were compared and survival analyses were performed.

RESULTS

In our heterogeneous LAC cohort, we confirmed survival disparities. Asians had the best survival followed by Hispanics, whites, and blacks. For each stage of disease, Asians and Hispanics had better outcomes than whites and blacks. Then, we evaluated the impact of SES on survival within each racial and ethnic group. We observed significantly longer survival for high SES patients compared to middle and low SES patients for all racial/ethnic groups.

CONCLUSIONS

While disparities across racial/ethnic groups are well-documented, our study is the first to identify socioeconomic disparities in survival for patients within the same group. These novel findings demonstrate the complex role of SES on race and ethnicity and identify the need to improve healthcare access even within select populations.