Agreement on cause of death between proxies, death certificates, and clinician adjudicators in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

Association of Muscle Strength With All-Cause Mortality in the Oldest Old: Prospective Cohort Study From 28 Countries

BACKGROUND

Ageing is associated with a gradual loss of muscle strength, which in the end may have consequences for survival. Whether muscle strength and mortality risk associate in a gradual or threshold-specific manner remains unclear. This study investigates the prospective association of muscle strength with all-cause mortality in the oldest old.

METHODS

We included 1890 adults aged ≥ 90 years (61.6% women, mean age 91.0 ± 1.5 years) from 27 European countries and Israel participating in the Survey of Health, Ageing and Retirement in Europe (SHARE) study. Muscle strength was assessed using handgrip dynamometry (unit: kilogram). Using time-varying Cox regression with restricted cubic splines, we determined the prospective association of muscle strength with mortality, controlling for age, sex, smoking, BMI, marital status, education, geographical region and self-perceived health.

RESULTS

Over a mean follow-up of 4.2 ± 2.4 years, more than half of the participants died (n = 971, 51.4%). The mean handgrip strength was 20.4 ± 8.0 kg for all participants, with men (26.7 ± 7.5 kg) showing significantly higher strength than women (16.4 ± 5.4 kg) (p < 0.001). Using the median level of muscle strength as reference (18 kg), lower and higher levels were associated in a gradual and curvilinear fashion with higher and lower mortality risk, respectively. The 10th percentile of muscle strength (10 kg) showed a hazard ratio (HR) of 1.27 (95% CI 1.13-1.43, p < 0.001). The 90th percentile (31 kg) showed an HR of 0.69 (95% CI 0.58-0.82, p < 0.001). Stratified for sex, the median levels of muscle strength were 26 kg for men and 16 kg for women. The 10th percentile of muscle strength showed HRs of 1.33 (95% CI 1.10-1.61, p < 0.001) at 15 kg for men and 1.19 (95% CI 1.05-1.35, p < 0.01) at 10 kg for women. The 90th percentile of muscle strength showed HRs of 0.75 (95% CI 0.59-0.95, p < 0.01) at 35 kg for men and 0.75 (95% CI 0.62-0.90, p < 0.001) at 23 kg for women. Sensitivity analyses, which excluded individuals who died within the first 2 years of follow-up, confirmed the main findings.

CONCLUSION

Rather than a specific threshold, muscle strength is gradually and inversely associated with mortality risk in the oldest old. As muscle strength at all ages is highly adaptive to resistance training, these findings highlight the importance of improving muscle strength in both men and women among the oldest old.

Sleep duration and all-cause mortality among stroke survivors

BACKGROUND

Post stroke sleep duration could increase the risk of death. This study tested the hypothesis that inadequate sleep duration is associated with increased mortality among stroke survivors.

METHODS

The REasons for Geographic And Racial Differences in Stroke (REGARDS), a national population-based longitudinal study, was the data source. Sleep duration was ascertained between 2013 and 2016 among stroke survivors who were subsequently followed up until death or censored on December 31, 2022. Sleep duration was estimated as the difference between wake-up time and bedtime to which was subtracted the time spent in bed without sleep. Cox proportional hazards regression models were employed to investigate the association between sleep duration and all-cause mortality adjusting for demographic factors, socioeconomic factors, behavioral factors, and co-morbidities.

RESULTS

A total of 468 non-Hispanic Black and White stroke survivors were included in this analysis. The mean age was 76.3 years, 52.6% were females and 56.0% were non-Hispanic White individuals. The distribution of short (≤6 h), adequate (7.0-8.9 h), and long sleep (≥9 h) was 30.3%, 44.7%, and 25%, respectively. Over a mean follow-up of 5.0 years, 190 (40.6%) deaths occurred. Compared to stroke survivors with adequate sleep (7.0-8.9 h), stroke survivors with long sleep (≥9 h) were at increased risk of all-cause mortality (HR=1.46, 95% CI=1.01, 2.12). However, short sleep (≤6 h) was not significantly associated with an increased risk of all-cause mortality (HR=1.31, 95% CI=0.90, 1.91). Subgroup analyses indicated higher risk in the age <75 years, females, non-Hispanic Black individuals, and those living in the Stroke Belt region, but those differences were not statistically significant.

CONCLUSION

In this study of stroke survivors, 9 hours or more of sleep per day was associated with an increased risk of all-cause mortality. This finding suggests that excessive sleep duration may be a warning sign of poor life expectancy in stroke survivors.

Association of educational attainment with cancer mortality in a national cohort study of black and white adults: A mediation analysis

Background

Low educational attainment is associated with excess cancer mortality. However, the mechanisms driving this association remain unknown.

Methods

Using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, we evaluated the associations of participant and parental/caregiver education with cancer mortality using Cox proportional hazards models, adjusting for socio-demographic characteristics and health conditions. We used principal components analysis to generate indices of measures representing the social determinants of health (SDOH) and health behaviors. We used structural equation modeling to determine if the association between educational attainment and cancer mortality was mediated by these domains.

Results

Among 30,177 REGARDS participants included in this analysis, 3798 (12.6%) had less than a high school degree. In fully adjusted models, those without a high school education experienced about 50% greater risk of death than high school graduates and higher (White participants HR: 1.47; 95% CI: 1.23, 1.76 and Black HR: 1.54; 95% CI: 1.33, 1.79). There was evidence of a modest mediation effect for the association between education and cancer mortality by the SDOH domain score (White total effect HR: 1.25; 95% CI: 1.18, 1.33, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.21; 95% CI: 1.14, 1.28 and Black total effect HR: 1.24; 95% CI: 1.18, 1.29, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.19; 95% CI: 1.14, 1.24). There was no evidence of mediation by the health behaviors score. No significant associations were found for female caregiver/mother's or male caregiver/father's education (N = 13,209).

Conclusions

In conclusion, participant education was strongly associated with cancer mortality, and this association was partially mediated by the SDOH domain score.

Urinary Biomarkers of Kidney Tubule Health and Mortality in Persons with CKD and Diabetes Mellitus

Key Points

Among adults with diabetes and CKD, biomarkers of kidney tubule health were associated with a greater risk of death, independent of eGFR, albuminuria, and additional risk factors. Higher urine levels of YKL-40 and KIM-1 were associated with a greater risk of death. For cause-specific death, UMOD was independently and inversely associated with the risk of cardiovascular death.

Background

Kidney disease assessed by serum creatinine and albuminuria are strongly associated with mortality in diabetes. These markers primarily reflect glomerular function and injury. Urine biomarkers of kidney tubule health were recently associated with the risk of kidney failure in persons with CKD and diabetes. Associations of these biomarkers with risk of death are poorly understood.

Methods

In 560 persons with diabetes and eGFR ≤60 ml/min per 1.73 m2 from the Reasons for Geographic and Racial Differences in Stroke study (47% male, 53% Black), we measured urine biomarkers of kidney tubule health at baseline: monocyte chemoattractant protein-1 (MCP-1), alpha-1-microglobulin, kidney injury molecule-1 (KIM-1), EGF, chitinase-3-like protein 1 (YKL-40), and uromodulin (UMOD). Cox proportional hazards regression was used to examine the associations of urine biomarkers with all-cause and cause-specific mortality in nested models adjusted for urine creatinine, demographics, mortality risk factors, eGFR, and urine albumin.

Results

The mean (SD) age was 70 (9.6) years, and baseline eGFR was 40 (3) ml/min per 1.73 m2. There were 310 deaths over a mean follow-up of 6.5 (3.2) years. In fully adjusted models, each two-fold higher urine concentration of KIM-1 and YKL-40 were associated with all-cause mortality (hazard ratio [HR] 1.15, 95% confidence interval [CI], 1.01 to 1.31 and 1.13, 95% CI, 1.07 to 1.20, respectively). When examining cause-specific mortality, higher UMOD was associated with a lower risk of cardiovascular death (adjusted HR per two-fold higher concentration 0.87, 95% CI, 0.77 to 0.99), and higher MCP-1 was associated with higher risk of cancer death (HR per two-fold higher concentration 1.52, 95% CI, 1.05 to 2.18).

Conclusion

Among persons with diabetes and CKD, higher urine KIM-1 and YKL-40 were associated with a higher risk of all-cause mortality independently of established risk factors. Urine UMOD and MCP-1 were associated with cardiovascular and cancer-related death, respectively.

The association of baseline depressive symptoms and stress on withdrawal in a national longitudinal cohort: the REGARDS study

PURPOSE

To measure the association of baseline psychological symptoms (depressive symptoms and perceived stress) with withdrawal from a cohort study.

METHODS

Depressive symptoms and perceived stress were obtained using validated measures during the baseline computer-assisted telephonic interview for the REasons for Geographic and Racial Differences in Stroke study a national longitudinal cohort (≥45 years, 42% Black, 55% women) recruited between 2003 and 2007. Participants who completed follow-up after September 1, 2019, were considered active. Primary outcome was time to study withdrawal. The association of psychological symptoms and time-to-withdrawal was measured using Cox proportional hazard regression models with incremental adjustments by demographic and clinical factors.

RESULTS

Out of 29,964 participants included in the analysis, 11,111 (37.1%) participants withdrew over the follow-up period (median: 11 years). Compared to participants with low depressive symptoms, those with moderate symptoms had 5% higher risk (aHR= 1.05; 95% CI= 1.00-1.10) and those with high level of depressive had 19% higher risk (aHR= 1.19; 95% CI= 1.11-1.27) of withdrawal in fully adjusted models. No significant association between perceived stress and withdrawal risk was observed.

CONCLUSIONS

Depressive symptoms were significantly associated with withdrawal. Prevalence of depressive symptoms at baseline is an important indicator of participant retention in large prospective cohorts.

Association of racial residential segregation with all-cause and cancer-specific mortality in the reasons for geographic and racial differences in stroke (REGARDS) cohort study

•Increased racial residential segregation increased the risk of all-cause mortality among White participants.•Higher interaction lowered the risk of all-cause mortality among White participants.•Higher isolation lowered the risk of cancer mortality among Black participants.

Associations of dietary and lifestyle inflammation scores with mortality due to CVD, cancer, and all causes among Black and White American men and women

One potential mechanism by which diet and lifestyle may affect chronic disease risk and subsequent mortality is through chronic systemic inflammation. In this study, we investigated whether the inflammatory potentials of diet and lifestyle, separately and combined, were associated with all-cause, all-CVD and all-cancer mortality risk. We analysed data on 18 484 (of whom 4103 died during follow-up) Black and White men and women aged ≥45 years from the prospective REasons for Geographic and Racial Differences in Stroke study. Using baseline (2003-2007) Block 98 FFQ and lifestyle questionnaire data, we constructed the previously validated inflammation biomarker panel-weighted, 19-component dietary inflammation score (DIS) and 4-component lifestyle inflammation score (LIS) to reflect the overall inflammatory potential of diet and lifestyle. From multivariable Cox proportional hazards models, the hazards ratios (HR) and their 95 % CI for the DIS-all-cause mortality and LIS-all-cause mortality risk associations were 1·32 (95 % CI (1·18, 1·47); Pfor trend < 0·01) and 1·25 (95 % CI (1·12, 1·38); Pfor trend < 0·01), respectively, among those in the highest relative to the lowest quintiles. The findings were similar by sex and race and for all-cancer mortality, but weaker for all-CVD mortality. The joint HR for all-cause mortality among those in the highest relative to the lowest quintiles of both the DIS and LIS was 1·91 (95 % CI 1·57, 2·33) (Pfor interaction < 0·01). Diet and lifestyle, via their contributions to systemic inflammation, separately, but perhaps especially jointly, may be associated with higher mortality risk among men and women.

Race and Sex Differences in Mortality in Individuals with Chronic Obstructive Pulmonary Disease

Rationale: Despite differences in chronic obstructive pulmonary disease (COPD) comorbidities, race- and sex-based differences in all-cause mortality and cause-specific mortality are not well described. Objectives: To examine mortality differences in COPD by race-sex and underlying mechanisms. Methods: Medicare claims were used to identify COPD among REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort participants. Mortality rates were calculated using adjudicated causes of death. Hazard ratios (HRs) for mortality comparing race-sex groups were modeled with Cox proportional hazards regression. Results: In the 2,148-member COPD subcohort, 49% were women, and 34% were Black individuals; 1,326 deaths occurred over a median 7.5 years (interquartile range, 3.9-10.5 yr) follow-up. All-cause mortality per 1,000 person-years comparing Black versus White men was 101.1 (95% confidence interval [CI], 88.3-115.8) versus 93.9 (95% CI, 86.3-102.3; P = 0.99); comparing Black versus White women, all-cause mortality per 1,000 person-years was 74.2 (95% CI, 65.0-84.8) versus 70.6 (95% CI, 63.5-78.5; P = 0.99). Cardiovascular disease (CVD) was the leading cause-specific mortality among all race-sex groups. HR for CVD and chronic lung disease mortality were nonsignificant comparing Black versus White men. HR for CVD death was higher in Black compared with White women (HR, 1.44; 95% CI, 1.06-1.95), whereas chronic lung disease death was lower (HR, 0.44; 95% CI, 0.25-0.77). These differences were attributable to higher CVD risk factor burden among Black women. Conclusions: In the REGARDS COPD cohort, there were no race-sex differences in all-cause mortality. CVD was the most common cause of death for all race-sex groups with COPD. Black women with COPD had a higher risk of CVD-related mortality than White women. CVD comorbidity management, especially among Black individuals, may improve mortality outcomes.

Ischemic stroke with cancer: Hematologic and embolic biomarkers and clinical outcomes

BACKGROUND

Patients with cancer and acute ischemic stroke (AIS) face high rates of recurrent thromboembolism or death.

OBJECTIVES

To examine whether hematologic and embolic biomarkers soon after AIS are associated with subsequent adverse clinical outcomes.

METHODS

We prospectively enrolled 50 adults with active solid tumor cancer and AIS at two hospitals from 2016 to 2020. Blood was collected 72-120 h after stroke onset. A 30-min transcranial Doppler (TCD) microemboli detection study was performed. The exposure variables were hematologic markers of coagulation (D-dimer, thrombin-antithrombin), platelet (P-selectin), and endothelial activation (thrombomodulin, soluble intercellular adhesion molecule-1 [sICAM-1], soluble vascular cell adhesion molecule-1 [sVCAM-1]), and the presence of TCD microemboli. The primary outcome was a composite of recurrent arterial/venous thromboembolism or death. We used Cox regression to evaluate associations between biomarkers and subsequent outcomes.

RESULTS

During an estimated median follow-up time of 48 days (IQR, 18-312), 43 (86%) participants developed recurrent thromboembolism or death, including 28 (56%) with recurrent thromboembolism, of which 13 were recurrent AIS (26%). In unadjusted analysis, D-dimer (HR 1.6; 95% CI 1.2-2.0), P-selectin (HR 1.9; 95% CI 1.4-2.7), sICAM-1 (HR 2.2; 95% CI 1.6-3.1), sVCAM-1 (HR 1.6; 95% CI 1.2-2.1), and microemboli (HR 2.2; 95% CI 1.1-4.5) were associated with the primary outcome, whereas thrombin-antithrombin and thrombomodulin were not. D-dimer was the only marker associated with recurrent AIS (HR 1.2; 95% CI 1.0-1.5). Results were generally consistent in analyses adjusted for important prognostic variables.

CONCLUSIONS

Markers of hypercoagulability and embolic disease may be associated with adverse clinical outcomes in cancer-related stroke.

The Risk of Heart Disease-Related Death Among Anaplastic Astrocytoma Patients After Chemotherapy: A SEER Population-Based Analysis

Background

Despite improved overall survival outcomes, chemotherapy has brought concerns for heart disease–related death (HDRD) among cancer patients. The effect of chemotherapy on the risk of HDRD in anaplastic astrocytoma (AA) patients remains unclear.

Methods

We obtained 7,129 AA patients from the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2016. Kaplan–Meier and Cox regression analysis were conducted to evaluate the effect of chemotherapy on the HDRD risk. Based on the competing risk model, we calculated the cumulative incidences of HDRD and non-HDRD and performed univariate and multivariate regression analyses. Then, a 1:1 propensity score matching (PSM) was used to improve the comparability between AA patients with and without chemotherapy. Landmark analysis at 216 and 314 months was employed to minimize immortal time bias.

Results

AA patients with chemotherapy were at a lower HDRD risk compared to those patients without chemotherapy (adjusted HR=0.782, 95%CI=0.736–0.83, P<0.001). For competing risk regression analysis, the cumulative incidence of HDRD in non-chemotherapy exceeded HDRD in the chemotherapy group (P<0.001) and multivariable analysis showed a lower HDRD risk in AA patients with chemotherapy (adjusted SHR=0.574, 95%CI=0.331–0.991, P=0.046). In the PSM-after cohort, there were no significant association between chemotherapy and the increased HDRD risk (adjusted SHR=0.595, 95%CI=0.316−1.122, P=0.11). Landmark analysis showed that AA patients who received chemotherapy had better heart disease–specific survival than those in the non-chemotherapy group (P=0.007) at the follow-up time points of 216 months. No difference was found when the follow-up time was more than 216 months.

Conclusion

AA patients with chemotherapy are associated with a lower risk of HDRD compared with those without chemotherapy. Our findings may help clinicians make a decision about the management of AA patients and provide new and important evidence for applying chemotherapy in AA patients as the first-line treatment. However, more research is needed to confirm these findings and investigate the correlation of the risk of HDRD with different chemotherapy drugs and doses.

Causes of Death in End-Stage Kidney Disease: Comparison between the United States Renal Data System and a Large Integrated Health Care System

INTRODUCTION

Using a large diverse population of incident end-stage kidney disease (ESKD) patients from an integrated health system, we sought to evaluate the concordance of causes of death (CODs) between the underlying COD from the United States Renal Data System (USRDS) registry and CODs obtained from Kaiser Permanente Southern California (KPSC).

METHODS

A retrospective cohort study was performed among incident ESKD patients who had mortality records and CODs reported in both KPSC and USRDS databases between January 1, 2007, and December 31, 2016. Underlying CODs reported by the KPSC were compared to the CODs reported by USRDS. Overall and subcategory-specific COD agreements were assessed using Cohen's weighted kappa statistic (95% CI). Proportions of positive and negative agreement were also determined.

RESULTS

Among 4,188 ESKD patient deaths, 4,118 patients had CODs recorded in both KPSC and USRDS. The most common KPSC CODs were circulatory system diseases (35.7%), endocrine/nutritional/metabolic diseases (24.2%), genitourinary diseases (12.9%), and neoplasms (9.6%). Most common USRDS CODs were cardiac disease (46.9%), withdrawal from dialysis (12.6%), and infection (10.1%). Of 2,593 records with causes listed NOT as "Other," 453 (17.4%) had no agreement in CODs between the USRDS and the underlying, secondary, tertiary, or quaternary causes recorded by KPSC. In comparing CODs recorded within KPSC to the USRDS, Cohen's weighted kappa (95% CI) was 0.20 (0.18-0.22) with overall agreement of 36.4%.

CONCLUSION

Among an incident ESKD population with mortality records, we found that there was only fair or slight agreement between CODs reported between the USRDS registry and KPSC, a large integrated health care system.

Development of the Verbal Autopsy Instrument for COVID-19 (VAIC)

BACKGROUND

Improving accuracy of identification of COVID-19-related deaths is essential to public health surveillance and research. The verbal autopsy, an established strategy involving an interview with a decedent's caregiver or witness using a semi-structured questionnaire, may improve accurate counting of COVID-19-related deaths.

OBJECTIVE

To develop and pilot-test the Verbal Autopsy Instrument for COVID-19 (VAIC) and a death adjudication protocol using it.

METHODS/KEY RESULTS

We used a multi-step process to design the VAIC and a protocol for its use. We developed a preliminary version of a verbal autopsy instrument specifically for COVID. We then pilot-tested this instrument by interviewing respondents about the deaths of 15 adults aged ≥65 during the initial COVID-19 surge in New York City. We modified it after the first 5 interviews. We then reviewed the VAIC and clinical information for the 15 deaths and developed a death adjudication process/algorithm to determine whether the underlying cause of death was definitely (40% of these pilot cases), probably (33%), possibly (13%), or unlikely/definitely not (13%) COVID-19-related. We noted differences between the adjudicated cause of death and a death certificate.

CONCLUSIONS

The VAIC and a death adjudication protocol using it may improve accuracy in identifying COVID-19-related deaths.

Social determinants of health and cancer mortality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study

BACKGROUND

Social determinants of health (SDOHs) cluster together and can have deleterious impacts on health outcomes. Individually, SDOHs increase the risk of cancer mortality, but their cumulative burden is not well understood. The authors sought to determine the combined effect of SDOH on cancer mortality.

METHODS

Using the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, the authors studied 29,766 participants aged 45+ years and followed them 10+ years. Eight potential SDOHs were considered, and retained SDOHs that were associated with cancer mortality (P < .10) were retained to create a count (0, 1, 2, 3+). Cox proportional hazard models estimated associations between the SDOH count and cancer mortality through December 31, 2017, adjusting for confounders. Models were age-stratified (45-64 vs 65+ years).

RESULTS

Participants were followed for a median of 10.6 years (interquartile range [IQR], 6.5, 12.7 years). Low education, low income, zip code poverty, poor public health infrastructure, lack of health insurance, and social isolation were significantly associated with cancer mortality. In adjusted models, among those <65 years, compared to no SDOHs, having 1 SDOH (adjusted hazard ratio [aHR], 1.39; 95% CI, 1.11-1.75), 2 SDOHs (aHR, 1.61; 95% CI, 1.26-2.07), and 3+ SDOHs (aHR, 2.09; 95% CI, 1.58-2.75) were associated with cancer mortality (P for trend <.0001). Among individuals 65+ years, compared to no SDOH, having 1 SDOH (aHR, 1.16; 95% CI, 1.00-1.35) and 3+ SDOHs (aHR, 1.26; 95% CI, 1.04-1.52) was associated with cancer mortality (P for trend = .032).

CONCLUSIONS

A greater number of SDOHs were significantly associated with an increased risk of cancer mortality, which persisted after adjustment for confounders.

A novel evolutionary-concordance lifestyle score is inversely associated with all-cause, all-cancer, and all-cardiovascular disease mortality risk

PURPOSE

Evolutionary discordance may contribute to the high burden of chronic disease-related mortality in modern industrialized nations. We aimed to investigate the associations of a 7-component, equal-weight, evolutionary-concordance lifestyle (ECL) score with all-cause and cause-specific mortality.

METHODS

Baseline data were collected in 2003-2007 from 17,465 United States participants in the prospective REasons for Geographic and Racial Differences in Stroke (REGARDS) study. The ECL score's components were: a previously reported evolutionary-concordance diet score, alcohol intake, physical activity, sedentary behavior, waist circumference, smoking history, and social network size. Diet was assessed using a Block 98 food frequency questionnaire and anthropometrics by trained personnel; other information was self-reported. Higher scores indicated higher evolutionary concordance. We used multivariable Cox proportional hazards regression models to estimate ECL score-mortality associations.

RESULTS

Over a median follow-up of 10.3 years, 3771 deaths occurred (1177 from cardiovascular disease [CVD], 1002 from cancer). The multivariable-adjusted hazard ratios (HR) (95% confidence intervals [CI]) for those in the highest relative to the lowest ECL score quintiles for all-cause, all-CVD, and all-cancer mortality were, respectively, 0.45 (0.40, 0.50), 0.47 (0.39, 0.58), and 0.42 (0.34, 0.52) (all P trend < 0.01). Removing smoking and diet from the ECL score attenuated the estimated ECL score-all-cause mortality association the most, yielding fifth quintile HRs (95% CIs) of 0.56 (0.50, 0.62) and 0.50 (0.46, 0.55), respectively.

CONCLUSIONS

Our findings suggest that a more evolutionary-concordant lifestyle may be inversely associated with all-cause, all-CVD, and all-cancer mortality. Smoking and diet appeared to have the greatest impact on the ECL-mortality associations.

Sensitivity and Specificity of the National Death Index for Multiple Causes of Death in People With HIV

OBJECTIVES

Inaccuracies in cause-of-death information in death certificates can reduce the validity of national death statistics and result in poor targeting of resources to reduce morbidity and mortality in people with HIV. Our objective was to measure the sensitivity, specificity, and agreement between multiple causes of deaths from death certificates obtained from the National Death Index (NDI) and causes determined by expert physician review.

METHODS

Physician specialists determined the cause of death using information collected from the medical records of 50 randomly selected HIV-infected people who died in San Francisco from July 1, 2016, through May 31, 2017. Using expert review as the gold standard, we measured sensitivity, specificity, and agreement.

RESULTS

The NDI had a sensitivity of 53.9% and a specificity of 66.7% for HIV deaths. The NDI had a moderate sensitivity for non-AIDS-related infectious diseases and non-AIDS-related cancers (70.6% and 75.0%, respectively) and high specificity for these causes (100.0% and 94.7%, respectively). The NDI had low sensitivity and high specificity for substance abuse (27.3% and 100.0%, respectively), heart disease (58.3% and 86.8%, respectively), hepatitis B/C (33.3% and 97.7%, respectively), and mental illness (50.0% and 97.8%, respectively). The measure of agreement between expert review and the NDI was lowest for HIV (κ = 0.20); moderate for heart disease (κ = 0.45) and hepatitis B/C (κ = 0.40); high for non-AIDS-related infectious diseases (κ = 0.76) and non-AIDS-related cancers (κ = 0.72); and low for all other causes of death (κ < 0.35).

CONCLUSIONS

Our findings support education and training of health care providers to improve the accuracy of cause-of-death information on death certificates.

Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort

Importance

Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain.

Objective

To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death.

Design, Setting, and Participants

This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020.

Main Outcomes and Measures

The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records.

Results

The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents.

Conclusions and Relevance

Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.

Association of Allostatic Load with All-Cause andCancer Mortality by Race and Body Mass Index in theREGARDS Cohort

Among 29,701 Black and White participants aged 45 years and older in the Reasons for Geographic and Racial Difference in Stroke (REGARDS) study, allostatic load (AL) was defined as the sum score of established baseline risk-associated biomarkers for which participants exceeded a set cutoff point. Cox proportional hazard regression was utilized to determine the association of AL score with all-cause and cancer-specific mortality, with analyses stratified by body-mass index, age group, and race. At baseline, Blacks had a higher AL score compared with Whites (Black mean AL score: 2.42, SD: 1.50; White mean AL score: 1.99, SD: 1.39; p < 0.001). Over the follow-up period, there were 4622 all-cause and 1237 cancer-specific deaths observed. Every unit increase in baseline AL score was associated with a 24% higher risk of all-cause (HR: 1.24, 95% CI: 1.22, 1.27) and a 7% higher risk of cancer-specific mortality (HR: 1.07, 95% CI: 1.03, 1.12). The association of AL with overall- and cancer-specific mortality was similar among Blacks and Whites and across age-groups, however the risk of cancer-specific mortality was higher among normal BMI than overweight or obese participants. In conclusion, a higher baseline AL score was associated with increased risk of all-cause and cancer-specific mortality among both Black and White participants. Targeted interventions to patient groups with higher AL scores, regardless of race, may be beneficial as a strategy to reduce all-cause and cancer-specific mortality.

Depressive symptoms do not discriminate: racial and economic influences between time-varying depressive symptoms and mortality among REGARDS participants

PURPOSE

Depressive symptoms relapse and remit over time, perhaps differentially by race and income. Few studies have examined whether time-varying depressive symptoms (TVDS) differentially predict mortality. We sought to determine whether race (white/black) and income (</≥$35,000) moderate the association between TVDS and mortality in a large cohort.

METHODS

The REGARDS study is a prospective cohort study among community-dwelling U.S. adults aged 45 years or older. Cox proportional hazard models were constructed to separately analyze the association between mortality (all cause, cardiovascular death, noncardiovascular death, and cancer death) and TVDS in race and income stratified models.

RESULTS

Point estimates were similar and statistically significant for white (aHR = 1.24 [95% CI: 1.10, 1.41]), black (aHR = 1.26 [95% CI: 1.11, 1.42]), and low-income participants (aHR = 1.28 [95% CI: 1.16, 1.43]) for the association between TVDS and mortality. High-income participants had a lower hazard (aHR = 1.19 [95% CI: 1.02, 1.38]). Baseline depressive symptoms predicted mortality in blacks only (aHR = 1.17, 95% CI: [1.00, 1.35]).

CONCLUSIONS

We found that TVDS significantly increased the immediate hazard of mortality similarly across race and income strata. TVDS may provide more robust evaluations of depression impact compared with the baseline measures, making apparent racial disparities cited in the extant literature a reflection of the imperfection of using baseline measures.

Chronic Kidney Disease Awareness and Longitudinal Health Outcomes: Results from the REasons for Geographic And Racial Differences in Stroke Study

BACKGROUND

The majority of people with chronic kidney disease (CKD) are unaware of their kidney disease. Assessing the clinical significance of increasing CKD awareness has critical public health and healthcare delivery implications. Whether CKD awareness among persons with CKD is associated with longitudinal health behaviors, disease management, and health outcomes is unknown.

METHODS

We analyzed data from participants with CKD in the REasons for Geographic And Racial Differences in Stroke study, a national, longitudinal, population-based cohort. Our predictor was participant CKD awareness. Outcomes were (1) health behaviors (smoking avoidance, exercise, and nonsteroidal anti-inflammatory drug use); (2) CKD management indicators (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, statin use, systolic blood pressure, fasting blood glucose, and body mass index); (3) change in estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR); and (4) health outcomes (incident end-stage kidney disease [ESKD], coronary heart disease [CHD], stroke, and death). Logistic and linear regressions were used to examine the association of baseline CKD awareness with outcomes of interest, adjusted for CKD stage and participant demographic and clinical factors.

RESULTS

Of 6,529 participants with baseline CKD, 285 (4.4%) were aware of their CKD. Among the 3,586 participants who survived until follow-up (median 9.5 years), baseline awareness was not associated with subsequent odds of health behaviors, CKD management indicators, or changes in eGFR and UACR in adjusted analyses. Baseline CKD awareness was associated with increased risk of ESKD (adjusted hazard ratio [aHR] 1.44; 95% CI 1.08-1.92) and death (aHR 1.18; 95% CI 1.00-1.39), but not with subsequent CHD or stroke, in adjusted models.

CONCLUSIONS

Individuals aware of their CKD were more likely to experience ESKD and death, suggesting that CKD awareness reflects disease severity. Most persons with CKD, including those that are high-risk, remain unaware of their CKD. There was no evidence of associations between baseline CKD awareness and longitudinal health behaviors, CKD management indicators, or eGFR decline and albuminuria.

Black-White Differences in Cardiovascular Disease Mortality: A Prospective US Study, 2003-2017

Objectives. To determine factors that explain the higher Black:White cardiovascular disease (CVD) mortality rates among US adults.Methods. We analyzed data from the Reasons for Geographic and Racial Differences in Stroke study from 2003 to 2017 to estimate Black:White hazard ratios (HRs) for CVD mortality within subgroups younger than 65 years and aged 65 years or older.Results. Among 29 054 participants, 41.0% who were Black and 54.9% who were women, 1549 CVD deaths occurred. Among participants younger than 65 years, the demographic-adjusted Black:White CVD mortality HR was 2.23 (95% confidence interval [CI] = 1.87, 2.65) and 1.21 (95% CI = 1.00, 1.47) after full adjustment. Among participants aged 65 years or older, the demographic-adjusted Black:White CVD mortality HR was 1.58 (95% CI = 1.39, 1.79) and 1.12 (95% CI = 0.97, 1.29) after full adjustment. When we used mediation analysis, socioeconomic status explained 21.2% (95% CI = 13.6%, 31.4%) and 38.0% (95% CI = 20.9%, 61.7%) of the Black:White CVD mortality risk difference among participants younger than 65 years and aged 65 years or older, respectively. CVD risk factors explained 56.6% (95% CI = 42.0%, 77.2%) and 41.3% (95% CI = 22.9%, 65.3%) of the Black:White CVD mortality difference for participants younger than 65 years and aged 65 years or older, respectively.Conclusions. The higher Black:White CVD mortality risk is primarily explained by racial differences in socioeconomic status and CVD risk factors.

Physical health composite and risk of cancer mortality in the REasons for Geographic and Racial Differences in Stroke Study

It is unclear how resting myocardial workload, as indexed by baseline measures of rate-pressure product (RPP) and physical activity (PA), is associated with the overall risk of cancer mortality. We performed prospective analyses among 28,810 men and women from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. We used a novel physical health (PH) composite index and categorized participants into one of four groups based on combinations from self-reported PA and RPP: 1) No PA and High RPP; 2) No PA and Low RPP; 3) Yes PA and High RPP; and 4) Yes PA and Low RPP. We examined the association between baseline PH composite and cancer mortality adjusted for potential confounders using Cox regression. A total of 1191 cancer deaths were observed over the 10-year observation period, with the majority being lung (26.87%) and gastrointestinal (21.49%) cancers. Even after controlling for sociodemographics, health behaviors, baseline comorbidity score, and medications, participants with No PA and High RPP had 71% greater risk of cancer mortality when compared to participants with PA and Low RPP (adjusted HR: 1.71, 95% CI: 1.42-2.06). These associations persisted after examining BMI, smoking, income, and gender as effect modifiers and all-cause mortality as a competing risk. Poorer physical health composite, including the novel RPP metric, was associated with a nearly 2-fold long-term risk of cancer mortality. The physical health composite has important public health implications as it provides a measure of risk beyond traditional measure of obesity and physical activity.

APOL1 Nephropathy Risk Alleles and Mortality in African American Adults: A Cohort Study

RATIONALE & OBJECTIVE

APOL1 nephropathy risk alleles are associated with the development of chronic kidney disease (CKD) in African Americans. Although CKD is an established risk factor for mortality, associations of APOL1 risk alleles with mortality are uncertain.

STUDY DESIGN

Prospective cohort.

SETTINGS & PARTICIPANTS

10,380 African American and 17,485 white American participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

EXPOSURES

APOL1 nephropathy risk alleles.

OUTCOMES

All-cause and cause-specific mortality.

ANALYTICAL APPROACH

Cox proportional hazards models were used to examine the association of APOL1 high-risk genotypes (2 risk alleles) versus APOL1 low-risk genotypes (0/1 risk allele) with all-cause and cause-specific mortality in African Americans and examine the risk for all-cause mortality in African Americans with high-risk genotypes versus African Americans with low-risk genotypes and white Americans.

RESULTS

APOL1 high-risk participants were younger and had a higher prevalence of albuminuria than low-risk participants. There was no statistically significant association of APOL1 high- versus low-risk genotypes with all-cause mortality in models adjusted for sociodemographic variables, comorbid conditions, and kidney function (HR, 0.88; 95% CI, 0.77-1.01). After further adjustment for genetic ancestry in a subset with available data, a statistically significant association emerged (HR, 0.81; 95% CI, 0.69-0.96). Associations differed by CKD status (Pinteraction=0.04), with African Americans with high-risk genotypes having lower risk for mortality than those with low-risk genotypes in fully adjusted models (HR, 0.78; 95% CI, 0.62-0.99) among those with CKD, but not those without CKD (HR, 0.84; 95% CI, 0.66-1.05). Compared with white Americans, African Americans with high-risk genotypes had a similar rate of mortality, whereas African Americans with low-risk genotypes had a higher rate of mortality (HR, 1.07; 95% CI, 1.00-1.14) in fully adjusted models.

LIMITATIONS

Lack of follow-up measures of kidney function.

CONCLUSIONS

African Americans with high-risk APOL1 genotypes had lower mortality than those with low-risk genotypes in multivariable-adjusted models including genetic ancestry.

Race differences in cardiovascular disease and breast cancer mortality among US women diagnosed with invasive breast cancer

BACKGROUND

Breast cancer (BC) survivors are at increased risk of cardiovascular disease (CVD) due to shared risk factors with BC and cardiotoxic treatment effects. We aim to investigate racial differences in mortality due to CVD and BC among women diagnosed with invasive BC.

METHODS

Data from 407 587 non-Hispanic Black (NHB) and White (NHW) women diagnosed with malignant BC (1990-2014) were obtained from the Surveillance, Epidemiology, and End Results database. Cumulative incidence of mortality due to CVD and BC was calculated by race and age (years). Cox models were used to obtain hazard ratios (HR) and 95% confidence intervals (95%CI) for the association of race/ethnicity with cause-specific mortality.

RESULTS

The 20-year cumulative incidence of CVD-related mortality was higher among younger NHBs than NHWs (e.g. age 55-69: 13.3% vs 8.9%, respectively). NHBs had higher incidence of BC-specific mortality than NHWs, regardless of age. There was a monotonic reduction in CVD-related mortality disparities with increasing age (age <55: HR = 3.71, 95%CI: 3.29, 4.19; age 55-68: HR = 2.31, 95%CI: 2.15, 2.49; age 69+: HR = 1.24, 95%CI: 1.19, 1.30). The hazard of BC-specific mortality among NHBs was approximately twice that of NHWs (e.g. age <55: HR = 1.98, 95%CI: 1.92, 2.04).

CONCLUSIONS

There are substantial differences in mortality due to CVD and BC between NHB and NHW women diagnosed with invasive BC. Racial differences were greatest among younger women for CVD-related mortality and similar across age groups for BC-specific mortality. Future studies should identify pathways through which race/ethnicity affects cause-specific mortality, to inform efforts towards reducing disparities.

Racial Differences in Plasma Levels of N-Terminal Pro-B-Type Natriuretic Peptide and Outcomes: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Importance

Recent studies have suggested that the natriuretic peptide system may be endogenously suppressed in black individuals who are free of prevalent cardiovascular disease. Whether natriuretic peptide levels contribute to racial disparities in clinical outcomes is unknown.

Objective

To examine racial differences in N-terminal pro-B-type natriuretic peptide (NTproBNP) levels and their association with all-cause mortality and cause-specific mortality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.

Design, Setting, and Participants

Baseline NTproBNP levels were measured in a randomly selected sample of 4415 REGARDS study participants. Those with prevalent cardiovascular disease and renal dysfunction were excluded. From July 1, 2003, to September 12, 2007, among the remaining 1998 individuals, racial differences in NTproBNP levels were estimated, and the percentage difference in NTproBNP levels by race was meta-analyzed and compared with published results on participants free of prevalent cardiovascular disease from the Dallas Heart Study and Atherosclerosis Risk in Communities study, using random effects modeling. The association of NTproBNP levels, race, all-cause mortality, and cause-specific mortality in the REGARDS study was studied using appropriate modeling techniques. Data analysis was conducted from July 1, 2003, to March 31, 2016.

Main Outcomes and Measures

Racial differences in NTproBNP levels and association with all-cause mortality and cause-specific mortality.

Results

Among the 1998 participants studied (972 women and 1026 men; median age, 63 years [interquartile range, 54-72 years]), median NTproBNP levels in black individuals were significantly lower than those in white individuals (46 pg/mL [interquartile range, 23-91] vs 60 pg/mL [interquartile range, 33-106]; P < .001). With multivariable adjustment, NTproBNP levels were up to 27% lower in black individuals as compared with white individuals (β, -0.32; 95% CI, -0.40 to -0.24; P < .001) in the REGARDS study. In meta-analysis of the 3 cohorts, NTproBNP levels were 35% lower in black individuals than white individuals. Among the REGARDS study participants, for every 1-SD higher log NTproBNP, there was a 31% increased risk of death in the multivariable-adjusted model (hazard ratio, 1.31; 95% CI, 1.11-1.54). This increase was driven primarily by association of NTproBNP with cardiovascular mortality (hazard ratio, 1.69; 95% CI, 1.19-2.41). No interaction between race and NTproBNP levels was observed with all-cause mortality and cause-specific mortality.

Conclusions and Relevance

Plasma NTproBNP levels are significantly lower in black individuals as compared with white individuals in the REGARDS study and in pooled results from the REGARDS study, Dallas Heart Study, and Atherosclerosis Risk in Communities study. Higher NTproBNP levels were associated with higher incidence of all-cause mortality and cardiovascular mortality in healthy black and white individuals, and this association did not differ by race.

Association between obesity and biomarkers of inflammation and metabolism with cancer mortality in a prospective cohort study

OBJECTIVE

To investigate the association between biomarkers of inflammation and metabolic dysregulation and cancer mortality by obesity status.

METHODS

Data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort was used to examine the associations between baseline biomarkers of inflammation (IL-6, IL-8, IL-10, and CRP) and metabolism (adiponectin, resisting and lipoprotein (a)) with cancer mortality among 1822 participants cancer-free at baseline. Weighted Cox proportional hazard regression with the robust sandwich method was used to estimate the hazard ratios and 95% confidence intervals (CIs) adjusting for baseline covariates and stratified by BMI (normal, overweight/obese) given the significant interaction between biomarkers and BMI (p < 0.1).

RESULTS

During a mean follow-up of 8 years, there were statistically significant associations between cancer mortality and being in the highest vs. lowest tertile of IL-6 (HR: 5.3; 95% CI: 1.6, 17.8), CRP (HR: 3.4; 95% CI: 1.0, 11.2) and resistin (HR: 3.7; 95% CI: 1.2, 11.2) among participants with normal BMI. IL-6 was also associated with a 3-fold (HR: 3.5; 95% CI: 1.5, 8.1) increased risk of cancer mortality among participants with overweight/obesity; however, neither CRP nor resistin was significantly associated with cancer mortality in this group.

CONCLUSIONS

Higher baseline inflammatory and metabolic biomarkers were associated with significantly increased risk of cancer mortality after adjusting for baseline risk factors and the associations varied by BMI. Cancer patients may benefit from interventions that modulate inflammatory and metabolic biomarkers.

[Out of pocket expenditure on health during the last year of life of Mexican elderly: analysis of the Enasem]

OBJECTIVE

To estimate the out-of-pocket expenses (OOPE) during the last year of life in Mexican older adults (OA).

MATERIALS AND METHODS

Estimation of the OOPE corresponding to the last year of life of OA, adjusting by type of management, affiliation and cause of death. Data from the National Health and Aging Study in Mexico (2012) were used. To calculate the total OOPE, the expenses in the last year were used in: medications, medical consultations and hospitalization. The OOPE was adjusted for inflation and is reported in US dollars 2018.

RESULTS

The mean OOPE was $6 255.3±18 500. In the ambulatory care group, the OOPE was $4 134.9±13 631.3. The OOPE in hospitalization was $7 050.6±19 971.0.

CONCLUSIONS

The probability of incurre in OOPE is lower when hospitalization is not required. With hospitalization, affiliation to social security and attending to public hospitals plays a protective role.

Race-based demographic, anthropometric and clinical correlates of N-terminal-pro B-type natriuretic peptide

BACKGROUND

Population studies have shown that black race is a natriuretic peptide (NP) deficiency state. We sought to assess whether the effects of age, sex, body mass index (BMI) and estimated glomerular filtration rate (eGFR) on N-terminal-pro-B-type NP (NT-proBNP) levels differ in white and black individuals.

METHODS

The study population consisted of a stratified random cohort from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. The study outcomes were the effects of age, sex, BMI and eGFR on NT-proBNP levels independent of socioeconomic and cardiovascular disease factors. Multivariable regression analyses were used to assess the effects of age, sex, BMI and eGFR on NT-proBNP levels in blacks and whites.

RESULTS

Of the 27,679 participants in the weighted sample, 54.7% were females, 40.6% were black, and the median age was 64 years. Every 10-year higher age was associated with 38% [95% confidence interval (CI): 30%-45%] and 34% (95% CI: 22%-43%) higher NT-proBNP levels in whites and blacks, respectively. Female sex was associated with 31% (95% CI: 20%-43%) higher NT-proBNP levels in whites and 28% (95% CI: 15%-45%) higher in blacks. There was a significant linear inverse relationship between BMI and NT-proBNP in whites and a non-linear inverse relationship in blacks. Whites and blacks had a non-linear inverse relationship between eGFR and NT-proBNP. However, the non-linear relationship between NT-proBNP and eGFR differed by race (p = 0.01 for interaction).

CONCLUSIONS

The association of age and sex with NT-proBNP levels was similar in blacks and whites but the form of the BMI and eGFR relationship differed by race.

Development of algorithms for identifying fatal cardiovascular disease in Medicare claims

BACKGROUND

Cause of death is often not available in administrative claims data.

OBJECTIVE

To develop claims-based algorithms to identify deaths due to fatal cardiovascular disease (CVD; ie, fatal coronary heart disease [CHD] or stroke), CHD, and stroke.

METHODS

Reasons for Geographic and Racial Differences in Stroke (REGARDS) study data were linked with Medicare claims to develop the algorithms. Events adjudicated by REGARDS study investigators were used as the gold standard. Stepwise selection was used to choose predictors from Medicare data for inclusion in the algorithms. C-index, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were used to assess algorithm performance. Net reclassification index (NRI) was used to compare the algorithms with an approach of classifying all deaths within 28 days following hospitalization for myocardial infarction and stroke to be fatal CVD.

RESULTS

Data from 2,685 REGARDS participants with linkage to Medicare, who died between 2003 and 2013, were analyzed. The C-index for discriminating fatal CVD from other causes of death was 0.87. Using a cut-point that provided the closest observed-to-predicted number of fatal CVD events, the sensitivity was 0.64, specificity 0.90, PPV 0.65, and NPV 0.90. The algorithms resulted in positive NRIs compared with using deaths within 28 days following hospitalization for myocardial infarction and stroke. Claims-based algorithms for discriminating fatal CHD and fatal stroke performed similarly to fatal CVD.

CONCLUSION

The claims-based algorithms developed to discriminate fatal CVD events from other causes of death performed better than the method of using hospital discharge diagnosis codes.

Tuberculosis Mortality in the United States: Epidemiology and Prevention Opportunities

Rationale: More information on risk factors for death from tuberculosis in the United States could help reduce the tuberculosis mortality rate, which has remained steady for more than a decade.Objective: To identify risk factors for tuberculosis-related death in adults.Methods: We performed a retrospective study of 1,304 adults with tuberculosis who died before treatment completion and 1,039 frequency-matched control subjects who completed tuberculosis treatment in 2005 to 2006 in 13 states reporting 65% of U.S. tuberculosis cases. We used in-depth record abstractions and a standard algorithm to classify deaths in persons with tuberculosis as tuberculosis-related or not. We then compared these classifications to causes of death as coded in death certificates. We used multivariable logistic regression to calculate adjusted odds ratios for predictors of tuberculosis-related death among adults compared with those who completed tuberculosis treatment.Results: Of 1,304 adult deaths, 942 (72%) were tuberculosis related, 272 (21%) were not, and 90 (7%) could not be classified. Of 847 tuberculosis-related deaths with death certificates available, 378 (45%) did not list tuberculosis as a cause of death. Adjusting for known risks, we identified new risks for tuberculosis-related death during treatment: absence of pyrazinamide in the initial regimen (adjusted odds ratio, 3.4; 95% confidence interval, 1.9-6.0); immunosuppressive medications (adjusted odds ratio, 2.5; 95% confidence interval, 1.1-5.6); incomplete tuberculosis diagnostic evaluation (adjusted odds ratio, 2.2; 95% confidence interval, 1.5-3.3), and an alternative nontuberculosis diagnosis before tuberculosis diagnosis (adjusted odds ratio, 1.6; 95% confidence interval, 1.2-2.2).Conclusions: Most persons who died with tuberculosis had a tuberculosis-related death. Intensive record review revealed tuberculosis as a cause of death more often than did death certificate diagnoses. New tools, such as a tuberculosis mortality risk score based on our study findings, may identify patients with tuberculosis for in-hospital interventions to prevent death.

Differences in Race and Ethnicity in Muscular Dystrophy Mortality Rates for Males under 40 Years of Age, 2006-2015

BACKGROUND/AIMS

Duchenne Muscular Dystrophy (DMD) has childhood onset, primarily affects males, and is usually fatal before the age of 40 years. Previous studies have indicated that this X-linked condition is more prevalent in whites than in blacks, but those were based on active surveillance, and limited to smaller populations and younger ages.

METHODS

US death data were used to calculate mortality rates by race and ethnicity, with MD as either the underlying or multiple cause of death (MCD). Poisson approximation was used for confidence intervals; chi-square was used to compare rates.

RESULTS

From 2006 to 2015, there were 3,256 deaths in males <40 years with MD as MCD, and 71% of these were aged 15-29 years. For whites, the average annual death rate was 0.43/100,000, which was significantly higher (p < 0.0001) that that of blacks (0.28), American Indian/Alaska Natives (0.20), and Asian/Pacific Islanders (0.21). The rate for non-Hispanic whites (0.46) was significantly higher (p < 0.0001) than the rates for Hispanic whites (0.31), Hispanic blacks (0.07), and non-Hispanic blacks (0.29).

CONCLUSION

Since DMD is the primary cause of deaths in young males with MD, mortality rates are a reasonable proxy for the relative difference in racial prevalence. It appears that DMD is significantly more common in white males than in males of other races.

Are Statutory Requirements Followed in the Certification of Traumatic, Unexpected, and Unattended Deaths in Missouri?

Medical examiners and coroners (ME/Cs) investigate deaths important to public health. This cross-sectional study evaluated 343,412 death certificates from 2007 to 2012 in Missouri. We examined agreement between cause and manner of death by year and ME/C contact as well as 2010-2012 trends in ME/C contact. There was near perfect agreement between cause and manner of death when an ME/C was contacted (kappa=0.97, p < 0.0001) and a significant increase in the proportion of deaths with ME/C contact from 2010 to 2012 (p =< 0.0001). There was a significantly higher proportion of ME/C-certified deaths using the electronic system in 2010-2012 (aOR = 1.18, 95% CI 1.15, 1.21) compared to the manual system in 2007-2009. Black, non-Hispanic (aOR = 1.50, 95% CI 1.43,1.57) and Hispanic (aOR = 1.31, 95% CI 1.13, 1.51) deaths, compared to White, non-Hispanic deaths, were associated with a significantly greater odds of ME/C certification. Race as an independent predictor of ME/C death certification warrants further research.

Risk Factors for Poststroke Cognitive Decline: The REGARDS Study (Reasons for Geographic and Racial Differences in Stroke)

BACKGROUND AND PURPOSE

Poststroke cognitive decline causes disability. Risk factors for poststroke cognitive decline independent of survivors' prestroke cognitive trajectories are uncertain.

METHODS

Among 22 875 participants aged ≥45 years without baseline cognitive impairment from the REGARDS cohort (Reasons for Geographic and Racial Differences in Stroke), enrolled from 2003 to 2007 and followed through September 2015, we measured the effect of incident stroke (n=694) on changes in cognitive functions and cognitive impairment (Six-Item Screener score <5) and tested whether patient factors modified the effect. Median follow-up was 8.2 years.

RESULTS

Incident stroke was associated with acute declines in global cognition, new learning, verbal memory, and executive function. Acute declines in global cognition after stroke were greater in survivors who were black (P=0.04), men (P=0.04), and had cardioembolic (P=0.001) or large artery stroke (P=0.001). Acute declines in executive function after stroke were greater in survivors who had <high school education versus college graduates (P=0.01). Incident stroke was associated with faster declines in global cognition and executive function but not new learning or verbal memory compared with prestroke slopes. Faster declines in global cognition over years after stroke were greater in survivors who were older (P<0.01), resided outside the Stroke Belt (P=0.005), or had cardioembolic stroke (P=0.01). Faster declines in executive function over years after stroke were greater in survivors who were older (P<0.01) or lacked hypertension (P=0.03).

CONCLUSIONS

Incident stroke alters a patient's cognitive trajectory, and this effect is greater with increasing age and cardioembolic stroke. Race, sex, geography, and hypertension status may modify the risk of poststroke cognitive decline.

Pre-diagnostic biomarkers of metabolic dysregulation and cancer mortality

INTRODUCTION

The obesogenic milieu is a pro-tumorigenic environment that promotes tumor initiation, angiogenesis and metastasis. In this prospective cohort, we examined the association between pre-diagnostic metabolic biomarkers, plasma adiponectin, resistin, leptin and lipoprotein (a), and the risk of cancer mortality.

METHODS

Prospective data was obtained from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort of Blacks and Whites followed from 2003 through 2012 for cancer mortality. We determined the association between metabolism biomarkers (log-transformed and tertiles) and risk of cancer mortality using Cox Proportional Hazards models with robust sandwich estimators to calculate the 95% confidence intervals (CIs), and adjusted for baseline covariates, including age, gender, income, education, physical activity, BMI, smoking status, alcohol use, and comorbidity score.

RESULTS

Among 1764 participants with available biomarker data, each SD higher log-leptin was associated with a 54% reduced risk of total cancer mortality (HR: 0.46, 95% CI: 0.23 – 0.92) and obesity-related cancer mortality (HR: 0.55, 95% CI: 0.39-0.79). Among Blacks only, each SD higher log-resistin was associated with a nearly 7-fold increased risk of cancer mortality (adjusted HR: 6.68, 95% CI: 2.10 – 21.21). There were no significant associations of adiponectin or Lp(a) and cancer mortality.

CONCLUSIONS

Leptin is involved in long-term regulation of energy balance, while resistin is involved in chronic inflammation and LDL production. These findings highlight the biological mechanisms linking metabolic dysregulation with cancer mortality, and the influence of resistin on cancer mortality only among Blacks suggests that this hormone may be a useful biomarker of racial differences in cancer mortality that deserves further study.

IMPACT

Our observed increased risk of cancer mortality associated with higher serum resistin levels among Blacks suggests that if validated in larger cohorts, clinical strategies focused on resistin control may be a promising cancer prevention strategy.

"They Said on the Death Certificate…But Really What I Think Happened": Characterizing Cause of Death in VA Medical Centers

Cause of death information is a vital resource for family and public health, yet significant issues persist regarding its determination, documentation and communication. In this study, we aim to characterize cause of death attribution process from the perspective of next-of-kin of Veterans who died in Veterans Affairs (VA) Medical Centers. Using a semi-structured guide, we explored next-of-kin's experiences of the Veteran's terminal hospitalization and conducted a content analysis of interview texts. In over two-third of cases next-of-kin's understanding was not consistent with their recollection of physicians' determination of cause of death. Discrepancies between official cause of death and lay understanding engendered confusion and distress. Findings have relevance for shaping the context of post-death patient/family-centered clinical practice and serve as a means for improving efficacy of cause of death communication and reducing potential for misunderstandings.

Metabolic dysregulation and cancer mortality in a national cohort of blacks and whites

Background

We examined the association between metabolic dysregulation and cancer mortality in a prospective cohort of Black and White adults.

Methods

A total of 25,038 Black and White adults were included in the analysis. Metabolic dysregulation was defined in two ways: 1) using the joint harmonized criteria for metabolic syndrome (MetS) and 2) based on factor analysis of 15 variables characterizing metabolic dysregulation. We estimated hazards ratios (HRs) and 95% confidence intervals (CIs) for the association of MetS and metabolic dysregulation with cancer mortality during follow-up using Cox proportional hazards models.

Results

About 46% of Black and 39% of White participants met the criteria for MetS. Overall, participants with MetS (HR: 1.22, 95% CI: 1.03–1.45) were at increased risk of cancer-related death. In race-stratified analysis, Black participants with MetS had significantly increased risk of cancer mortality compared with those without MetS (HR: 1.32, 95% CI: 1.01–1.72), increasing to more than a 2-fold risk of cancer mortality among those with five metabolic syndrome components (HR: 2.35, 95% CI: 1.01–5.51).

Conclusions

There are marked racial differences in the prevalence of metabolic dysregulation defined as MetS based on the harmonized criteria. The strong positive associations between MetS and cancer mortality suggests that efforts to improve cancer outcomes in general, and racial disparities in cancer outcomes specifically, may benefit from prevention and management of MetS and its components.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3807-2) contains supplementary material, which is available to authorized users.

Olfactory Dysfunction Predicts Subsequent Dementia in Older U.S. Adults

OBJECTIVES

To investigate the relationship between olfactory dysfunction and subsequent diagnosis of dementia.

DESIGN

Longitudinal study of a population representative of U.S. older adults.

SETTING

Home interviews (National Social Life, Health, and Aging Project).

PARTICIPANTS

Men and women aged 57 to 85 (N = 2,906).

MEASUREMENTS

Objective odor identification ability was measured at baseline using a validated five-item test. Five years later, the respondent, or a proxy if the respondent was too sick to interview or had died, reported physician diagnosis of dementia. The association between baseline olfactory dysfunction and an interval dementia diagnosis was tested using multivariate logistic regression, controlling for age, sex, race and ethnicity, education, comorbidities (modified Charlson Comorbidity Index), and cognition at baseline (Short Portable Mental Status Questionnaire).

RESULTS

Older adults with olfactory dysfunction had more than twice the odds of having developed dementia 5 years later (odds ratio = 2.13, 95% confidence interval = 1.32-3.43), controlling for the above covariates. Having more odor identification errors was associated with greater probability of an interval dementia diagnosis (P = .04, 1-degree of freedom linear-trend test).

CONCLUSION

We show for the first time in a nationally representative sample that home-dwelling older adults with normal cognition and difficulty identifying odors face higher odds of being diagnosed with dementia 5 years later, independent of other significant risk factors. This validated five-item odor identification test is an efficient, low-cost component of the physical examination that can provide useful information while assessing individuals' risk of dementia. Use of such testing may provide an opportunity for early interventions to reduce the attendant morbidity and public health burden of dementia.

Global Sensory Impairment Predicts Morbidity and Mortality in Older U.S. Adults

OBJECTIVES

To evaluate global sensory impairment (GSI, an integrated measure of sensory dysfunction) as a predictor of physical function, cognition, overall health, and mortality.

DESIGN

Prospective study.

SETTING

The National Social Life, Health, and Aging Project.

PARTICIPANTS

A national probability sample of 3,005 home-dwelling older U.S. adults assessed at baseline (2005-06) and 5-year follow-up (2010-11).

MEASUREMENTS

Gait speed, activity, disability, cognition, overall health, 5-year mortality.

RESULTS

At baseline, older adults with worse GSI were slower (Timed Up and Go times: odds ratio (OR) = 1.32, 95% confidence interval (CI) = 1.17-1.50) and had more activity of daily living deficits (≥2: OR = 1.26, 95% CI = 1.10-1.46). Five years later, they were still slower (timed walk: OR = 1.22, 95% CI = 1.05-1.42), had more disabilities (≥2 instrumental activities of daily living; OR = 1.45, 95% CI = 1.23-1.70), were less active (daytime activity according to accelerometry: β = -2.7, 95% CI = -5.2 to -0.2), had worse cognitive function (Montreal Cognitive Assessment; β = -0.64, 95% CI = -0.84 to -0.44), more likely to have poorer overall health (OR = 1.16, 95% CI = 1.03-1.31) and lose weight (>10%: OR = 1.31, 95% CI = 1.04-1.64), and have died (OR = 1.45, 95% CI = 1.19-1.76). All analyses were adjusted for relevant confounders at baseline, including age, sex, race and ethnicity, education, smoking, problem drinking, body mass index, comorbidities, and cognitive function.

CONCLUSION

GSI predicts impaired physical function, cognitive dysfunction, significant weight loss, and mortality 5 years later in older U.S. adults. Multisensory evaluation may identify vulnerable individuals, offering the opportunity for early intervention to mitigate adverse outcomes.

Causes of death in long-term lung cancer survivors: a SEER database analysis

BACKGROUND

Long-term (>5 years) lung cancer survivors represent a small but distinct subgroup of lung cancer patients and information about the causes of death of this subgroup is scarce.

METHODS

The Surveillance, Epidemiology and End Results (SEER) database (1988-2008) was utilized to determine the causes of death of long-term survivors of lung cancer. Survival analysis was conducted using Kaplan-Meier analysis and multivariate analysis was conducted using a Cox proportional hazard model. Clinicopathological characteristics and survival outcomes were assessed for the whole cohort.

RESULTS

A total of 78,701 lung cancer patients with >5 years survival were identified. This cohort included 54,488 patients surviving 5-10 years and 24,213 patients surviving >10 years. Among patients surviving 5-10 years, 21.8% were dead because of primary lung cancer, 10.2% were dead because of other cancers, 6.8% were dead because of cardiac disease and 5.3% were dead because of non-malignant pulmonary disease. Among patients surviving >10 years, 12% were dead because of primary lung cancer, 6% were dead because of other cancers, 6.9% were dead because of cardiac disease and 5.6% were dead because of non-malignant pulmonary disease. On multivariate analysis, factors associated with longer cardiac-disease-specific survival in multivariate analysis include younger age at diagnosis (p < .0001), white race (vs. African American race) (p = .005), female gender (p < .0001), right-sided disease (p = .003), adenocarcinoma (vs. large cell or small cell carcinoma), histology and receiving local treatment by surgery rather than radiotherapy (p < .0001).

CONCLUSION

The probability of death from primary lung cancer is still significant among other causes of death even 20 years after diagnosis of lung cancer. Moreover, cardiac as well as non-malignant pulmonary causes contribute a considerable proportion of deaths in long-term lung cancer survivors.

Risk of cardiac death among cancer survivors in the United States: a SEER database analysis

BACKGROUND

Population-based data on the risk of cardiac death among cancer survivors are needed. This scenario was evaluated in cancer survivors (>5 years) registered within the Surveillance, Epidemiology and End Results (SEER) database.

METHODS

The SEER database was queried using SEER*Stat to determine the frequency of cardiac death compared to other causes of death; and to determine heart disease-specific and cancer-specific survival rates in survivors of each of the 10 most common cancers in men and women in the SEER database.

RESULTS

For cancer-specific survival rate, the highest rates were related to thyroid cancer survivors; while the lowest rates were related to lung cancer survivors. For heart disease-specific survival rate, the highest rates were related to thyroid cancer survivors; while the lowest rates were related to both lung cancer survivors and urinary bladder cancer survivors. The following factors were associated with a higher likelihood of cardiac death: male gender, old age at diagnosis, black race and local treatment with radiotherapy rather than surgery (P < 0.0001 for all parameters).

CONCLUSION

Among cancer survivors (>5 years), cardiac death is a significant cause of death and there is a wide variability among different cancers in the relative importance of cardiac death vs. cancer-related death.

Impact of tumor size on the outcome of patients with small renal cell carcinoma

BACKGROUND

​This study aims to establish potential correlation between tumor size and outcomes in patients with T1a kidney cancer registered within the surveillance, epidemiology and end results (SEER) database.

METHODS

SEER database (2004-2013) has been accessed through SEER*Stat program to determine the correlation between tumor size and cancer-specific survival in patients with T1a kidney cancer.  Survival analysis was conducted through Kaplan-Meier analysis and log-rank testing.

RESULTS

Five year kidney cancer-specific survival rates show progressive decline with increasing tumor size.  Moreover, kidney cancer-specific survival has been compared according to the initial local treatment modality (observation, ablation, partial or radical nephrectomy) across different size categories (<1 cm, 1-2 cm, 2-3 cm and 3-4 cm).  Survival curves of different treatment modalities were almost overlapping for patients with renal mass < 1cm. For patients with tumor size 1-2 cm, treatment modalities were overlapping at the first 60 months then the curve of observation diverged (P <0.0001). For patients with tumor size 2-3 cm and 3-4 cm, the curve of observation diverged early in the time course (P <0.0001).

CONCLUSION

Primary tumor size is an important factor that should be taken into consideration when evaluating the different treatment options for patients with small kidney cancers.​.

Influence of Type II Diabetes and High Depressive Symptoms on the Likelihood for Developing Activities of Daily Living (ADL) Disability and Mortality in Older Puerto Ricans

OBJECTIVE

To examine the development of activities of daily living (ADL) disability and mortality according to diabetes and high depressive symptoms among Puerto Rican adults aged 60 and older.

METHOD

Data came from Wave I and Wave II of the Puerto Rican Elderly: Health Conditions Study ( n = 3,419). Logistic regression was used. Using insulin and receiving psychiatric treatment were proxy measures of disease severity for diabetes and depressive symptoms, respectively.

RESULTS

High depressive symptoms at baseline were associated with developing ADL disability (OR = 2.21; 95% CI = [1.68, 2.91]). Diabetes at baseline was associated with mortality at follow-up (OR = 1.72; 95% CI = [1.34, 2.19]). Baseline diabetes was associated with developing ADL disability but only for those who reported using insulin (OR = 1.69; 95% CI = [1.08, 2.61]). Participants with comorbid diabetes and high depressive symptoms had the highest odds for developing ADL disability and mortality.

DISCUSSION

Diabetes and high depressive symptoms are risk factors of developing ADL disability and mortality for older Puerto Ricans.

Comparison of Expert Adjudicated Coronary Heart Disease and Cardiovascular Disease Mortality With the National Death Index: Results From the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

BACKGROUND

The National Death Index (NDI) is widely used to detect coronary heart disease (CHD) and cardiovascular disease (CVD) deaths, but its reliability has not been examined recently.

METHODS AND RESULTS

We compared CHD and CVD deaths detected by NDI with expert adjudication of 4010 deaths that occurred between 2003 and 2013 among participants in the REGARDS (REasons for Geographic And Racial Differences in Stroke) cohort of black and white adults in the United States. NDI derived CHD mortality had sensitivity 53.6%, specificity 90.3%, positive predictive value 54.2%, and negative predictive value 90.1%. NDI-derived CVD mortality had sensitivity 73.4%, specificity 84.5%, positive predictive value 70.6%, and negative predictive value 86.2%. Among NDI-derived CHD and CVD deaths, older age (odds ratios, 1.06 and 1.04 per 1-year increase) was associated with a higher probability of disagreement with the adjudicated cause of death, whereas among REGARDS adjudicated CHD and CVD deaths a history of CHD or CVD was associated with a lower probability of disagreement with the NDI-derived causes of death (odds ratios, 0.59 and 0.67, respectively).

CONCLUSIONS

The modest accuracy and differential performance of NDI-derived cause of death may impact CHD and CVD mortality statistics.

Paleolithic and Mediterranean Diet Pattern Scores Are Inversely Associated with All-Cause and Cause-Specific Mortality in Adults

Background: Poor diet quality is associated with a higher risk of many chronic diseases that are among the leading causes of death in the United States. It has been hypothesized that evolutionary discordance may account for some of the higher incidence and mortality from these diseases.Objective: We investigated associations of 2 diet pattern scores, the Paleolithic and the Mediterranean, with all-cause and cause-specific mortality in the REGARDS (REasons for Geographic and Racial Differences in Stroke) study, a longitudinal cohort of black and white men and women ≥45 y of age.Methods: Participants completed questionnaires, including a Block food-frequency questionnaire (FFQ), at baseline and were contacted every 6 mo to determine their health status. Of the analytic cohort (n = 21,423), a total of 2513 participants died during a median follow-up of 6.25 y. We created diet scores from FFQ responses and assessed their associations with mortality using multivariable Cox proportional hazards regression models adjusting for major risk factors.Results: For those in the highest relative to the lowest quintiles of the Paleolithic and Mediterranean diet scores, the multivariable adjusted HRs for all-cause mortality were, respectively, 0.77 (95% CI: 0.67, 0.89; P-trend < 0.01) and 0.63 (95% CI: 0.54, 0.73; P-trend < 0.01). The corresponding HRs for all-cancer mortality were 0.72 (95% CI: 0.55, 0.95; P-trend = 0.03) and 0.64 (95% CI: 0.48, 0.84; P-trend = 0.01), and for all-cardiovascular disease mortality they were 0.78 (95% CI: 0.61, 1.00; P-trend = 0.06) and HR: 0.68 (95% CI: 0.53, 0.88; P-trend = 0.01).Conclusions: Findings from this biracial prospective study suggest that diets closer to Paleolithic or Mediterranean diet patterns may be inversely associated with all-cause and cause-specific mortality.

Measures of Kidney Disease and the Risk of Venous Thromboembolism in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study

BACKGROUND

Kidney disease has been associated with venous thromboembolism (VTE) risk, but results conflict and there is little information regarding blacks.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

30,239 black and white adults 45 years or older enrolled in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study 2003 to 2007.

PREDICTORS

Estimated glomerular filtration rate (eGFR) using the combined creatinine-cystatin C (eGFR_cr-cys) equation and urinary albumin-creatinine ratio (ACR).

OUTCOMES

The primary outcome was adjudicated VTE, and secondary outcomes were provoked and unprovoked VTE, separately. Mortality was a competing-risk event.

RESULTS

During 4.6 years of follow-up, 239 incident VTE events occurred over 124,624 person-years. Cause-specific HRs of VTE were calculated using proportional hazards regression adjusted for age, sex, race, region of residence, and body mass index. Adjusted VTE HRs for eGFR_cr-cys of 60 to <90, 45 to <60, and <45 versus ≥90mL/min/1.73m² were 1.28 (95% CI, 0.94-1.76), 1.30 (95% CI, 0.77-2.18), and 2.13 (95% CI, 1.21-3.76). Adjusted VTE HRs for ACR of 10 to <30, 30 to <300, and ≥300 versus <10mg/g were 1.14 (95% CI, 0.84-1.56), 1.15 (95% CI, 0.79-1.69), and 0.64 (95% CI, 0.25-1.62). Associations were similar for provoked and unprovoked VTE.

LIMITATIONS

Single measurement of eGFR and ACR may have led to misclassification. Smaller numbers of events may have limited power.

CONCLUSIONS

There was an independent association of low eGFR (<45 vs ≥90mL/min/1.73m²) with VTE risk, but no association of ACR and VTE.

Empirical redefinition of comprehensive health and well-being in the older adults of the United States

The World Health Organization (WHO) defines health as a "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Despite general acceptance of this comprehensive definition, there has been little rigorous scientific attempt to use it to measure and assess population health. Instead, the dominant model of health is a disease-centered Medical Model (MM), which actively ignores many relevant domains. In contrast to the MM, we approach this issue through a Comprehensive Model (CM) of health consistent with the WHO definition, giving statistically equal consideration to multiple health domains, including medical, physical, psychological, functional, and sensory measures. We apply a data-driven latent class analysis (LCA) to model 54 specific health variables from the National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of US community-dwelling older adults. We first apply the LCA to the MM, identifying five health classes differentiated primarily by having diabetes and hypertension. The CM identifies a broader range of six health classes, including two "emergent" classes completely obscured by the MM. We find that specific medical diagnoses (cancer and hypertension) and health behaviors (smoking) are far less important than mental health (loneliness), sensory function (hearing), mobility, and bone fractures in defining vulnerable health classes. Although the MM places two-thirds of the US population into "robust health" classes, the CM reveals that one-half belong to less healthy classes, independently associated with higher mortality. This reconceptualization has important implications for medical care delivery, preventive health practices, and resource allocation.

Distinct age and self-rated health crossover mortality effects for African Americans: Evidence from a national cohort study

The predictive effects of age and self-rated health (SRH) on all-cause mortality are known to differ across race and ethnic groups. African American adults have higher mortality rates than Whites at younger ages, but this mortality disparity diminishes with advancing age and may "crossover" at about 75-80 years of age, when African Americans may show lower mortality rates. This pattern of findings reflects a lower overall association between age and mortality for African Americans than for Whites, and health-related mechanisms are typically cited as the reason for this age-based crossover mortality effect. However, a lower association between poor SRH and mortality has also been found for African Americans than for Whites, and it is not known if the reduced age and SRH associations with mortality for African Americans reflect independent or overlapping mechanisms. This study examined these two mortality predictors simultaneously in a large epidemiological study of 12,181 African Americans and 17,436 Whites. Participants were 45 or more years of age when they enrolled in the national REasons for Geographic and Racial Differences in Stroke (REGARDS) study between 2003 and 2007. Consistent with previous studies, African Americans had poorer SRH than Whites even after adjusting for demographic and health history covariates. Survival analysis models indicated statistically significant and independent race*age, race*SRH, and age*SRH interaction effects on all-cause mortality over an average 9-year follow-up period. Advanced age and poorer SRH were both weaker mortality risk factors for African Americans than for Whites. These two effects were distinct and presumably tapped different causal mechanisms. This calls into question the health-related explanation for the age-based mortality crossover effect and suggests that other mechanisms, including behavioral, social, and cultural factors, should be considered in efforts to better understand the age-based mortality crossover effect and other longevity disparities.