Social determinants of death among the elderly: a systematic literature review

Spatial Analysis of Home and Community-Based Services and Number of Deaths Among Older Adults in Taiwan

This study examined the geographical distribution of home- and community-based services (HCBS) resources in Taiwan's Long-Term Care 2.0 policy and explored its association with the number of deaths among older adults. The main outcome of the study was determination of the number of deaths among older adults in townships (N = 346) in 2021. The results showed that home-based HCBS had a significant positive association with mortality among older adults; moreover, community-based and complementary services, which are highly clustered within a township and among its neighbors, exert a significant protective effect on mortality among older adults. Stratified analyses showed a significantly lower mortality among older adults using adult foster care and transportation services, but a significantly higher mortality among older adults using home-based professional care and respite care services, after considering the sociodemographic characteristics of older adults, urbanization, and the number of long-term care resources in the spatial analysis.

Overadjustment bias in systematic reviews and meta-analyses of socio-economic inequalities in health: a meta-research scoping review

BACKGROUND

Overadjustment bias occurs when researchers adjust for an explanatory variable on the causal pathway from exposure to outcome, which leads to biased estimates of the causal effect of the exposure. This meta-research review aimed to examine how previous systematic reviews and meta-analyses of socio-economic inequalities in health have managed overadjustment bias.

METHODS

We searched Medline and Embase until 16 April 2021 for systematic reviews and meta-analyses of observational studies on associations between individual-level socio-economic position and health outcomes in any population. A set of criteria were developed to examine methodological approaches to overadjustment bias adopted by included reviews (rated Yes/No/Somewhat/Unclear).

RESULTS

Eighty-four reviews were eligible (47 systematic reviews, 37 meta-analyses). Regarding approaches to overadjustment, whereas 73% of the 84 reviews were rated as Yes for clearly defining exposures and outcomes, all other approaches were rated as Yes for <55% of reviews; for instance, 5% clearly defined confounders and mediators, 2% constructed causal diagrams and 35% reported adjusted variables for included studies. Whereas only 2% included overadjustment in risk of bias assessment, 54% included confounding. Of the 37 meta-analyses, 16% conducted sensitivity analyses related to overadjustment.

CONCLUSIONS

Our findings suggest that overadjustment bias has received insufficient consideration in systematic reviews and meta-analyses of socio-economic inequalities in health. This is a critical issue given that overadjustment bias is likely to result in biased estimates of health inequalities and accurate estimates are needed to inform public health interventions. There is a need to highlight overadjustment bias in review guidelines.

Analysis of social determinants of health and individual factors found in health equity frameworks: Applications to injury research

INTRODUCTION

This research evaluated existing health equity frameworks as they relate to social determinants of health (SDOHs) and individual factors that may impact injury outcomes and identify gaps in coverage using the Healthy People (HP) 2030 key domains.

METHODS

The study used a list of health equity frameworks sourced from previous literature. SDOHs and individual factors from each framework were identified and categorized into the Healthy People 2030 domains. Five injury topic areas were used as examples for how SDOHs and individual factors can be compared to injury topic-specific health disparities to identify health equity frameworks to apply to injury research.

RESULTS

The study identified 59 SDOHs and individual factors from the list of 33 health equity frameworks. The number of SDOHs and individual factors identified varied by Healthy People 2030 domain: Neighborhood and Built Environment contained 16 (27.1%) SDOHs and individual actors, Social and Community Context contained 22 (37.3%), Economic Stability contained 10 (16.9%), Healthcare Access and Quality contained 10 (16.9%), and Education Access and Quality contained one (1.7%). Twenty-three (39.0%) SDOHs/individual factors related to traumatic brain injury, thirteen (22.0%) related to motor vehicle crashes and suicide, 11 (18.6%) related to drowning and older adult falls. Eight frameworks (24.2%) covered all HP 2030 key domains and may be applicable to injury topics.

CONCLUSIONS

Incorporating health equity into research is critical. Health equity frameworks can provide a way to systematically incorporate health equity into research. The findings from this study may be useful to health equity research by providing a resource to injury and other public health fields.

PRACTICAL APPLICATIONS

Health equity frameworks are a practical tool to guide injury research, translation, evaluation, and program implementation. The findings from this study can be used to guide the application of health equity frameworks in injury research for specific topic areas.

Territory Differences in Adaptation to Heat among Persons Aged 65 Years and Over in Spain (1983-2018)

Climate change is currently regarded as the greatest global threat to human health, and its health-related consequences take different forms according to age, sex, socioeconomic level, and type of territory. The aim of this study is to ascertain the differences in vulnerability and the heat-adaptation process through the minimum mortality temperature (MMT) among the Spanish population aged ≥65 years by territorial classification. A retrospective, longitudinal, ecological time-series study, using provincial data on daily mortality and maximum daily temperature across the period 1983-2018, was performed, differentiating between urban and nonurban populations. The MMTs in the study period were higher for the ≥65-year age group in urban provinces, with a mean value of 29.6 °C (95%CI 29.2-30.0) versus 28.1 °C (95%CI 27.7-28.5) in nonurban provinces. This difference was statistically significant (p < 0.05). In terms of adaptation levels, higher average values were obtained for nonurban areas, with values of 0.12 (95%CI -0.13-0.37), than for urban areas, with values of 0.09 (95%CI -0.27-0.45), though this difference was not statistically significant (p < 0.05). These findings may contribute to better planning by making it possible to implement more specific public health prevention plans. Lastly, they highlight the need to conduct studies on heat-adaptation processes, taking into account various differential factors, such as age and territory.

Predicting Patient Mortality for Earlier Palliative Care Identification in Medicare Advantage Plans: Features of a Machine Learning Model

BACKGROUND

Machine learning (ML) can offer greater precision and sensitivity in predicting Medicare patient end of life and potential need for palliative services compared to provider recommendations alone. However, earlier ML research on older community dwelling Medicare beneficiaries has provided insufficient exploration of key model feature impacts and the role of the social determinants of health.

OBJECTIVE

This study describes the development of a binary classification ML model predicting 1-year mortality among Medicare Advantage plan members aged ≥65 years (N=318,774) and further examines the top features of the predictive model.

METHODS

A light gradient-boosted trees model configuration was selected based on 5-fold cross-validation. The model was trained with 80% of cases (n=255,020) using randomized feature generation periods, with 20% (n=63,754) reserved as a holdout for validation. The final algorithm used 907 feature inputs extracted primarily from claims and administrative data capturing patient diagnoses, service utilization, demographics, and census tract-based social determinants index measures.

RESULTS

The total sample had an actual mortality prevalence of 3.9% in the 2018 outcome period. The final model correctly predicted 44.2% of patient expirations among the top 1% of highest risk members (AUC=0.84; 95% CI 0.83-0.85) versus 24.0% predicted by the model iteration using only age, gender, and select high-risk utilization features (AUC=0.74; 95% CI 0.73-0.74). The most important algorithm features included patient demographics, diagnoses, pharmacy utilization, mean costs, and certain social determinants of health.

CONCLUSIONS

The final ML model better predicts Medicare Advantage member end of life using a variety of routinely collected data and supports earlier patient identification for palliative care.

Mortality among Canadian population with multimorbidity: A retrospective cohort study

Objective

The aim of this study was to examine the effect of multimorbidity and the joint effect of chronic diseases on all-cause mortality among subjects aged 35 years and above.

Study Design

Population-based retrospective cohort study.

Methods

Multimorbidity was defined by the respondent's self-report of having two or more chronic diseases of the nine considered. The Canadian Community Health Surveys conducted in 2003/2004, 2005/2006 and 2007 to 2014 were linked with the Canadian Vital Statistics Death Database to examine the association between multimorbidity and all-cause mortality in subjects aged 35 years and above. Cox's proportional hazards models were used to estimate risk of multimorbidity on death after adjusting for the confounders in three age groups.

Results

Multimorbidity had an increased risk of death in all three age groups with the youngest having the highest risk after adjusting for potential confounders (35 to 54 years: hazard ratio (HR) = 3.77, 95% CI: 3.04, 4.67; 55 to 64 years: HR = 2.64, 95% CI: 2.36, 2.95; 65 years and above: HR = 1.71; 95% CI:1.63,1.80). Subjects with cancer had the highest risk of death in the three age groups. When the interactions between chronic diseases were considered, subjects with COPD and diabetes had a significantly increased risk of death in comparison to those without COPD or diabetes in the 55 to 64 years. (HR = 2.59, 95% CI: 2.01, 3.34).

Conclusions

Prevention of multimorbidity should be targeted not only in the older population but also in the younger populations. Synergistic effects of chronic diseases should be considered in the management of multimorbidities.

Survival and characteristics of older adults receiving home-based medical care: A nationwide analysis in Taiwan

BACKGROUND

In Taiwan, the National Health Insurance Administration initiated the integrated home-based medical care (iHBMC) program in 2016 to improve accessibility to health care for homebound patients. This study aimed to describe the characteristics of older people receiving iHBMC services in Taiwan as well as the relationship between patient characteristics and survival.

METHODS

All older adults registered in the iHBMC application dataset were enrolled between March 1, 2016, and December 31, 2018. Data on social determinants of health (income level, residential area), functional status, consciousness status, nasogastric tube or urinary catheter placement, and major diseases were retrieved from the database. Data on the frequency of multidisciplinary team members' visits were collected. The survival rate was investigated using the Kaplan-Meier method. A Cox proportional hazards univariate regression was conducted to analyze factors influencing survival rates.

RESULTS

A total of 41,079 patients aged ≥65 years were enrolled in iHBMC services. The results showed that the one-year survival rates were 72.1%, 67.4%, and 14.7% in the home-based primary care (HBPC), home-based primary care plus (HBPC-Plus), and home-based palliative care (HBPalC), respectively. Nearly two-thirds of the HBPC-Plus patients underwent nasogastric tube placement. The Cox proportional hazards univariate regression analysis showed that a low urbanization level, a low income level, a low functional status, and an impaired consciousness status were significant predictors of poor survival after adjustment for confounding variables.

CONCLUSIONS

Older adults receiving iHBMC services had a high mortality rate. The high rate of feeding tube use indicated that education and support for both clinical practitioners and family caregivers regarding careful hand feeding are warranted. There was a relationship between low income levels and poor survival in rural areas. Further research on whether social care could impact prognosis should be considered.

Mortality inequalities measured by socioeconomic indicators in Brazil: a scoping review

OBJECTIVE

Summarize the literature on the relationship between composite socioeconomic indicators and mortality in different geographical areas of Brazil.

METHODS

This scoping review included articles published between January 1, 2000, and August 31, 2020, retrieved by means of a bibliographic search carried out in the Medline, Scopus, Web of Science, and Lilacs databases. Studies reporting on the association between composite socioeconomic indicators and all-cause, or specific cause of death in any age group in different geographical areas were selected. The review summarized the measures constructed, their associations with the outcomes, and potential study limitations.

RESULTS

Of the 77 full texts that met the inclusion criteria, the study reviewed 24. The area level of composite socioeconomic indicators analyzed comprised municipalities (n = 6), districts (n = 5), census tracts (n = 4), state (n = 2), country (n = 2), and other areas (n = 5). Six studies used composite socioeconomic indicators such as the Human Development Index, Gross Domestic Product, and the Gini Index; the remaining 18 papers created their own socioeconomic measures based on sociodemographic and health indicators. Socioeconomic status was inversely associated with higher rates of all-cause mortality, external cause mortality, suicide, homicide, fetal and infant mortality, respiratory and circulatory diseases, stroke, infectious and parasitic diseases, malnutrition, gastroenteritis, and oropharyngeal cancer. Higher mortality rates due to colorectal cancer, leukemia, a general group of neoplasms, traffic accident, and suicide, in turn, were observed in less deprived areas and/or those with more significant socioeconomic development. Underreporting of death and differences in mortality coverage in Brazilian areas were cited as the main limitation.

CONCLUSIONS

Studies analyzed mortality inequalities in different geographical areas by means of composite socioeconomic indicators, showing that the association directions vary according to the mortality outcome. But studies on all-cause mortality and at the census tract level remain scarce. The results may guide the development of new composite socioeconomic indicators for use in mortality inequality analysis.

Health equity guiding frameworks and indices in injury: A review of the literature

BACKGROUND

In early 2021, CDC released the CORE Health Equity Strategy, which resolves to integrate a comprehensive health equity approach to the work of the Agency. One priority of the Injury Center's Division of Injury Prevention is to move health equity research in injury forward. The purpose of this research is to perform an initial exploration of health equity guiding frameworks and indices to better understand which of these has been applied to injury research topics.

METHODS

A PubMed and CINAHL search of meta-analysis and systematic review articles was conducted from January 1998 through April 2022. Articles of any type and additional frameworks/indices were also identified from staff knowledge of the literature. Books were also considered, where accessible. The following areas were reviewed for each resource: population addressed, guiding framework/index, other health equity variables, gaps identified, and whether the articles addressed an injury topic.

FINDINGS

The PubMed/CINAHL search produced 230 articles, and an additional 29 articles and 8 books were added from previous knowledge of the literature, resulting in a total of 267 resources for review. There were 60 frameworks/indices compiled that were relevant to health equity. Out of all the resources, three reported on an injury topic and used the PROGRESS-Plus framework, the WHO Social Determinants of Health Conceptual Framework, and a social-ecological framework.

CONCLUSIONS

This study found there were many frameworks/indices for measuring health equity; however, there were few injury-related meta-analysis and systematic review articles. Some frameworks/indices may be more appropriate than others for measuring health equity in injury topic areas, depending on which social determinants of health (SDOHs) they address.

PRACTICAL APPLICATIONS

Measuring health equity in injury and other public health research areas can help build a foundation of evidence. Moving forward, injury researchers can consider the frameworks/indices identified through this study in their health equity injury research.

Risk factors and clustering of mortality among older adults in the India Human Development Survey

With wide socioeconomic mortality differential among older adults in India, a constant question of death clustering across high-risk families and communities arises. The present study uses a follow-up survey from India to investigate the socioeconomic, demographic and health predictors of old-age mortality clustering. Data of 16,964 older adults nested within 12,981 households from 2352 communities were used from India Human Development Survey (IHDS) round-I (2005) who were further tracked down in round-II (2012). Bivariate association between the determinants of old-age mortality was investigated using the log-rank test. The multivariate analysis involved estimating the random-intercept Weibull proportional hazard model with three levels—individual (level 1), family (level 2) and community (level 3). We analyzed the sensitivity of multivariate results to unobservable variable and selection biases using the e-value method. The empirical analysis confirms that the risk of mortality is significantly heterogeneous between the families. The health status of older adults and the family’s socioeconomic status in the early years emerged as prominent predictors of a longer lifespan. With a strong association between household income and mortality hazard risk, the present study urges early life interventions as those started in late-life might have negligible impact on keeping the older adults alive and healthy.

Modifiable predictive factors and all-cause mortality in the non-hospitalized elderly population: An umbrella review of meta-analyses

OBJECTIVE

This umbrella review aimed to summarize the association between modifiable predictive factors and all-cause mortality in the non-hospitalized elderly population, and estimated the credibility and strength of the current evidence.

METHODS

PubMed, Embase, Web of science, and EBSCOhost were searched up to February 28, 2022. Random-effect summary effect sizes and 95% confidence intervals (CIs), heterogeneity, small-study effect, excess significance bias, as well as 95% prediction intervals (PIs) were calculated. Methodological quality was assessed with the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool. The credibility of the included meta-analyses was graded from convincing to weak using established criteria. This umbrella review was registered with PROSPERO, CRD 42021282183.

RESULTS

In total, 32 predictive factors involving 49 associations extracted from 35 meta-analyses were analyzed. Forty-three of the 49 (87.8%) associations presented nominal significant effects by the random-effect model (P < 0.05), of which 34 had harmful associations and nine had beneficial associations with all-cause mortality. Frailty (FRAIL scale), low short physical performance battery (SPPB) score, and fewer daily steps carried a more than three-fold risk for all-cause mortality. Convincing evidence showed that weight fluctuation, prefrailty and frailty status, sarcopenia, low SPPB score, fewer daily steps, and fatigue increased the risk of all-cause mortality, while daily moderate-to-vigorous physical activity (MVPA) duration and total physical activity participation reduced the risk of death. There were twenty, nine, five, and six associations that yielded highly suggestive, suggestive, weak, and non-significant grades of evidence. Thirty-four (69.4%) of the associations exhibited significant heterogeneity. Twenty-two associations presented 95% PIs excluding the null value, two indicated small-study effects, and three had evidence for excess significance bias, respectively. The methodological quality of most meta-analyses was rated as low (37.1%) or critically low (42.9%).

CONCLUSIONS

A summary of the currently available meta-analyses suggests that a broad range of modifiable predictive factors are significantly associated with all-cause mortality risk in the non-hospitalized elderly population. The most credible evidence indicates that physical function represented by frailty and sarcopenia, as well as physical activity, are significant predictors for all-cause mortality. This umbrella review may provide prognostic information to direct appropriate diagnostic evaluation and treatment goals in the future. More solid evidence is still needed coming from moderate-to-high quality meta-analyses.

Change in self-reported health: A signal for early intervention in a medicare population

BACKGROUND

Health plans and risk-bearing provider organizations seek information sources to inform proactive interventions for patients at risk of adverse health events. Interventions should take into account the strong relationship between social context and health. This retrospective cohort study of a Medicare Advantage population examined whether a change in self-reported health-related quality of life (HRQOL) signals a subsequent change in healthcare needs.

METHODS

A retrospective longitudinal analysis of administrative claims data was conducted for participants in a Medicare Advantage plan with prescription drug coverage (MAPD) who responded to 2 administrations of the Centers for Disease Control and Prevention 4-item Healthy Days survey within 6-18 months during 2015-2018. Changes in HRQOL, as measured by the Healthy Days instrument, were compared with changes in utilization and costs, which were considered to be a reflection of change in healthcare needs.

RESULTS

A total of 48,841 individuals met inclusion criteria. Declining HRQOL was followed by increases in utilization and costs. An adjusted analysis showed that every additional unhealthy day reported one year after baseline was accompanied by an $8 increase in monthly healthcare costs in the subsequent six months for the average patient.

CONCLUSIONS

Declining HRQOL signaled subsequent increases in healthcare needs and utilization.

IMPLICATIONS

Findings suggest that HRQOL assessments in general, and the Healthy Days instrument in particular, could serve as a leading indicator of the need for interventions designed to mitigate poor health outcomes and rising healthcare costs.

LEVEL OF EVIDENCE

III.

Malnutrition According to GLIM Criteria and Adverse Outcomes in Community-Dwelling Chinese Older Adults: A Prospective Analysis

OBJECTIVES

The Global Leadership Initiative on Malnutrition (GLIM) has proposed a consensus scheme for classifying malnutrition. This study examined the prevalence of malnutrition according to GLIM criteria and evaluated if these criteria were associated with adverse outcomes in community-dwelling older adults.

DESIGN

This was a prospective cohort study.

SETTING AND PARTICIPANTS

Community-dwelling Chinese men and women aged ≥65 years in Hong Kong.

METHODS

A health check including questionnaire interviews and physical measurements was conducted at baseline and 14-year follow-up. Participants were classified as malnourished at baseline according to the GLIM criteria based on 2 phenotypic components (low body mass index and reduced muscle mass) and 1 etiologic component (inflammation). Adverse outcomes including sarcopenia, frailty, falls, mobility limitation, hospitalization, and mortality were assessed at 14-year follow-up. Adjusted multiple logistic regression and Cox proportional hazards model were performed to examine the associations between malnutrition and adverse outcomes and presented as odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

Data of 3702 participants [median age: 72 years (IQR 68-76)] were available at baseline. Malnutrition was present in 397 participants (10.7%). Malnutrition was significantly associated with higher risk of sarcopenia (n = 898, OR 2.25; 95% CI 1.04-4.86), frailty (Fried (n = 971, OR 2.83; 95% CI 1.47-5.43), FRAIL scale (n = 985, OR 2.30; 95% CI 1.06-4.98)) and all-cause mortality (n = 3702, HR: 1.62; 95% CI 1.39-1.89). There was no significant association between malnutrition and falls (n = 987, OR 1.09; 95% CI 0.52-2.31), mobility limitation (n = 989, OR 0.98; 95% CI 0.36-2.67), and hospitalization (n = 989, OR 1.37; 95% CI 0.67-2.77).

CONCLUSIONS AND IMPLICATIONS

Among community-dwelling Chinese older adults, malnutrition according to selected GLIM criteria was a predictor of sarcopenia, frailty, and mortality at 14-year follow-up; whereas no association was found for falls, mobility limitation, and hospitalization. Clinicians may consider applying the GLIM criteria to identify malnourished community-dwelling older adults.

Depressivity and mortality risk in a cohort of elderly men. A role of cognitive and vascular ill-health, and social participation

Objectives: Depressive symptoms in the elderly have been shown to be associated with increased mortality. The purpose of this study was to examine symptoms of depression in octogenarian men and their association with all-cause mortality, and whether physical, cognitive and social factors influence this association.Methods: Out of the 703 initially included 55-years-old men, from the prospective cohort study "Men born in 1914", we studied 163 survivors who could take a part in a survey at age 81, and followed them until their death.Results: Those men who had at least mild depressive symptoms, defined with Zung Self-rating Depression Scale, were found to have an increased mortality risk (HR = 1.52; CI =1.10-2.08; p = 0.01). This association persisted significantly after adjusting for: education, global cognition at age 81, cognitive abilities at age 68, vascular risk factors and comorbidities. Instead, it was attenuated after adjustments for Activities of Daily Life (ADL) - dependency and for a grade of Satisfaction with Participation in daily life.Conclusion: In octogenarian men with survival above the average, mild depressive symptoms predict all-cause mortality. Neither cognitive capacity nor vascular comorbidity explained this association, but lower Satisfaction with Participation in daily life, especially in combination with moderate ADL-dependency.

Environmental Correlates of Reaching a Centenarian Age: Analysis of 144,665 Deaths in Washington State for 2011-2015

Objective: This study examined the association of several social and environmental factors on the likelihood of reaching centenarian age for older adults in Washington State. Methods: A survival analysis of reaching centenarian age for older adults aged 75 years and above was performed using Washington State mortality data from 2011−2015. Models were adjusted for sex, race, education, marital status, and neighborhood level social and environmental variables at the block group level. Geographic clusters of increased chance of becoming a centenarian were also mapped. Results: In the adjusted model, increased neighborhood walkability, lower education level, higher socioeconomic status, and a higher percent of working age population were positively associated with reaching centenarian age. Being widowed, divorced/separated, or never married were also positively correlated compared to being married. Additionally, being white or female were positively correlated with reaching centenarian status. Discussion: Several social and environmental factors are correlated with becoming a centenarian in Washington State. In this study, we explore findings that are consistent with previous research, as well as some that have not been previously explained. More research is needed to expand upon these findings in this rapidly growing field.

Multimorbidity and mortality in older adults: A systematic review and meta-analysis

OBJECTIVE

To review literature and provide a pooled effect for the association between multimorbidity and mortality in older adults.

METHODS

A systematic review was performed of articles held on the PUBMED database published up until January 2015. Studies which used different diseases and other conditions to define frailty, evaluated multimorbidity related only to mental health or which presented disease homogeneity were not included. A meta-analysis using random effect to obtain a pooled effect of multimorbidity on mortality in older adults was conducted only with studies which reported hazard ratio (HR). Stratified analysis and univariate meta-regression were performed to evaluate sources of heterogeneity.

RESULTS

Out of 5806 identified articles, 26 were included in meta-analysis. Overall, positive association between multimorbidity and mortality [HR: 1.44 (95%CI: 1.34; 1.55)] was detected. The number of morbidities was positively related to risk of death [HR: 1.20 (95%CI: 1.10; 1.30)]. Compared to individuals without multimorbidity, the risk of death was 1.73 (95%CI: 1.41; 2.13) and 2.72 (95%CI: 1.81; 4.08) for people with 2 or more and 3 or more morbidities, respectively. Heterogeneity between studies was high (96.5%). The sample, adjustment and follow-up modified the associations. Only nine estimates performed adjustment which included demographic, socioeconomic and behaviour variables. Disabilities appear to mediate the effect of multimorbidity on mortality.

CONCLUSIONS

Multimorbidity was associated with an increase in risk of death. Multimorbidity measurement standardization is needed to produce more comparable estimates. Adjusted analysis which includes potential confounders might contribute to better understanding of causal relationships between multimorbidity and mortality.

Disability and all-cause mortality in the older population: evidence from the English Longitudinal Study of Ageing

Despite the vast body of literature studying disability and mortality, evidence to support their association is scarce. This work investigates the role of disability in explaining all-cause mortality among individuals aged 50+ who participated in the English Longitudinal Study of Aging. The aim is to explain the gender paradox in health and mortality by analysing whether the association of disability with mortality differs between women and men. Disability was conceived following the International Classification of Functioning, Disability and Health (ICF), proposed by the WHO, that conceptualizes disability as a combination of three components: impairment, activity limitation and participation restriction. Latent variable models were used to identify domain-specific factors and general disability. The association of the latter with mortality up to 10 years after enrolment was estimated using discrete-time survival analysis. Our work confirms the validity of the ICF framework and finds that disability is strongly associated with mortality, with a time-varying effect among men, and a smaller constant effect for women. Adjusting for demographic, socioeconomic and behavioural factors attenuated the association for both sexes, but overall the effects remained high and significant. These findings confirm the existence of gender paradox by showing that, when affected by disability, women survive longer than men, although if men survive the first years they appear to become more resilient to disability. Sensitivity analyses suggested that the gender paradox cannot be solely explained by gender-specific health conditions: there must be other mechanisms acting within the pathway between disability and mortality that need to be explored.

The effect of race on long term mortality in mechanically ventilated patients

OBJECTIVE

Determine the impact of race on one-year mortality following mechanical ventilation.

BACKGROUND

There is a lack of prospective studies on the effect of race on survival following mechanical ventilation.

METHODS

Observational study of adult patients on ventilatory support for <24 h prior to enrollment. Socioeconomic factors, laboratory and clinical data were recorded. Primary outcome was one-year mortality.

RESULTS

We enrolled 178 patients; 100 African American (AA), 78 other races (OTH). One-year mortality for AA was 49% and 33% for OTH (p = 0.035). After correcting for covariates, race was not significantly associated with mortality (p = 0.42). AA patients had higher mean arterial blood pressure, serum creatinine, heart rate, and peak (p < 0.01) and mean (p = 0.05) airway pressures.

CONCLUSIONS

AA patients who underwent mechanical ventilation had greater one-year mortality, although race per se was not a significant factor. It remains to be determined if strict blood pressure control and lower airway pressures may improve survival in this racial group.