Health and Social Conditions of the Poorest Versus Wealthiest Counties in the United States

Racial and ethnic and socioeconomic disparities in childhood cancer incidence trends in the United States, 2000-2019

BACKGROUND

Population-based surveillance of pediatric cancer incidence trends is critical to determine high-risk populations, drive hypothesis generation, and uncover etiologic heterogeneity. We provide a comprehensive update to the current understanding of pediatric cancer incidence trends by sex, race and ethnicity, and socioeconomic status (SES).

METHODS

The Surveillance, Epidemiology, and End Results 22 data (2000-2019) was used to summarize age-adjusted incidence rates for children and adolescents aged 0-19 years at diagnosis. The annual percentage change (APC) and 95% confidence interval (CI) were estimated to evaluate incidence trends by sex, race and ethnicity, and SES overall and for cancer subtypes. Tests of statistical significance were 2-sided.

RESULTS

Substantial variation was observed overall and for several histologic types in race and ethnicity- and SES-specific rates. Overall, we observed a statistically significant increase in incidence rates (APC = 0.8%, 95% CI = 0.6% to 1.1%). All race and ethnic groups saw an increase in incidence rates, with the largest occurring among non-Hispanic American Indian and Alaska Native children and adolescents (APC = 1.7%, 95% CI = 0.5% to 2.8%) and the smallest increase occurring among non-Hispanic White children and adolescents (APC = 0.7%, 95% CI = 0.5% to 1.0%). The lowest SES quintiles saw statistically significant increasing trends, while the highest quintile remained relatively stable (quintile 1 [Q1] APC = 1.6%, 95% CI = 0.6% to 2.6%; quintile 5 [Q5] APC = 0.3%, 95% CI = -0.1% to 0.7%).

CONCLUSIONS

Childhood cancer incidence is increasing overall and among every race and ethnic group. Variation by race and ethnicity and SES may enable hypothesis generation on drivers of disparities observed.

Rural and socioeconomic differences in the effectiveness of the HEART Pathway accelerated diagnostic protocol

BACKGROUND

The HEART Pathway is a validated accelerated diagnostic protocol (ADP) for patients with possible acute coronary syndrome (ACS). This study aimed to compare the safety and effectiveness of the HEART Pathway based on patient rurality (rural vs. urban) or socioeconomic status (SES).

METHODS

We performed a preplanned subgroup analysis of the HEART Pathway Implementation Study. The primary outcomes were death or myocardial infarction (MI) and hospitalization at 30 days. Proportions were compared by SES and rurality with Fisher's exact tests. Logistic regression evaluated for interactions of ADP implementation with SES or rurality and changes in outcomes within subgroups.

RESULTS

Among 7245 patients with rurality and SES data, 39.9% (2887/7245) were rural and 22.2% were low SES (1607/7245). The HEART Pathway identified patients as low risk in 32.2% (818/2540) of urban versus 28.1% (425/1512) of rural patients (p = 0.007) and 34.0% (311/915) of low SES versus 29.7% (932/3137) high SES patients (p = 0.02). Among low-risk patients, 30-day death or MI occurred in 0.6% (5/818) of urban versus 0.2% (1/425) rural (p = 0.67) and 0.6% (2/311) with low SES versus 0.4% (4/932) high SES (p = 0.64). Following implementation, 30-day hospitalization was reduced by 7.7% in urban patients (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.66-0.87), 10.6% in low SES patients (aOR 0.68, 95% CI 0.54-0.86), and 4.5% in high SES patients (aOR 0.83, 95% CI 0.73-0.94). However, rural patients had a nonsignificant 3.3% reduction in hospitalizations.

CONCLUSIONS

HEART Pathway implementation decreased 30-day hospitalizations regardless of SES and for urban patients but not rural patients. The 30-day death or MI rate was similar among low-risk patients.

Differences in incident and recurrent myocardial infarction among White and Black individuals aged 35 to 84: Findings from the ARIC community surveillance study

BACKGROUND

No previous study has examined racial differences in recurrent acute myocardial infarction (AMI) in a community population. We aimed to examine racial differences in recurrent AMI risk, along with first AMI risk in a community population.

METHODS

The community surveillance of the Atherosclerosis Risk in Communities Study (2005-2014) included 470,000 people 35 to 84 years old in 4 U.S. communities. Hospitalizations for recurrent and first AMI were identified from ICD-9-CM discharge codes. Poisson regression models were used to compare recurrent and first AMI risk ratios between Black and White residents.

RESULTS

Recurrent and first AMI risk per 1,000 persons were 8.8 (95% CI, 8.3-9.2) and 20.7 (95% CI, 20.0-21.4) in Black men, 6.8 (95% CI, 6.5-7.0) and 14.1 (95% CI, 13.8-14.5) in White men, 5.3 (95% CI, 5.0-5.7) and 16.2 (95% CI, 15.6-16.8) in Black women, and 3.1 (95% CI, 3.0-3.3) and 8.8 (95% CI, 8.6-9.0) in White women, respectively. The age-adjusted risk ratios (RR) of recurrent AMI were higher in Black men vs White men (RR, 1.58 95% CI, 1.30-1.92) and Black women vs White women (RR, 2.09 95% CI, 1.64-2.66). The corresponding RRs were slightly lower for first AMI: Black men vs White men, RR, 1.49 (95% CI, 1.30-1.71) and Black women vs White women, RR, 1.65 (95% CI, 1.42-1.92) CONCLUSIONS: Large disparities exist by race for recurrent AMI risk in the community. The magnitude of disparities is stronger for recurrent events than for first events, and particularly among women.

Cancer disparities related to poverty and rurality for 22 top cancers in Florida

We aimed to examine poverty and rurality as potential predictors of cancer health disparities. This cross-sectional study used data from the Florida Cancer Data System on all cancer diagnoses in the years 2014-2018 to determine age-adjusted incidence and mortality (per 100,000 population) for the 22 most common cancer sites within rural and urban counties, and high poverty and low poverty communities. Rural/urban and high/low poverty related cancer disparities were tested for statistical significance using the Rate Ratio statistical test. Overall cancer incidence was significantly lower in rural areas than in urban, but significantly higher in high poverty communities. Rurality and poverty were both associated with disparity in cancer incidence risk for tobacco-related cancers. The overall mortality was 22% higher in high poverty areas compared to low poverty areas. Ten cancer sites had mortality disparity from 83% to 17% higher in high poverty areas. Only three cancer sites, all tobacco-related, had higher mortality in rural areas than urban areas, demonstrating the intersectional nature of inhaled and smokeless tobacco use in rural low-income communities. Cancer and mortality rates in rural and urban areas may be largely driven by poverty. The high disparities related to high poverty areas reflects poor access to preventative care and treatment. Low income communities, rural or urban, will require focused efforts to address challenges specific to each population.

Varied Health Spending Growth Across US States Was Associated With Incomes, Price Levels, And Medicaid Expansion, 2000-19

Little is known about health care spending variation across the US for recent years. To estimate health spending by state and payer, we combined data from the government's State Health Expenditure Accounts, which have estimates through 2014, with other primary data on spending. In 2019 state-specific per person spending ranged from $7,250 to $14,500. After adjustment for inflation, annualized per person spending growth for each state ranged from 1.0 percent in Washington, D.C., to 4.2 percent in South Dakota between 2013 and 2019. The factors that explained the most variation across states were incomes (25.3 percent) and consumer prices (21.7 percent). Medicaid expansion was associated with increases in total spending per person, although the median of spending in expansion states showed slower growth in out-of-pocket spending than the median in nonexpansion states. Contemporary estimates of state health spending are valuable for tracking divergent expenditure trajectories in the US and assessing the associated factors.

COVID-19 double jeopardy: the overwhelming impact of the social determinants of health

Background

The COVID-19 pandemic has strained healthcare systems by creating a tragic imbalance between needs and resources. Governments and healthcare organizations have adapted to this pronounced scarcity by applying allocation guidelines to facilitate life-or-death decision-making, reduce bias, and save as many lives as possible. However, we argue that in societies beset by longstanding inequities, these approaches fall short as mortality patterns for historically discriminated against communities have been disturbingly higher than in the general population.

Methods

We review attack and fatality rates; survey allocation protocols designed to deal with the extreme scarcity characteristic of the earliest phases of the pandemic; and highlight the larger ethical perspectives (Utilitarianism, non-Utilitarian Rawlsian justice) that might justify such allocation practices.

Results

The COVID-19 pandemic has dramatically amplified the dire effects of disparities with respect to the social determinants of health. Patients in historically marginalized groups not only have significantly poorer health prospects but also lower prospects of accessing high quality medical care and benefitting from it even when available. Thus, mortality among minority groups has ranged from 1.9 to 2.4 times greater than the rest of the population. Standard allocation schemas, that prioritize those most likely to benefit, perpetuate and may even exacerbate preexisting systemic injustices.

Conclusions

To be better prepared for the inevitable next pandemic, we must urgently begin the monumental project of addressing and reforming the structural inequities in US society that account for the strikingly disparate mortality rates we have witnessed over the course of the current pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01629-0.

Risk Factors for Surgical Site Infection in the Undeserved Population After Ventral Hernia Repair: A 3936 Patient Single-Center Study Using National Surgical Quality Improvement Project

Background: Ventral hernia repair (VHR) is one of the most common surgical procedures performed in the United States. Surgical site infections (SSI) carry significant morbidity for the patient and pose a very challenging problem for the surgeon, associated with up to 6.6% of cases. Thus, surgeons should be well versed in the risk factors implicated in SSI after VHR. Given the high burden of diabetes, obesity, and smoking in our patient population, we sought to study the rate of SSI and the risk factors that led to SSI in our population. Study Design: This is a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for the years 2014-2019. We identified patients who underwent VHR at a single institution in the Bronx, New York. The rate of SSI was calculated, and then, risk factors for SSI were identified using logistic regression analysis. Results: A total of 3936 patients underwent VHR. Incisional hernias made up 41% of the cohort, and there were 37.4% laparoscopic repairs. During the 30-day follow-up, SSI was identified in 101 patients (2.6%). Factors associated with SSI include emergent surgery (adjusted odds ratio [aOR] = 2.57), body mass index >35 kg/m² (aOR = 2.38), insulin-dependent diabetes mellitus (aOR = 2.36), and incisional hernia (aOR = 1.81). In addition, a laparoscopic approach was found to be a protective factor (aOR = 0.43, 95% confidence interval 0.25-0.75). Surprisingly, different from other studies, smoking cigarettes was not associated with SSI in our cohort. Conclusions: The rate of SSI after VHR in our institution is 2.6%, which is within that reported in the literature. Most of the variables associated with SSI are modifiable and are similar to those previously reported. Laparoscopic repairs appear to be protective for its occurrence.

Improving Equity in Cancer Care in the Face of a Public Health Emergency

ABSTRACT

Cancer health disparities have been well documented among different populations in the United States for decades. While the cause of these disparities is multifactorial, the COVID-19 pandemic has highlighted the structural barriers to health and health care and the gaps in public health infrastructure within the United States. The most long-standing inequities are rooted in discriminatory practices, current and historical, which have excluded and disenfranchised many of the most vulnerable populations in the nation. These systemic barriers are themselves a public health crisis, resulting in increased mortality rates in communities of color from both COVID-19 and cancer. While implementing programs to temporarily improve cancer equity locally or regionally is laudable, it is imperative to develop a public health strategy focused on alleviating the root causes of health inequities to improve the health and well-being of every citizen and ensure readiness for the next public health emergency.

From Provider to Advocate: The Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement

Treating a patient with traumatic brain injury requires an interdisciplinary approach because of the pervasive, profound and protean manifestations of this condition. In this review, key aspects of the medical history and review of systems will be described in order to highlight how the role of any provider must evolve to become a better patient advocate. Although this review is written from the vantage point of a vision care provider, it is hoped that patients, caregivers and providers will recognize the need for a team approach.

Stimuli-responsive natural gums-based drug delivery systems for cancer treatment

Chemotherapy as the main cancer treatment method has non-specific effects and various side-effects. Accordingly, significant attempts have been conducted to enhance its efficacy through design and development of "smart" drug delivery systems (DDSs). In this context, natural gums, as a nice gift by the nature, can be exploited as stimuli-responsive DDSs for cancer treatment in part due to their renewability, availability, low cost, bioactivity, biocompatibility, low immunogenicity, biodegradability, and acceptable stability in both in vitro and in vivo conditions. However, some shortcomings (e.g., poor mechanical properties and high hydration rate) restrict their biomedical application ranges that can be circumvented through modification process (e.g., grafting of stimuli-responsive polymers or small molecules) to obtain tailored biomaterials. This review article aimed to compile the stimuli-responsive DDSs based on natural gums. In addition, different types of stimuli, the fundamental features of natural gums, as well as their chemical modification approaches are also shortly highlighted.

Sudden Cardiac Death in the Young: Incidence, Trends, and Risk Factors in a Nationwide Study

BACKGROUND

Sudden cardiac death (SCD) in the young is devastating. Contemporary incidence remains unclear with few recent nationwide studies and limited data addressing risk factors for causes. We aimed to determine incidence, trends, causes, and risk factors for SCD in the young.

METHODS AND RESULTS

The National Coronial Information System registry was reviewed for SCD in people aged 1 to 35 years from 2000 to 2016 in Australia. Subjects were identified by the International Classification of Diseases, Tenth Revision code relating to circulatory system diseases (I00-I99) from coronial reports. Baseline demographics, circumstances, and cause of SCD were obtained from coronial and police reports, alongside autopsy and toxicology analyses where available. During the study period, 2006 cases were identified (median age, 28±7 years; men, 75%; mean body mass index, 29±8 kg/m²). Annual incidence ranged from 0.91 to 1.48 per 100 000 age-specific person-years, which was the lowest in 2013 to 2015 compared with previous 3-year intervals on Poisson regression model (P=0.001). SCD incidence was higher in nonmetropolitan versus metropolitan areas (0.99 versus 0.53 per 100 000 person-years; P<0.001). The most common cause of SCD was coronary artery disease (40%), followed by sudden arrhythmic death syndrome (14%). Incidence of coronary artery disease-related SCD decreased from 2001-2003 to 2013-2015 (P<0.001). Proportion of SCD related to sudden arrhythmic death syndrome increased during the study period (P=0.02) although overall incidence was stable (P=0.22). Residential remoteness was associated with coronary artery disease-related SCD (odds ratio, 1.44 [95% CI, 1.24-1.67]; P<0.001). For every 1-unit increase, body mass index was associated with increased likelihood of SCD from cardiomegaly (odds ratio, 1.08 [95% CI, 1.05-1.11]; P<0.001) and dilated cardiomyopathy (odds ratio, 1.04 [95% CI, 1.01-1.06]; P=0.005).

CONCLUSIONS

Incidence of SCD in the young and specifically coronary artery disease-related SCD has declined in recent years. Proportion of SCD related to sudden arrhythmic death syndrome increased over the study period. Geographic remoteness and obesity are risk factors for specific causes of SCD in the young.

Identifying characteristics of high-poverty counties in the United States with high well-being: an observational cross-sectional study

OBJECTIVE

To identify county characteristics associated with high versus low well-being among high-poverty counties.

DESIGN

Observational cross-sectional study at the county level to investigate the associations of 29 county characteristics with the odds of a high-poverty county reporting population well-being in the top quintile versus the bottom quintile of well-being in the USA. County characteristics representing key determinants of health were drawn from the Robert Wood Johnson Foundation County Health Rankings and Roadmaps population health model.

SETTING

Counties in the USA that are in the highest quartile of poverty rate.

MAIN OUTCOME MEASURE

Gallup-Sharecare Well-being Index, a comprehensive population-level measure of physical, mental and social health. Counties were classified as having a well-being index score in the top or bottom 20% of all counties in the USA.

RESULTS

Among 770 high-poverty counties, 72 were categorised as having high well-being and 311 as having low well-being. The high-well-being counties had a mean well-being score of 71.8 with a SD of 2.3, while the low-well-being counties had a mean well-being score of 60.2 with a SD of 2.8. Among the six domains of well-being, basic access, which includes access to housing and healthcare, and life evaluation, which includes life satisfaction and optimism, differed the most between high-being and low-well-being counties. Among 29 county characteristics tested, six were independently and significantly associated with high well-being (p<0.05). These were lower rates of preventable hospital stays, higher supply of primary care physicians, lower prevalence of smoking, lower physical inactivity, higher percentage of some college education and higher percentage of heavy drinkers.

CONCLUSIONS

Among 770 high-poverty counties, approximately 9% outperformed expectations, reporting a collective well-being score in the top 20% of all counties in the USA. High-poverty counties reporting high well-being differed from high-poverty counties reporting low well-being in several characteristics.

Neighborhood Environments, SNAP-Ed Eligibility, and Health Behaviors: An Analysis of the California Health Interview Survey (CHIS)

Neighborhood conditions are associated with health outcomes, but whether individual health behaviors are independent of or associated with the settings are not clear. We analyzed the California Health Interview Survey (CHIS) (N = 11,152) data to determine if the perceptions and behaviors of similar individuals with an income low enough to be eligible for SNAP-Ed services differed based on whether they lived in high- or low-income neighborhoods. We found that SNAP-Ed eligible individuals living in low-income neighborhoods walked for transportation more frequently (3.04 times versus 2.38 times, p = 0.001), drank sugary beverages more frequently in the past month (2.93 times versus 1.69 times, p = 0.000), and had a higher risk of obesity than similar low-income individuals living in high-income neighborhoods (0.34 versus 0.26, p = 0.012).

Epidemiology of breast cancer, a paradigm of the "common soil" hypothesis

Breast cancer is the leading cause of death in women aged 20-50 years, with some geographical difference. The yearly incidence of the disease is increasing while the related mortality is steadily decreasing. Breast cancer is associated not only with specific hormones or factors related with reproduction, but mostly to more general environmental factors, linked to socioeconomic conditions and lifestyles (smoking, stress, physical exercise and particularly dietary habits). The latter, indeed, are risk factors or conditions common to hormone-dependent tumors and other chronic degenerative disorders, such as ischemic cardio cerebro-vascular and neuro-degenerative disease. Breast cancer can indeed be considered as a paradigm of the so-called "common soil" concept, according to which the above mentioned conditions, although having different clinical manifestations, share some pathogenetic mechanisms and risk factors and intermediate predisposing phenotypes (see Type2 diabetes, metabolic syndrome or obesity). In an epidemiological perspective, evidence has been accumulated on the common response of breast cancer and cardiovascular disorders to healthy lifestyles and in particular to the beneficial effects of a close adhesion to the Mediterranean dietary model. The latter would mainly be effective thanks to its anti-inflammatory properties, thus controlling the subclinical condition of low-grade inflammation, a common risk factor of all the "common soil" disorders. Results from the prospective cohort of the Moli-sani Study (nearly 25,000 adults from the general population of the Southern Italy region of Molise) are highly suggestive in this context. In a public health perspective, the "common soil" hypothesis may thus promote the application of preventive strategies, particularly targeting lifestyles, for a broad spectrum of widely prevalent disorders, ranging from breast cancer to myocardial infarction or cognitive impairment conditions.

Association between socioeconomic factors at diagnosis and survival in breast cancer: A population-based study

Background

The associations between socioeconomic statuses and survival outcomes of breast cancer remain unclear. No model has included both histological and socioeconomic factors to predict the survival of breast cancer. This study was designed to develop nomograms to predict breast cancer–specific survival (BCSS) and overall survival (OS) with consideration of socioeconomic factors for breast cancer patients.

Materials and methods

We included a total of 207 749 female patients, diagnosed with malignant breast cancer between 2007 and 2012 from the Surveillance, Epidemiology, and End Results database. BCSS and OS were evaluated with Gray's test and log‐rank tests, respectively. Marital statuses, insurance statuses, residence, median household income, poverty rate, unemployment rate, and education level were included as socioeconomic factors in univariate and multivariate Cox regression analyses. Clinicopathological factors and socioeconomic factors were integrated to construct nomograms. Calibration plots and concordance indexes (C‐indexes) were used to evaluate the accuracy and discrimination of the models.

Results

Four and three socioeconomic factors were involved in constructing the nomograms for 3‐, 5‐, and 7‐year BCSS and OS, respectively. The C‐indexes of the final nomograms were higher than those of the TNM staging system for predicting BCSS (0.835 vs 0.782; P < .001) and OS (0.773 vs 0.676; P < .001). The performance of the nomograms for predicting OS was significantly lower when excluding socioeconomic factors (P < .001).

Conclusion

These findings may highlight the importance of developing health‐related policies and the necessity of targeted social support‐based interventions for high‐risk patients.

Association of Cardiovascular Disease With Premature Mortality in the United States

Importance

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in the United States. Despite substantial declines in CVD mortality rates during past decades, progress against cardiovascular deaths in midlife has stagnated, with rates increased in some US racial/ethnic groups.

Objective

To examine the trends in premature (ages 25-64 years) mortality from CVD from 2000 to 2015 by demographics and county-level factors, including education, rurality, and the prevalence of smoking, obesity, and diabetes.

Design, Setting, and Participants

This descriptive study used US national mortality data from the Surveillance, Epidemiology, and End Results data set and included all CVD deaths among individuals ages 25 to 64 years from January 2000 to December 2015. The data analysis began in February 2018.

Exposures

Age, sex, race/ethnicity, and county-level factors.

Main Outcomes and Measures

Age-standardized mortality rates and average annual percent change (AAPC) in rates by age, sex, race/ethnicity, and county-level factors (in quintiles) and relative risks of CVD mortality across quintiles of each county-level factor.

Results

In 2000 to 2015, 2.3 million CVD deaths occurred among individuals age 25 to 64 years in the United States. There were significant declines in CVD mortality for black, Latinx, and Asian and Pacific Islander individuals (AAPC: range, -1.7 to -3.2%), although black people continued to have the highest CVD mortality rates. Mortality rates were second highest for American Indian/Alaskan Native individuals and increased significantly among those aged 25 to 49 years (AAPC: women, 2.1%; men, 1.3%). For white individuals, mortality rates plateaued among women age 25 to 49 years (AAPC, 0.05%). Declines in mortality rates were observed for most major CVD subtypes except for ischemic heart disease, which was stable in white women and increased in American Indian/Alaska Native women, hypertensive heart disease, for which significant increases in rates were observed in most racial/ethnic groups, and endocarditis, for which rates increased in white individuals and American Indian/Alaska Native men. Counties with the highest prevalence of diabetes (quintile 5 vs quintile 1: relative risk range 1.6-1.8 for white individuals and 1.4-1.6 for black individuals) had the most risk of CVD mortality.

Conclusions and Relevance

There have been substantial declines in premature CVD mortality in much of the US population. However, increases in CVD mortality before age 50 years among American Indian/Alaska Native individuals, flattening rates in white people, and overall increases in deaths from hypertensive disease suggest that targeted public health interventions are needed to prevent these premature deaths.

Independent Relationship of Changes in Death Rates with Changes in US Presidential Voting

BACKGROUND

The outcome of the 2016 presidential election is commonly attributed to socioeconomic and ethnic/racial issues, but health issues, including "deaths of despair," may also have contributed.

OBJECTIVE

To assess whether changes in age-adjusted death rates were independently associated with changes in presidential election voting in 2016 vs. 2008.

DESIGN

We used publicly available data in each of 3112 US counties to correlate changes in a county's presidential voting in 2016 compared with 2008 with recent changes in its age-adjusted death rate, after controlling for population and rural-urban status, median age, race/ethnicity, income, education, unemployment rate, and health insurance rate.

DESIGN SETTING

Cross-sectional analysis of county-specific data.

SETTING/PARTICIPANTS

All 3112 US counties.

MAIN MEASURES

The independent correlation of a county's change in age-adjusted death rate between 2000 and 2015 with its net percentage Republican gain or loss in the presidential election of 2016 vs. 2008.

KEY RESULTS

In 2016, President Trump increased the Republican presidential vote percentage in 83.8% of counties compared with Senator McCain in 2008. Counties with an increased Republican vote percentage in 2016 vs. 2008 had a 15% higher 2015 age-adjusted death rate than counties with an increased Democratic vote percentage. Since 2000, overall death rates declined by less than half as much, and death rates from drugs, alcohol, and suicide increased 2.5 times as much in counties with Republican gains compared with counties with Democratic gains. In multivariable analyses, Republican net presidential gain in 2016 vs. 2008 was independently correlated with slower reductions in a county's age-adjusted death rate. Although correlation cannot infer causality, modest reductions in death rates might theoretically have shifted Pennsylvania, Michigan, and Wisconsin to Secretary Clinton.

CONCLUSIONS

Less of a reduction in age-adjusted death rates was an independent correlate of an increased Republican percentage vote in 2016 vs. 2008. Death rates may be markers of dissatisfactions and fears that influenced the 2016 Presidential election outcomes.

Premature mortality from all causes and drug poisonings in the USA according to socioeconomic status and rurality: an analysis of death certificate data by county from 2000-15

BACKGROUND

Increasing premature mortality among some groups of Americans has been largely driven by increases in drug poisoning deaths. However, to our knowledge, a formal descriptive study by race and ethnicity, socioeconomic status, rurality, and geography has not been done. In this study, we examined US trends in premature all-cause and drug poisoning mortality between 2000 and 2015 at the county level among white, black, and Latino people.

METHODS

We used US mortality data for the period Jan 1, 2000, to Dec 31, 2015, including underlying cause of death and demographic data, collected from death certificates by the Centers for Disease Control and Prevention National Center for Health Statistics, and ascertained county attributes from the 2011-15 Census American Community Survey. We categorised counties into quintiles on the basis of the percentage of people unemployed, the percentage of people with a bachelor's degree, median income, and rurality. We estimated premature (ie, deaths in those aged 25-64 years) age-standardised mortality for all causes (by race and ethnicity) and drug poisoning, by county, for the periods of 2000-03 and 2012-15. We estimated annual percentage changes in mortality (2000-15) by county-level characteristics.

FINDINGS

Premature mortality declined from 2000-03 to 2012-15 among black and Latino people, but increased among white people in many US counties. Drug poisoning mortality increased in counties throughout the country. Significant increases between 2000 and 2015 occurred across low and high socioeconomic status and urban and rural counties among white people aged 25-64 years (annual percentage change range 4·56% per year [95% CI 3·56-5·57] to 11·51% per year [9·41-13·65]), black people aged 50-64 years (2·27% per year [0·42-4·16] to 9·46% per year [7·02-11·96]), Latino women aged 25-49 years (2·43% per year [1·18-3·71] to 5·01% per year [3·80-6·23]), and Latino men aged 50-64 years (2·42% per year [0·53-4·34] to 5·96% per year [3·86-8·11]). Although drug poisoning mortality increased rapidly in counties with the lowest socioeconomic status and in rural counties, most deaths during 2012-15 occurred in the largest metropolitan counties (121 395 [76%] in metropolitan counties with ≥250 000 people vs 2175 [1%] in the most rural counties), reflecting population size.

INTERPRETATION

Premature mortality has declined among black and Latino people in the USA, and increased among white people, particularly in less affluent and rural counties. Increasing drug poisoning mortality was not limited to poor white people in rural areas. Rapid increases have occurred in communities throughout the USA regardless of race and ethnicity, socioeconomic status, or rurality. Widespread public health interventions are needed to addess this public health emergency.

FUNDING

National Institutes of Health.

Cancer statistics, 2019

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2015, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2016, were collected by the National Center for Health Statistics. In 2019, 1,762,450 new cancer cases and 606,880 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2006-2015) was stable in women and declined by approximately 2% per year in men, whereas the cancer death rate (2007-2016) declined annually by 1.4% and 1.8%, respectively. The overall cancer death rate dropped continuously from 1991 to 2016 by a total of 27%, translating into approximately 2,629,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the racial gap in cancer mortality is slowly narrowing, socioeconomic inequalities are widening, with the most notable gaps for the most preventable cancers. For example, compared with the most affluent counties, mortality rates in the poorest counties were 2-fold higher for cervical cancer and 40% higher for male lung and liver cancers during 2012-2016. Some states are home to both the wealthiest and the poorest counties, suggesting the opportunity for more equitable dissemination of effective cancer prevention, early detection, and treatment strategies. A broader application of existing cancer control knowledge with an emphasis on disadvantaged groups would undoubtedly accelerate progress against cancer.

Actionable Analysis: Toward a Jurisdictional Evaluation of Primary Care Access in the Community Context

Primary care is the foundation of health care systems and has potential to alleviate inequities in population health. We examined multiple measures of adult primary care access, health status, and socioeconomic position at the New York City Council District level—a unit of analysis both relevant to and actionable by local policymakers. The results showed significant associations between measures of primary care access and health status after adjustment for socioeconomic factors. We found that an increase of 1 provider per 10 000 people was associated with a 1% decrease in diabetes rates and a 5% decrease in rates of adults without an influenza immunization. Furthermore, higher rates of primary care providers in high-poverty districts accepted Medicaid and had Patient-Centered Medical Home recognition, increasing constituent accessibility. Our findings highlight the significant contribution of primary care access to community health; policies and resource allocation must prioritize primary care facility siting and provider recruitment in low-access areas.

Implementation Research to Address the United States Health Disadvantage: Report of a National Heart, Lung, and Blood Institute Workshop

Four decades ago, U.S. life expectancy was within the same range as other high-income peer countries. However, during the past decades, the United States has fared worse in many key health domains resulting in shorter life expectancy and poorer health-a health disadvantage. The National Heart, Lung, and Blood Institute convened a panel of national and international health experts and stakeholders for a Think Tank meeting to explore the U.S. health disadvantage and to seek specific recommendations for implementation research opportunities for heart, lung, blood, and sleep disorders. Recommendations for National Heart, Lung, and Blood Institute consideration were made in several areas including understanding the drivers of the disadvantage, identifying potential solutions, creating strategic partnerships with common goals, and finally enhancing and fostering a research workforce for implementation research. Key recommendations included exploring why the United States is doing better for health indicators in a few areas compared with peer countries; targeting populations across the entire socioeconomic spectrum with interventions at all levels in order to prevent missing a substantial proportion of the disadvantage; assuring partnership have high-level goals that can create systemic change through collective impact; and finally, increasing opportunities for implementation research training to meet the current needs. Connecting with the research community at large and building on ongoing research efforts will be an important strategy. Broad partnerships and collaboration across the social, political, economic, and private sectors and all civil society will be critical-not only for implementation research but also for implementing the findings to have the desired population impact. Developing the relevant knowledge to tackle the U.S. health disadvantage is the necessary first step to improve U.S. health outcomes.

Assessing Years of Life Lost Versus Number of Deaths in the United States, 1995-2015

OBJECTIVES

To assess years of life lost to each cause of death in the United States between 1995 and 2015, and compare it with the number of deaths.

METHODS

We used Vital Statistics mortality data and defined "life-years lost" as remaining life expectancy for each decedent's age, sex, and race. We calculated the share of life-years lost to each cause of death in each year, and examined reasons for changes.

RESULTS

In 2015, heart disease caused the most deaths, but cancer caused 23% more life-years lost. Life-years lost to heart disease declined 6% since 1995, whereas life-years lost to cancer increased 16%. The increase for cancer was entirely attributable to population growth and longer life expectancy; had these factors remained constant, life-years lost to heart disease and cancer would have fallen 56% and 38%, respectively. Accidents (including overdoses), suicides, and homicides each caused twice the share of life-years lost as deaths. Measuring life-years lost highlighted racial disparities in heart disease, homicides, and perinatal conditions.

CONCLUSIONS

Life-years lost may provide additional context for understanding long-term mortality trends.

Using Structural Equation Modeling to Assess the Links between Tobacco Smoke Exposure, Volatile Organic Compounds, and Respiratory Function for Adolescents Aged 6 to 18 in the United States

Asthma is an inflammatory airway disease that affects 22 million Americans in the United States. Research has found associations between impaired respiratory function, including asthma and increased symptoms among asthmatics, and common indoor air pollutants, including tobacco smoke exposure and volatile organic compounds (VOCs). However, findings linking VOC exposure and asthma are inconsistent and studies are of mixed quality due to design limitations, challenges measuring VOC exposure, small sample sizes, and suboptimal statistical methodologies. Because of the correlation between tobacco smoke exposure and VOCs, and associations between both tobacco smoke and VOCs with respiratory function, it is crucial that statistical methodology employed to assess links between respiratory function and individual air pollutants control for these complex relationships. This research uses Structural Equation Modeling (SEM) to assess the relationships between respiratory function, tobacco smoke exposure, and VOC exposure among a nationally-representative sample of adolescents. SEM allows for multiple outcome variables, the inclusion of both observed and latent variables, and controls the effects of confounding and correlated variables, which is critically important and is lacking in earlier studies when estimating the effects of correlated air pollutants on respiratory function. We find evidence of associations between respiratory function and some types of VOCs, even when controlling for the effects of tobacco smoke exposure and additional covariates. Furthermore, we find that poverty has an indirect effect on respiratory function through its relationships with tobacco smoke exposure and some types of VOCs. This analysis demonstrates how SEM is a robust analytic tool for assessing associations between respiratory function and multiple exposures to pollutants.