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Zhu Y, Williams J, Beyene K, Trani JF, Babulal GM. Traumatic Brain Injury, Seizures, and Cognitive Impairment Among Older Adults. JAMA Netw Open 2024; 7:e2426590. [PMID: 39115844 PMCID: PMC11310819 DOI: 10.1001/jamanetworkopen.2024.26590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 06/11/2024] [Indexed: 08/11/2024] Open
Abstract
Importance Traumatic brain injury (TBI), seizures, and dementia increase with age. There is a gap in understanding the associations of TBI, seizures, and medications such as antiseizure and antipsychotics with the progression of cognitive impairment across racial and ethnic groups. Objective To investigate the association of TBI and seizures with the risk of cognitive impairment among cognitively normal older adults and the role of medications in moderating the association. Design, Setting, and Participants This multicenter cohort study was a secondary analysis of the Uniform Data Set collected between June 1, 2005, and June 30, 2020, from the National Alzheimer's Coordination Center. Statistical analysis was performed from February 1 to April 3, 2024. Data were collected from participants from 36 Alzheimer's Disease Research Centers in the US who were 65 years or older at baseline, cognitively normal at baseline (Clinical Dementia Rating of 0 and no impairment based on a presumptive etiologic diagnosis of AD), and had complete information on race and ethnicity, age, sex, educational level, and apolipoprotein E genotype. Exposure Health history of TBI, seizures, or both conditions. Main Outcomes and Measures Progression to cognitive impairment measured by a Clinical Dementia Rating greater than 0. Results Among the cohort of 7180 older adults (median age, 74 years [range, 65-102 years]; 4729 women [65.9%]), 1036 were African American or Black (14.4%), 21 were American Indian or Alaska Native (0.3%), 143 were Asian (2.0%), 332 were Hispanic (4.6%), and 5648 were non-Hispanic White (78.7%); the median educational level was 16.0 years (range, 1.0-29.0 years). After adjustment for selection basis using propensity score weighting, seizure was associated with a 40% higher risk of cognitive impairment (hazard ratio [HR], 1.40; 95% CI, 1.19-1.65), TBI with a 25% higher risk of cognitive impairment (HR, 1.25; 95% CI, 1.17-1.34), and both seizure and TBI were associated with a 57% higher risk (HR, 1.57; 95% CI, 1.23-2.01). The interaction models indicated that Hispanic participants with TBI and seizures had a higher risk of cognitive impairment compared with other racial and ethnic groups. The use of antiseizure medications (HR, 1.23; 95% CI, 0.99-1.53), antidepressants (HR, 1.32; 95% CI, 1.17-1.50), and antipsychotics (HR, 2.15; 95% CI, 1.18-3.89) was associated with a higher risk of cognitive impairment, while anxiolytic, sedative, or hypnotic use (HR, 0.88; 95% CI, 0.83-0.94) was associated with a lower risk. Conclusions and Relevance This study highlights the importance of addressing TBI and seizures as risk factors for cognitive impairment among older adults. Addressing the broader social determinants of health and bridging the health divide across various racial and ethnic groups are essential for the comprehensive management and prevention of dementia.
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Affiliation(s)
- Yiqi Zhu
- School of Social Work, Adelphi University, Garden City, New York
| | - Jonathan Williams
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri
| | - Kebede Beyene
- Department of Pharmaceutical and Administrative Sciences, University of Health Sciences and Pharmacy in St Louis, St Louis, Missouri
| | - Jean-Francois Trani
- National Conservatory of Arts and Crafts, Paris, France
- Institute of Public Health, Washington University School of Medicine, St Louis, Missouri
- Department of Psychology, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
- Brown School of Social Work, Washington University in St Louis, St Louis, Missouri
| | - Ganesh M. Babulal
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri
- Institute of Public Health, Washington University School of Medicine, St Louis, Missouri
- Department of Psychology, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Howard JT, Stewart IJ, Walker LE, Amuan M, Rayha K, Janak JC, Pugh MJ. Comparison of Racial and Ethnic Mortality Disparities among Post-9/11 Veterans with and without Traumatic Brain Injury to the Total U.S. Adult Population. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02004-1. [PMID: 38622427 DOI: 10.1007/s40615-024-02004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/27/2024] [Accepted: 04/07/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION The extent of racial/ethnic disparities and whether they are attenuated in the Veteran population compared to the total US population is not well understood. We aimed to assess racial/ethnic mortality disparities from all-cause, cardiovascular (CVD) and cancer among post-9/11 military Veterans with and without exposure to TBI, compared to the total US population. METHODS This cohort study included 2,502,101 US military Veterans (18,932,083 person-years) who served after 09/11/2001 with 3 or more years of care in the Military Health System (MHS); or had 3 or more years of care in the MHS and 2 or more years of care in the Veterans Health Administration. Mortality follow-up occurred from 01/01/2002 to 12/31/2020. Mortality rate ratios (MRR) from negative binomial regression models were reported for racial/ethnic groups compared to White non-Hispanic Veterans for all-cause, CVD and cancer mortality. Veteran MRR were compared to the total US population. RESULTS Mortality rates for Black Non-Hispanic Veterans were higher for all-cause (MRR = 1.21;95%CI: 1.13-1.29; p < 0.001), CVD (MRR = 1.78;95%CI: 1.62-1.96; p < 0.001) and cancer (MRR = 1.17;95%CI: 1.10-1.25; p < 0.001) than in White Non-Hispanic Veterans. Among Veterans with TBI, only Black Non-Hispanics had higher mortality than White Non-Hispanics and only for CVD (MRR = 1.32;95%CI: 1.12-1.54; p < 0.001), while CVD mortality was higher among Veterans without TBI (MRR = 1.77;95%CI: 1.63-1.93;p < 0.001). MRR for Black Non-Hispanics in the total US population, were consistently higher than those in the Veteran population for all-cause (MRR = 1.52;95%CI: 1.46-1.58; p < 0.001), CVD (MRR = 2.03;95%CI: 1.95-2.13; p < 0.001) and cancer (MRR = 1.26;95%CI: 1.22-1.30; p < 0.001). CONCLUSION This Veteran cohort experienced less racial/ethnic disparity in mortality than the total US population, especially among Veterans with TBI.
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Affiliation(s)
- Jeffrey T Howard
- Department of Public Health, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249, USA.
| | - Ian J Stewart
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
- Military Cardiovascular Outcomes Research Program, Bethesda, MD, USA
| | - Lauren E Walker
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Megan Amuan
- University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, Utah, USA
- United States Department of Veterans Affairs, 550 Foothill Dr, Salt Lake City, Utah, USA
| | - Kara Rayha
- Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, USA
| | | | - Mary Jo Pugh
- University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, Utah, USA
- United States Department of Veterans Affairs, 550 Foothill Dr, Salt Lake City, Utah, USA
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Dismuke-Greer C, Esmaeili A, Ozieh MN, Gujral K, Garcia C, Del Negro A, Davis B, Egede L. Racial/Ethnic and Geographic Disparities in Comorbid Traumatic Brain Injury-Renal Failure in US Veterans and Associated Veterans Affairs Resource Costs, 2000-2020. J Racial Ethn Health Disparities 2024; 11:652-668. [PMID: 36864369 PMCID: PMC10474245 DOI: 10.1007/s40615-023-01550-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 03/04/2023]
Abstract
Studies have identified disparities by race/ethnicity and geographic status among veterans with traumatic brain injury (TBI) and renal failure (RF). We examined the association of race/ethnicity and geographic status with RF onset in veterans with and without TBI, and the impact of disparities on Veterans Health Administration resource costs. METHODS Demographics by TBI and RF status were assessed. We estimated Cox proportional hazards models for progression to RF and generalized estimating equations for inpatient, outpatient, and pharmacy cost annually and time since TBI + RF diagnosis, stratified by age. RESULTS Among 596,189 veterans, veterans with TBI progressed faster to RF than those without TBI (HR 1.96). Non-Hispanic Black veterans (HR 1.41) and those in US territories (HR 1.71) progressed faster to RF relative to non-Hispanic Whites and those in urban mainland areas. Non-Hispanic Blacks (-$5,180), Hispanic/Latinos ($-4,984), and veterans in US territories (-$3,740) received fewer annual total VA resources. This was true for all Hispanic/Latinos, while only significant for non-Hispanic Black and US territory veterans < 65 years. For veterans with TBI + RF, higher total resource costs only occurred ≥ 10 years after TBI + RF diagnosis ($32,361), independent of age. Hispanic/Latino veterans ≥ 65 years received $8,248 less than non-Hispanic Whites and veterans living in US territories < 65 years received $37,514 less relative to urban veterans. CONCLUSION Concerted efforts to address RF progression in veterans with TBI, especially in non-Hispanic Blacks and those in US territories, are needed. Importantly, culturally appropriate interventions to improve access to care for these groups should be a priority of the Department of Veterans Affairs priority for these groups.
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Affiliation(s)
- Clara Dismuke-Greer
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Healthcare System, 795 Willow Road, 152 MPD, Menlo Park, CA, 94025, USA.
| | - Aryan Esmaeili
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Healthcare System, 795 Willow Road, 152 MPD, Menlo Park, CA, 94025, USA
| | - Mukoso N Ozieh
- Center for Advancing Population Science (CAPS), Division of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine, Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Nephrology, Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA
| | - Kritee Gujral
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Healthcare System, 795 Willow Road, 152 MPD, Menlo Park, CA, 94025, USA
| | - Carla Garcia
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Healthcare System, 795 Willow Road, 152 MPD, Menlo Park, CA, 94025, USA
| | | | - Boyd Davis
- Department of English Emerita, College of Liberal Arts & Sciences, The University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Leonard Egede
- Center for Advancing Population Science (CAPS), Division of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Maldonado J, Huang JH, Childs EW, Tharakan B. Racial/Ethnic Differences in Traumatic Brain Injury: Pathophysiology, Outcomes, and Future Directions. J Neurotrauma 2023; 40:502-513. [PMID: 36029219 DOI: 10.1089/neu.2021.0455] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability in the United States, exacting a debilitating physical, social, and financial strain. Therefore, it is crucial to examine the impact of TBI on medically underserved communities in the U.S. The purpose of the current study was to review the literature on TBI for evidence of racial/ethnic differences in the U.S. Results of the review showed significant racial/ethnic disparities in TBI outcome and several notable differences in other TBI variables. American Indian/Alaska Natives have the highest rate and number of TBI-related deaths compared with all other racial/ethnic groups; Blacks/African Americans are significantly more likely to incur a TBI from violence when compared with Non-Hispanic Whites; and minorities are significantly more likely to have worse functional outcome compared with Non-Hispanic Whites, particularly among measures of community integration. We were unable to identify any studies that looked directly at underlying racial/ethnic biological variations associated with different TBI outcomes. In the absence of studies on racial/ethnic differences in TBI pathobiology, taking an indirect approach, we looked for studies examining racial/ethnic differences in oxidative stress and inflammation outside the scope of TBI as they are known to heavily influence TBI pathobiology. The literature indicates that Blacks/African Americans have greater inflammation and oxidative stress compared with Non-Hispanic Whites. We propose that future studies investigate the possibility of racial/ethnic differences in inflammation and oxidative stress within the context of TBI to determine whether there is any relationship or impact on TBI outcome.
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Affiliation(s)
- Justin Maldonado
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott and White Health and Texas A&M University College of Medicine, Temple, Texas, USA
| | - Ed W Childs
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Binu Tharakan
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
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Arango-Lasprilla JC, Watson JD, Rodriguez M, Ramos-Usuga D, Mascialino G, Perrin PB. Employment probability trajectories in hispanics over the 10 years after traumatic brain injury: A model systems study. NeuroRehabilitation 2022; 51:397-405. [DOI: 10.3233/nre-220066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Research has found that Hispanics with traumatic brain injury (TBI) have reduced functional outcomes compared to non-Hispanic Whites, including lower probabilities of post-injury employment. However, previous studies were cross-sectional, combined racial/ethnic minority groups, and did not examine the factors that predict return to work of Hispanics longitudinally. OBJECTIVE: To determine the demographic and injury-related predictors of employment probability trajectories during the first 10 years after TBI. METHODS: 1,346 Hispanics in the TBI Model Systems Database was included. Hierarchical linear modeling was used to examine baseline predictors of employment probability trajectories across this time period. RESULTS: Employment probability demonstrated a quadratic movement over time, with an initial increase followed by a plateau or slight decrease. Hispanics with TBI had higher employment probability trajectories if they had been younger at the time of injury, spent less time in posttraumatic amnesia, had greater years of education, had been employed at the time of injury, had higher annual earnings at the time of injury, and had experienced a non-violent mechanism of injury. CONCLUSION: Culturally adapted treatment programs with a focus on early intervention incorporating vocational rehabilitation and employment programs for Hispanics with TBI who present with these risk factors are needed.
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Affiliation(s)
| | - Jack D. Watson
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Miriam Rodriguez
- Department of Health and Wellness Design, School of Public Health, Indiana University - Bloomington, Bloomington, IN, USA
| | - Daniela Ramos-Usuga
- Biomedical Research Doctorate Program, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Guido Mascialino
- Escuela de Psicología, Universidad de Las Américas, Quito, Ecuador
| | - Paul B. Perrin
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, USA
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Emotional Disturbances After Traumatic Brain Injury: Prevalence, Assessment, and Treatment. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2021. [DOI: 10.1007/s40141-021-00311-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Race/Ethnicity and Retention in Traumatic Brain Injury Outcomes Research: A Traumatic Brain Injury Model Systems National Database Study. J Head Trauma Rehabil 2019; 33:219-227. [PMID: 29863614 DOI: 10.1097/htr.0000000000000395] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To investigate the contribution of race/ethnicity to retention in traumatic brain injury (TBI) research at 1 to 2 years postinjury. SETTING Community. PARTICIPANTS With dates of injury between October 1, 2002, and March 31, 2013, 5548 whites, 1347 blacks, and 790 Hispanics enrolled in the Traumatic Brain Injury Model Systems National Database. DESIGN Retrospective database analysis. MAIN MEASURE Retention, defined as completion of at least 1 question on the follow-up interview by the person with TBI or a proxy. RESULTS Retention rates 1 to 2 years post-TBI were significantly lower for Hispanic (85.2%) than for white (91.8%) or black participants (90.5%) and depended significantly on history of problem drug or alcohol use. Other variables associated with low retention included older age, lower education, violent cause of injury, and discharge to an institution versus private residence. CONCLUSIONS The findings emphasize the importance of investigating retention rates separately for blacks and Hispanics rather than combining them or grouping either with other races or ethnicities. The results also suggest the need for implementing procedures to increase retention of Hispanics in longitudinal TBI research.
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Disparities in Health Care Utilization of Adults With Traumatic Brain Injuries Are Related to Insurance, Race, and Ethnicity: A Systematic Review. J Head Trauma Rehabil 2019; 33:E40-E50. [PMID: 28926481 DOI: 10.1097/htr.0000000000000338] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To characterize racial/ethnic and insurance disparities in the utilization of healthcare services among US adults with traumatic brain injury (TBI). METHODS The PubMed database was used to search for articles that directly examined the association between race/ethnicity and insurance disparities and healthcare utilization among patients with TBI. Eleven articles that met the criteria and were published between June 2011 and June 2016 were finally included in the review. RESULTS Lack of insurance was significantly associated with decreased use of inhospital and posthospital healthcare services among patients with TBI. However, mixed results were reported for the associations between insurance types and healthcare utilization. The majority of studies reported that racial/ethnic minorities were less likely to use inhospital and posthospital healthcare services, while some studies did not indicate any significant relation between race/ethnicity and healthcare utilization among patients with TBI. CONCLUSIONS This review provides evidence of a relation between insurance status and healthcare utilization among US adults with TBI. Insurance status may also account for some portion of the relation between race/ethnicity and healthcare utilization.
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Dismuke-Greer CE, Gebregziabher M, Ritchwood T, Pugh MJ, Walker RJ, Uchendu US, Egede LE. Geographic Disparities in Mortality Risk Within a Racially Diverse Sample of U.S. Veterans with Traumatic Brain Injury. Health Equity 2018; 2:304-312. [PMID: 30374469 PMCID: PMC6203888 DOI: 10.1089/heq.2018.0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Traumatic brain injury (TBI) is a signature injury among the U.S. veterans. Hispanic U.S. veterans diagnosed with TBI have been found to have higher risk-adjusted mortality. This study examined the adjusted association of geographic location with all-cause mortality in 114,593 veterans diagnosed with TBI between January 1, 2000 and December 31, 2010, and followed through December 31, 2014. Methods: National Veterans Health Administration (VHA) databases containing administrative data including International Classification of Diseases, 9th Revision (ICD-9) codes, sociodemographic characteristics, and survival were linked. TBI was identified based on ICD-9 codes. Cox proportional hazards regression methods were used to examine the association of time from first TBI ICD-9 code to death with geographic location, after adjustment for TBI severity, race/ethnicity, other sociodemographic characteristics, military factors, and Elixhauser comorbidities. Results: Relative to urban mainland veterans with a median survival of 76.4 months, veterans living in the U.S. territories had a median survival of 69.1 months, whereas rural mainland veterans had a median survival of 77.1 months, and highly rural mainland veterans had a mean survival of 77.6 months. The final model adjusted for race/ethnicity, TBI severity, sociodemographic, military, and comorbidity covariates showed that residing in the U.S. territories was associated with a higher risk of death (hazard ratios=1.24; 95% confidence interval 1.15-1.34) relative to residing on the U.S. mainland. The race/ethnicity disparity previously found for the U.S. veterans diagnosed with TBI seems to be accounted for by living in the U.S. territories. Conclusion: The study shows that among veterans with TBI, mortality rates were higher in those who reside in the U.S. territories, even after adjustment. Previous documented higher mortality among Hispanic veterans seems to be explained by residing in the U.S. territories. The VA has a mission of ensuring equitable treatment of all veterans, and should investigate targeted policies and interventions to improve the survival of the U.S. territory veterans diagnosed with TBI.
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Affiliation(s)
- Clara E Dismuke-Greer
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,Division of Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Mulugeta Gebregziabher
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Tiarney Ritchwood
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Mary Jo Pugh
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.,IDEAS Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Uche S Uchendu
- Chief Officer for Health Equity, US Department of Veterans Affairs, Washington, DC.,Principal, Health Management Associates, Washington, DC
| | - Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, Wisconsin
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Peterson K, Anderson J, Boundy E, Ferguson L, McCleery E, Waldrip K. Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map. Am J Public Health 2018; 108:e1-e11. [PMID: 29412713 PMCID: PMC5803811 DOI: 10.2105/ajph.2017.304246] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Continued racial/ethnic health disparities were recently described as "the most serious and shameful health care issue of our time." Although the 2014 US Affordable Care Act-mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types. OBJECTIVES To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA. SEARCH METHODS Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities. SELECTION CRITERIA We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review). DATA COLLECTION AND ANALYSIS Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by clinical area. For areas with multiple studies in the same population and outcome, we pooled their reported hazard ratios (HRs) using random effects models (StatsDirect version 2.8.0; StatsDirect Ltd., Altrincham, England). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: odds ratio or HR of mortality for racial/ethnic minority group versus Whites, clinical area, strength of evidence, statistical significance, and racial group. MAIN RESULTS From 2840 citations, we included 25 studies. Studies were large (n ≥ 10 000) and involved nationally representative cohorts, and the majority were of fair quality. Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans. However, we found modest mortality disparities (HR or OR = 1.07, 1.52) for Black veterans with stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, or stroke; for American Indian and Alaska Native veterans undergoing noncardiac major surgery; and for Hispanic veterans with HIV or traumatic brain injury (most low strength). AUTHOR'S CONCLUSIONS Although the VHA's equal access health care system has reduced many racial/ethnic mortality disparities present in the private sector, our review identified mortality disparities that have persisted mainly for Black veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, we could not draw strong conclusions about this evidence. More disparities research is needed for American Indian and Alaska Native, Asian, and Hispanic veterans overall and for more of the largest life expectancy gaps. Public Health Implications. Because of the relatively high prevalence of diabetes in Black veterans, further research to better understand and reduce this mortality disparity may be prioritized as having the greatest potential impact. However, other mortality disparities affect thousands of veterans and cannot be ignored.
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Affiliation(s)
- Kim Peterson
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Johanna Anderson
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Erin Boundy
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Lauren Ferguson
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Ellen McCleery
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Kallie Waldrip
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
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