Covid-19 patterns among adults with intellectual and developmental disability and the general population in New York state during the first year of the pandemic

BACKGROUND

People with intellectual and developmental disabilities (IDD) in the US, especially those living in group homes, experienced comparatively higher Covid-19 case/case fatality rates than the general population during the first year of the pandemic. There is no information about the patterns of case/case fatality rates during this time.

OBJECTIVE

This study compared Covid-19 case/case fatality rates among people with IDD living in residential group homes to the general population across the first year of the pandemic in New York State (NYS).

METHODS

Covid-19 positive cases and deaths collected from New York Disability Advocates (NYDA), a coalition of organizations serving individuals with IDD, was compared to data for the NYS general population from the first pandemic year. Case rates/100,000 and case fatality rates were calculated for the study period. Joinpoint Trend Analysis Software was used to analyze patterns in weekly case/case fatality rates.

RESULTS

Case fatality rates for people with IDD were higher than for the overall state population throughout the pandemic's first year. Case rates were higher among people with IDD across most of this year. Although the patterns in rates were similar, there was a sharp increase in cases for those with IDD during Fall 2020 beginning eight weeks before the general NYS population and a significant decrease in fatalities in late December 2020 into January 2021.

CONCLUSIONS

Consistently higher case fatality rates and significant differences in case/case fatality rates for people with IDD living in group homes require further consideration. Planning for future emergencies will require an enhanced federal/state understanding of the needs of people with IDD and a responsive surveillance system.

Counting disability in the National Health Interview Survey and its consequence: Comparing the American Community Survey to the Washington Group disability measures

BACKGROUND

The objective of the National Health Interview Survey (NHIS) is to provide data that can be used to monitor the health of the US population.

OBJECTIVE

In this study, we evaluate whether the disability questions currently used in the NHIS - the Washington Group questions - threaten the ability of this survey to fulfil its stated objective for disabled people.

METHODS

Data were from the 2011-2012 NHIS with linkage to mortality status through 2019. We examined whether people who reported a disability in the American Community Survey disability questions had their disability counted in the Washington Group questions. We then examined the consequence of use of the Washington Group as opposed to the American Community Survey questions, on estimates of disability prevalence and comparative mortality risk.

RESULTS

We find that when compared to their predecessor, the American Community Survey disability questions, the Washington Group questions accounted for less than half of disabled people, primarily counting disabled people with more than one disability status, but not counting many disabled people with only one disability status. As a result of this undercount, disability prevalence rates based on the Washington Group questions underestimate the size of the disabled population in the US, and overestimate the comparatively higher mortality risk associated with disability status.

CONCLUSIONS

These results underscore the need to re-evaluate the disability questions used in the NHIS, and invest in the development of improved and expanded disability questionnaires for use in national surveys.

Educational Attainment and Perceived Need for Future ADL Assistance

The current study examined whether educational attainment was associated with perceived need of assistance with future activities of daily living (ADL) among middle-aged and early older-aged adults in the United States. Data for 54,946 adults aged 40-65 years from the 2011-2014 National Health Interview Survey (NHIS) were analyzed using ordered logistic regression. Adults with more education will on average need less ADL assistance than adults with less education. Paradoxically, this study found that higher levels of formal education were associated with perceiving more need for future ADL assistance. This association was also found to vary between males and females. Building knowledge of long-term care planning into existing public educational structures and providing this knowledge to adults no longer involved in the formal educational system through medical providers may lead to better anticipation of future care needs.

Health equity for people with intellectual and developmental disability requires vast improvements to data collection: Lessons from the COVID-19 pandemic

The COVID-19 pandemic drastically underscored the lack of proper health surveillance for people with intellectual and developmental disability (IDD) in the USA. This data equity failure resulted in researchers having to rely on nontraditional data sources to develop an understanding of how this population was faring during the pandemic. To begin addressing this data equity concern, in this commentary, we (1) discuss the difficulties in accessing data during the pandemic specifically related to people with IDD; (2) provide guidance regarding how existing data can be used to examine COVID-19 outcomes for people with IDD; and (3) provide recommendations for improving data collection for people with IDD in light of lessons learned during the pandemic. In sum, the data currently available to examine COVID-19 as well as other health outcomes among people with IDD are severely limited, compromising the ability to both understand and address health disparities among this population.

The association between the Patient Protection and Affordable Care Act and healthcare affordability among US adults with intellectual disability

BACKGROUND

Historically, US adults with intellectual disability (ID) experience worse healthcare access than the general population. However, the implementation of the Patient Protection and Affordable Care Act (ACA) may have reduced disparities in healthcare access.

METHODS

Using a pre-ACA 2011-2013 sample and a post-ACA implementation 2014-2016 sample from the National Health Interview Survey data, we examined the association between the ACA's introduction and healthcare access among adults with ID (N = 623). Negative binomial regression models were used to test the association between the ACA and the total number of foregone healthcare services. Binary logistic regression was used to explore whether the ACA's implementation was associated with the increased likelihood of possessing health insurance as well as the decreased likelihood of any and particular measures of foregone healthcare services due to cost.

RESULTS

The study provides evidence that the ACA's implementation was associated with the decreased likelihood of the total number and any foregone care services owing to cost. Findings also revealed that the ACA's implementation was associated with expansion of health insurance coverage and decreasing instances of foregone care services for medical care, dental care, specialist visit and mental care among adults with ID. However, persons with ID were still at a higher risk of foregone prescription medicines, follow-up medical care and eyeglasses due to cost in the post-ACA years.

CONCLUSIONS

The study provides evidence that healthcare access among Americans with ID improved after the ACA's implementation. However, challenges in access to follow-up care, eyeglasses and prescription medicines persist and require policy solutions, which extend beyond the ACA's provisions.

Age differences in long-term mortality among male nonveterans, noncombat veterans, and combat veterans

Research documenting differences in mortality risk across the life course between veterans and nonveterans has not accounted for combat status. To address this gap in the literature, the current study examined differences in long-term mortality among midlife and older-adult male nonveterans, noncombat veterans, and combat veterans. Data were drawn from Wave 2 (2004/2005) of the Midlife Development in the United States survey and linked to 2020 mortality data (N = 2,024). Based on interpretation of a veteran-combat status by age interaction term, compared to nonveterans, noncombat veterans experienced a mortality advantage at younger ages, ORmain effect = 0.12, 95% CI [0.03, 0.54], p = .006, and a mortality disadvantage at older ages, ORinteraction term = 1.06, 95% CI [1.01, 1.05], p = .004, with the crossover occurring at 73.4 years. A similar pattern was present among combat veterans, with the mortality advantage at younger ages not reaching significance, ORmain effect = 0.16; 95% CI [0.02, 1.18], p = .072; a mortality advantage at older ages, ORinteraction term = 1.03, 95% CI [1.00, 1.05], p = .040; and the crossover occurring 4.2 years earlier at 69.2 years. The findings suggest that combat status may accelerate the age-related mortality disadvantage among veterans. Studies of health and mortality outcomes among veterans should, therefore, account for combat status. When data allow, future studies should confirm whether this pattern is present in nationally representative samples.

Risk Factors Explaining Military Deaths From Suicide, 2008-2017:A Latent Class Analysis

Military suicide prevention efforts would benefit from population-based research documenting patterns in risk factors among service members who die from suicide. We use latent class analysis to analyze patterns in identified risk factors among the population of 2660 active-duty military service members that the Department of Defense Suicide Event Report (DoDSER) system indicates died by suicide between 2008 and 2017. The largest of five empirically derived latent classes was primarily characterized by the dissolution of an intimate relationship in the past year. Relationship dissolution was common in the other four latent classes, but those classes were also characterized by job, administrative, or legal problems, or mental health factors. Distinct demographic and military-status differences were apparent across the latent classes. Results point to the need to increase awareness among mental health service providers and others that suicide among military service members often involves a constellation of potentially interrelated risk factors.

Postmortem Diagnostic Overshadowing: Reporting Cerebral Palsy on Death Certificates

Postmortem diagnostic overshadowing-defined as inaccurately reporting a disability as the underlying cause of death-occurs for over half of adults with cerebral palsy. This practice obscures cause of death trends, reducing the effectiveness of efforts to reduce premature mortality among this marginalized health population. Using data from the National Vital Statistics System 2005 to 2017 U.S. Multiple Cause of Death files (N = 29,996), we identify factors (sociodemographic characteristics, aspects of the context and processing of death, and comorbidities) associated with the inaccurate reporting of cerebral palsy as the underlying cause of death. Results suggest that inaccurate reporting is associated with heightened contexts of clinical uncertainty, the false equivalence of disability and health, and potential racial-ethnic bias. Ending postmortem diagnostic overshadowing will require training on disability and health for those certifying death certificates and efforts to redress ableist death certification policies.

COVID-19 mortality burden and comorbidity patterns among decedents with and without intellectual and developmental disability in the US

BACKGROUND

While there is ample evidence of increased COVID-19 mortality risk among people with intellectual and developmental disability (IDD), research has not documented whether this higher risk resulted in increased COVID-19 mortality burden in the US or whether comorbidity patterns among COVID-19 deaths are similar or distinct for people with IDD.

OBJECTIVE

To determine the differences in COVID-19 mortality burden between decedents with and without IDD during the first year of the pandemic.

METHODS

This study uses 2020 US death certificate data to compare COVID-19 mortality burden and comorbidity patterns among decedents with and without IDD.

RESULTS

COVID-19 was the leading cause of death among decedents with IDD in 2020, compared with the 3rd leading cause among decedents without IDD. The proportion of deaths from COVID-19 was also higher for decedents with compared to without IDD. Comorbidities resulting from COVID-19 were similar among decedents with and without IDD, but there were some differences among reported pre-existing conditions, notably higher rates of hypothyroidism and seizures among decedents with IDD.

CONCLUSION

The COVID-19 mortality burden was greater for people with than without IDD during the first year of the pandemic. The continued practice of postmortem diagnostic overshadowing prevents analyzing whether this difference continues through today. Action is needed by the Centers for Disease Control and Prevention to mitigate this data inequity. Out of an abundance of caution, medical providers should carefully monitor symptoms among COVID-19 patients with IDD diagnosed with hypothyroidism and/or seizures.

Factors associated with the reporting of Down syndrome as the underlying cause of death on US death certificates

BACKGROUND

Efforts aimed at preventing premature mortality for people with Down syndrome are hindered by the practice of reporting disability as the underlying cause of death. Prior research suggests this form of diagnostic overshadowing may be the result of increased uncertainty surrounding the death.

METHODS

This study uses bivariable analysis and multivariable logistic regression models to investigate associations between sociodemographic characteristics, comorbidities, and death context and processing characteristics with the reporting of Down syndrome as the underlying cause of death in 2005-2017 US Multiple Cause of Death data files.

RESULTS

The reporting of Down syndrome as the underlying cause of death was associated with characteristics indicative of an increased amount of uncertainty surrounding the death. Results also suggest other mechanisms may inform inaccurate reporting, such as racial bias, and the continued conflation of disability and health.

CONCLUSIONS

Medical personnel certifying death certificates should strive for accuracy when reporting the causes of death. To ensure this outcome, even in the midst of increased uncertainty, Down syndrome should not be reported as the underlying cause of death unless the decedent was diagnosed with Alzheimer's disease or unspecified dementia. Future research should further explore the possibility that increased death certification errors for adults with Down syndrome, or other developmental disabilities, are associated with racial bias.

Expanding Understanding of Racial-Ethnic Differences in ADHD Prevalence Rates among Children to Include Asians and Alaskan Natives/American Indians

BACKGROUND

Prior studies show that ADHD prevalence rates vary by race-ethnicity, but these studies do not include a full range of racial-ethnic minority groups.

OBJECTIVE

This study aimed to understand differences in ADHD prevalence among children across a wider range of racial-ethnic groups, overall and stratified by biological sex.

METHOD

Data on children aged 5 to 17 from the 2004 to 2018 National Health Interview Survey Sample Child Files were used in analyses (N = 120,129).

RESULTS

Compared to Non-Hispanic White children, ADHD prevalence was lower among Hispanic and Non-Hispanic Asian children. This difference was present for both males and females. Across all racial-ethnic groups, males had higher ADHD prevalence than females.

CONCLUSION

Results from this study provide further evidence that racial-ethnic disparities in ADHD prevalence rates persist across sex and provide initial evidence of substantially lower ADHD prevalence among Non-Hispanic Asians. Implications, limitations, and future research directions derived from the results are discussed.

Cause of death trends among adults with and without cerebral palsy in the United States, 2013-2017

BACKGROUND

Adults with cerebral palsy (CP) in the United States die much earlier than those without CP, a health inequality likely shaped by causes of death. Existing research has not considered demographic differences in mortality patterns.

OBJECTIVES

To analyze differences in cause of death for adults who did/did not have CP reported on their death certificates and to assess sex and racial-ethnic difference in causes of death among adult decedents with CP.

METHODS

Data are from the 2013-2017 US Multiple Cause of Death Mortality files (N = 13,332,871; n = 13,897 with CP). Multiple logistic regression models were used to compare differences in causes of death between adults with and without CP and to determine sex and racial-ethnic differences in causes of death among adults with CP. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated.

RESULTS

As compared with decedents without CP, those with CP were more likely to die from pneumonitis (aOR 31.14, 95% CI 29.42-32.96), influenza/pneumonia (8.78, 8.30-9.29), respiratory failure (17.24, 15.19-18.69), and choking (20.66, 18.86-22.62) and less likely to die from heart disease (0.61, 0.58-0.65), cancer (0.12, 0.11-0.13), chronic lower respiratory diseases (0.50, 0.44-0.56), and cerebrovascular diseases (0.66, 0.59-0.75). Among adults with CP, female decedents were more likely than males to die from respiratory failure (1.21, 1.03-1.42), and non-Hispanic Black decedents were more likely than non-Hispanic White decedents to die from heart disease (1.24, 1.07-1.45) and cerebrovascular disease (1.77, 1.29-2.49).

CONCLUSIONS

In 2013-2017, heart disease was the leading cause of death for adults with and without CP. However, for people with compared to those without CP, likelihood of death from likely preventable respiratory causes of death was higher. Non-Hispanic Black adults were more likely than non-Hispanic White adults to die from heart and cerebrovascular diseases. Public health, clinical, and rehabilitation efforts must use a multifaceted approach to address respiratory and circulatory health among people with CP.

DATABASE

United States National Vital Statistics System of the Centers for Disease Control and Prevention Multiple Cause of Death Mortality files (National Bureau of Economic Research: https://www.nber.org/research/data/vital-statistics-mortality-data-nber).

Racial-ethnic inequities in age at death among adults with/without intellectual and developmental disability in the United States

To identify potential differences in racial-ethnic inequities in mortality between adults with/without intellectual and developmental disability, we compared patterns in age at death by race-ethnic status among adults who did/did not have intellectual and developmental disability reported on their death certificate in the United States. Data were from the 2005-2017 U.S. Multiple Cause-of-Death Mortality files. Average age at death by racial-ethnic status was compared between adults, age 18 and older, with/without different types of intellectual and developmental disability reported on their death certificate (N = 32,760,741). A multiple descent pattern was observed among adults without intellectual or developmental disability, with age at death highest among Whites, followed by Asians, Hispanics and Blacks, then American Indians. In contrast, a bifurcated pattern was observed among adults with intellectual disability, with age at death highest among Whites, but lower and similar among all racial-ethnic minority groups. The severity of racial-ethnic inequities in age at death was most pronounced among adults with cerebral palsy. Policy makers and public health experts should be aware that racial-ethnic inequities are different for adults with intellectual and developmental disability - all minorities with intellectual and developmental disability are at greater risk of premature death than their White counterparts.

Age differences in allostatic load among veterans: The importance of combat exposure

The current study examinedage differences in allostatic load among nonveterans, noncombat veterans, and combat veterans. Participants included 280 individuals from the Midlife Development in the United States (MIDUS) survey, including 164 veterans (n = 48 combat veterans; n = 116 noncombat veterans) and 116 nonveterans. Age differences in allostatic load were similar among nonveterans and noncombat veterans, B = 0.002, SE = .011, p = .878, with older adults showing higher levels of allostatic load than their comparatively younger counterparts. Among combat veterans, however, a different pattern emerged. In this group, levels of allostatic load were similar across age, seemingly due to higher levels of allostatic load among younger combat veterans, B = -0.029, SE = .014, p = .031, ƞ_p ²  =  .022. Results reveal the importance of considering combat exposure when examining health outcomes of military veterans, particularly in the context of age.

Attention deficit hyperactivity disorder and the age pattern of adult mortality

We draw upon the life-course perspective and examine whether Attention Deficit Hyperactivity Disorder (ADHD) moderates the age pattern of adult mortality using data from the 2007 and 2012 National Health Interview Survey Sample Adult File linked to National Death Index data through 2015. Overall, 7.0% of respondents died by 2015. Discrete-time hazard analysis indicates that the log odds of mortality were significantly lower among 18 and 19 year old adults ever diagnosed with ADHD and significantly higher among 46 to 64 year old adults ever diagnosed with ADHD, with a crossover occurring at age 33. Results were similar among men and women. It is not known specifically which risks drive changes in the risk of mortality documented among persons with ADHD during the transition to adulthood, the increased risk of mortality in midlife, or whether some risks operate more or less at particular ages. Additional research can lead to targeted, age- and life-course stage-focused interventions for specific risks and contribute to the reduction of ADHD-related mortality.

Racial-ethnic differences in educational trajectories for individuals with intellectual disability

BACKGROUND

Racial-ethnic differences in educational attainment have not been explored among adults with intellectual disability (ID). Because adults with ID and racial-ethnic minority groups have been historically marginalised from educational pathways through life, they have likely experienced cumulative disadvantage. Therefore, investigating the intersection of ID and race-ethnicity is necessary to increase understanding of educational attainment among adults with ID.

METHODS

Using 1986-2017 National Health Interview Survey data, we examined the educational trajectories of adults with ID, stratified by race-ethnicity (N = 4610). Generalised ordered logistic regression models were utilised to estimate the effect of birth cohort on educational attainment by race-ethnicity among adults with ID.

RESULTS

Results support prior findings that educational attainment increased for adults with ID around the 1950-1959 birth cohort; however, this was only the case for non-Hispanic Whites. For racial-ethnic minority groups, the probability of attaining a high school degree did not increase until comparatively later birth cohorts: non-Hispanic Black adults did not have their largest gains in educational attainment until the 1960-1969 birth cohort; Hispanic adults did not have their largest gains in attainment until the 1980-1999 birth cohort.

CONCLUSION

This study provides evidence of improvements in educational attainment for all adults with ID across birth cohorts. However, racial-ethnic disparities were also present - educational attainment levels for non-Hispanic Blacks remained lower than for non-Hispanic Whites across all birth cohorts in the study. Hispanics were able to catch up to and surpass both non-Hispanic Whites and non-Hispanic Blacks by the end of the study period, despite lower levels of education in the early birth cohorts. Results from this study highlight the need to attend to race-ethnicity when examining educational outcomes among adults with ID.

Risk Factors Associated With COVID-19 Outcomes Among People With Intellectual and Developmental Disabilities Receiving Residential Services

IMPORTANCE

Although there is evidence of more severe COVID-19 outcomes, there is no information describing the risk factors for COVID-19 diagnosis and/or mortality among people with intellectual and developmental disabilities (IDD) receiving residential support services in the US.

OBJECTIVE

To identify associations between demographic characteristics, residential characteristics, and/or preexisting health conditions and COVID-19 diagnosis and mortality for people with IDD receiving residential support services.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study tracked COVID-19 outcomes for 543 individuals with IDD. Participants were receiving support services from a single organization providing residential services in the 5 boroughs of New York City from March 1 to October 1, 2020. Statistical analysis was performed from December 2020 to February 2021.

EXPOSURES

Resident-level characteristics, including age, sex, race/ethnicity, disability status, residential characteristics, and preexisting medical conditions.

MAIN OUTCOMES AND MEASURES

COVID-19 diagnosis was confirmed by laboratory test. COVID-19 mortality indicated that the individual died from COVID-19 during the course of the study. Logistic regression models were used to evaluate associations between demographic characteristics, residential characteristics, and preexisting health conditions and COVID-19 diagnosis and mortality.

RESULTS

Among the 543 individuals with IDD in the study, the median (interquartile range) age was 57.0 (45-65) years; 217 (40.0%) were female, and 274 (50.5%) were Black, Asian/Pacific Islander, American Indian or Alaskan Native, or Hispanic. The case rate was 16 759 (95% CI, 13 853-20 131) per 100 000; the mortality rate was 6446 (95% CI, 4671-8832) per 100 000; and the case-fatality rate was 38.5% (95% CI, 29.1%-48.7%). Increased age (odds ratio [OR], 1.04; 95% CI, 1.02-1.06), Down syndrome (OR, 2.91; 95% CI, 1.49-5.69), an increased number of residents (OR, 1.07; 95% CI, 1.00-1.14), and chronic kidney disease (OR, 4.17; 95% CI, 1.90-9.15) were associated with COVID-19 diagnosis. Heart disease (OR, 10.60; 95% CI, 2.68-41.90) was associated with COVID-19 mortality.

CONCLUSIONS AND RELEVANCE

This study found that, similar to the general population, increased age and preexisting health conditions were associated with COVID-19 outcomes for people with IDD receiving residential support services in New York City. As with older adults living in nursing homes, number of residents was also associated with more severe COVID-19 outcomes. Unique to people with IDD was an increased risk of COVID-19 diagnosis for people with Down syndrome.

COVID-19 case-fatality disparities among people with intellectual and developmental disabilities: Evidence from 12 US jurisdictions

Background

There is evidence from two US states that people with intellectual and developmental disabilities (IDD) are at more severe risk during the COVID-19 pandemic. Research has not explored whether this increased risk is consistent across the US.

Objective

This study compared COVID-19 case-fatality rates among people with IDD in 11 states and the District of Columbia that are publicly reporting data.

Methods

Cumulative data reported through March 31 – April 13, 2021 were analyzed. Case-fatality rates and risk ratio with 95% confidence intervals for IDD settings were compared the overall case-fatality rate for the jurisdictions from Johns Hopkins’ Center for Systems Science and Engineering COVID-19 data.

Results

Settings were reported as receiving any services, community or institutional residential services, or living in own/family home. Comparison of case-fatality rates between people with IDD and their respective jurisdiction populations demonstrates that case-fatality rates were consistently higher for people with IDD living in congregate residential settings (fifteen instances) and receiving 24/7 nursing services (two instances). Results were mixed for people with IDD living in their own or a family home (eight instances).

Conclusions

These findings highlight that people with IDD, especially those living in residential settings, are experiencing higher case-fatality rates from COVID-19 than the general population across multiple US jurisdictions. Short-term and long-term public health interventions addressing COVID-19 risks will not be able to properly address the needs of people with IDD until all states begin reporting COVID-19 outcomes for this population.

Cohort Change in the Prevalence of ADHD Among U.S. Adults: Evidence of a Gender-Specific Historical Period Effect

Objective: To document inter- and intra-cohort changes in adult ADHD and examine whether changes vary by gender. Method: We analyze data from the 2007 and 2012 U.S. National Health Interview Survey. Results: The prevalence of ADHD among adults aged 18 to 64 years increased from 3.41% in 2007 to 4.25% in 2012. As expected, patterns of inter- and intra-cohort change varied by gender. At younger ages, inter-cohort gender differences are more distinct due to a spike in prevalence among boys/men born in or after 1980. Consistent with a gender-specific historical period effect, recent intra-cohort increases among women have narrowed the gender gap. Conclusion: The gender gap in the prevalence of ADHD among adults decreased by 31.1% from 2007 to 2012 due to increased prevalence among adult women of all ages. We discuss these results in relation to diagnostic practice, adult health and well-being, data limitations and needs, and directions for future research.

Uncertainty and the reporting of intellectual disability on death certificates: a cross-sectional study of US mortality data from 2005 to 2017

OBJECTIVE

To investigate whether uncertainty surrounding the death is associated with the inaccurate reporting of intellectual disability as the underlying cause of death.

DESIGN

National Vital Statistics System 2005-2017 US Multiple Cause-of-Death Mortality files.

SETTING

USA.

PARTICIPANTS

Adults with an intellectual disability reported on their death certificate, aged 18 and over at the time of death. The study population included 26 555 adults who died in their state of residence between 1 January 2005 and 31 December 2017.

PRIMARY OUTCOME AND MEASURES

Decedents with intellectual disability reported on their death certificate were identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code for intellectual disability (F70-79). Bivariate analysis and multilevel logistic regression models were used to investigate whether individual-level and state-level characteristics indicative of increased uncertainty at the time of death were associated with the inaccurate reporting of intellectual disability as the underlying cause of death.

RESULTS

Inaccurate reporting of intellectual disability as the underlying cause of death was associated with sociodemographic characteristics, death context characteristics and comorbidities indicative of an increased amount of uncertainty surrounding the death. Most striking were increased odds of having intellectual disability reported as the underlying cause of death for decedents who had a choking event (OR=14.7; 95% CI 12.9 to 16.6, p<0.001), an external cause of death associated with a high degree of uncertainty, reported on their death certificate.

CONCLUSION

It is imperative that medical personnel not let increased uncertainty lead to the inaccurate reporting of intellectual disability as the underlying cause of death as this practice obscures cause of death trends for this population. Instead, even in instances when increased uncertainty surrounds the death, certifiers should strive to accurately identify the disease or injury causing death, and report the disability in Part II of the death certificate.

Assessing state level variation in signature authority and cause of death accuracy, 2005-2017

•

In 2005–2017, US states liberalized statutes on cause of death signature authority.

•

State variation in signature authority contributes to cause of death inaccuracies.

•

Logistic regressions suggest certifier type influences death certificate accuracy.

•

Death certificate training is needed across the array of professional certifiers.

•

Cause of Death Signature Authority database allows for more robust analysis of certification errors.

This study utilized a convergent mixed-methods design to examine whether variation in death certificate certifier type predicts the accuracy of cause of death reporting in the US. We analyzed the content of state statutes, amendments, and policies concerning cause of death signature authority in 2005–2017 to create the Cause of Death Signature Authority (CoDSA) database. After merging the CoDSA data with 2005–2017 National Vital Statistics System Multiple Cause of Death Mortality files for adults with cerebral palsy (CP) (N = 29,996), we employed logistic regression models to determine the likelihood that different certifier groups made one particular type of death certification error – inaccurately reporting CP as the underlying cause of death (UCOD). The content analysis provided evidence of significant liberalization of cause of death signature authority, with 23 states expanding signature authority to include physician extenders. Logistic regression analysis revealed differences in UCOD accuracy based on certifier type. Compared to medical examiners, the likelihood of CP being reported as the UCOD, was: 41% higher (CI 1.12, 1.78) for coroners; 25% higher (1.05, 1.49) for mixed-system death investigators; 24% higher (1.08, 1.42) for physicians; and 16% higher (1.00, 1.34) for physician extenders. Inaccuracies limit public health efforts aimed at improving the health and longevity for disadvantaged populations, such as people with CP. Poor performance among cause of death certifiers may indicate systemic problems with death certification that should be addressed with more robust training for all professional groups with signature authority.

Self-Reported ADHD and Adult Health in the United States

Objective: Informed by a social determinants of health framework, we investigate the relationship between self-reported ADHD diagnosis status and adult health, and whether observed associations are attenuated by biomedical and socioeconomic factors. Method: Using 2007 National Health Interview Survey data (N = 19,104), we present multivariate logistic regression analyses of associations between self-reported ADHD diagnosis status and five adult health outcomes. Results: ADHD diagnosis was significantly associated with higher odds of injury, physical health conditions, functional limitations, fair/poor health, and psychological distress in fully specified models (adjusted odds ratios [AORs] = 1.62-2.36). Inclusion of controls for exogenous demographic characteristics, psychiatric comorbidities and health behaviors, and adult social and economic statuses attenuated but did not eliminate observed associations between ADHD and poorer adult health. Conclusion: Research on adult health outcomes for those with ADHD should include consideration of the mechanisms by which a diagnosis of ADHD leads to cumulative social disadvantages that independently contribute to poorer health outcomes.

Cause of death in adults with intellectual disability in the United States

BACKGROUND

Prior studies report that adults with intellectual disability (ID) have cause of death patterns distinct from adults in the general population but do not provide comparative analysis by specific causes of death.

METHODS

Data are from the National Vital Statistics System 2005-2017 US Multiple Cause-of-Death Mortality files. We utilised adjusted odds ratios to identify causes of death that were more common for adults whose death certificate indicated ID (N = 22 512) than for adults whose death certificate did not indicate ID (N = 32 738 229), controlling for severity level of ID. We then examine the associations between biological sex and race-ethnicity and causes of death solely among adults with ID.

RESULTS

The leading cause of death for adults with and without ID indicated on their death certificate was heart disease. Adults with ID, regardless of the severity of the disability, had substantially higher risk of death from pneumonitis, influenza/pneumonia and choking. Adults with mild/moderate ID also had higher risk of death from diabetes mellitus. Differences in cause of death trends were associated with biological sex and race-ethnicity.

CONCLUSIONS

Efforts to reduce premature mortality for adults with ID should attend to risk factors for causes of death typical in the general population such as heart disease and cancer, but also should be cognisant of increased risk of death from choking among all adults with ID, and diabetes among adults with mild/moderate ID. Further research is needed to better understand the factors determining comparatively lower rates of death from neoplasms and demographic differences in causes of death among adults with ID.

COVID-19 outcomes among people with intellectual and developmental disability in California: The importance of type of residence and skilled nursing care needs

Background

People with intellectual and developmental disabilities (IDD) appear to be at greater risk for severe outcomes from COVID-19. The roles of congregate living and skilled nursing care needs in this disparity are unclear.

Objective

To determine the impact of residential setting and level of skilled nursing care on COVID-19 outcomes for people receiving IDD services, compared to those not receiving IDD services.

Methods

Utilizing publicly available California data on COVID-19 outcomes for people receiving IDD services (early May through October 2, 2020), we report outcomes based on seven types of residence, differentiated by number of residents and level of skilled nursing care provided. We compared these results to the larger California published outcomes.

Results

Compared to Californians not receiving IDD services, in general, those receiving IDD services had a 60% lower case rate, but 2.8 times higher case-fatality rate. COVID-19 outcomes varied significantly among Californians receiving IDD services by type of residence and skilled nursing care needs: higher rates of diagnosis in settings with larger number of residents, higher case-fatality and mortality rates in settings that provided 24-h skilled nursing care.

Conclusions

Diagnosis with COVID-19 among Californians receiving IDD services appears to be related to the number of individuals within the residence, while adverse COVID-19 outcomes were associated with level of skilled nursing care. When data is available, future research should examine whether these relationships persist even when controlling for age and pre-existing conditions.

COVID-19 outcomes among people with intellectual and developmental disability living in residential group homes in New York State

BACKGROUND

People with intellectual and developmental disabilities (IDD) may be at higher risk of severe outcomes from COVID-19.

OBJECTIVE

To describe COVID-19 outcomes among people with IDD living in residential groups homes in the state of New York and the general population of New York State.

METHODS

Data for people with IDD are from a coalition of organizations providing over half of the residential services for the state of New York, and from the New York State Department of Health. Analysis describes COVID-19 case rates, case-fatality, and mortality among people with IDD living in residential group homes and New York State through May 28, 2020.

RESULTS

People with IDD living in residential group homes were at greater risk of severe COVID-19 outcomes: case rates - 7,841 per 100,000 for people with IDD compared to 1,910 for New York State; case-fatality - 15.0% for people with IDD compared to 7.9% for New York State; and mortality rate - 1,175 per 100,000 for people with IDD compared to 151 per 100,000 for New York State. Differences in cases and mortality rate were confirmed across regions of the state, but case-fatality rate was only higher for people with IDD in and around the New York City region.

CONCLUSIONS

COVID-19 appears to present a greater risk to people with IDD, especially those living in congregate settings. A full understanding of the severity of this risk will not be possible until US states begin publicly sharing all relevant data they have on COVID-19 outcomes among this population.

Intellectual and developmental disability and COVID-19 case-fatality trends: TriNetX analysis

Background

Despite possibly higher risk of severe outcomes from COVID-19 among people with intellectual and developmental disabilities (IDD), there has been limited reporting of COVID-19 trends for this population.

Objective

To compare COVID-19 trends among people with and without IDD, overall and stratified by age.

Methods

Data from the TriNetX COVID-19 Research Network platform was used to identify COVID-19 patients. Analysis focused on trends in comorbidities, number of cases, number of deaths, and case-fatality rate among patients with and without IDD who had a positive diagnosis for COVID-19 through May 14, 2020.

Results

People with IDD had higher prevalence of specific comorbidities associated with poorer COVID-19 outcomes. Distinct age-related differences in COVID-19 trends were present among those with IDD, with a higher concentration of COVID-19 cases at younger ages. In addition, while the overall case-fatality rate was similar for those with IDD (5.1%) and without IDD (5.4%), these rates differed by age: ages ≤17 – IDD 1.6%, without IDD <0.01%; ages 18–74 – IDD 4.5%, without IDD 2.7%; ages ≥75– IDD 21.1%, without IDD, 20.7%.

Conclusions

Though of concern for all individuals, COVID-19 appears to present a greater risk to people with IDD, especially at younger ages. Future research should seek to document COVID-19 trends among people with IDD, with particular attention to age related trends.

The inseparability of human agency and linked lives

The notion that people make choices and take actions that determine the outcomes of their lives - human agency - is a central principle of the life course paradigm. Unfortunately, conceptualizations of agency, like larger developmental and sociological theories, often assume that agency is limited to individuals who are "developmentally normal." We draw upon the thought of social scientists and disability scholars, as well as the life history of a woman with intellectual disability, to address the logical, ethical, and empirical flaws of this assumption. To rectify these problems, life course theory and research should pay greater attention to how agency is interwoven with another central principle of the life course paradigm: linked lives. This principle is that an individual's life cannot be understood in isolation of their interdependencies with other persons. Although human agency and linked lives are discussed as separate principles of the life course, they are not separate in lived experience. We demonstrate that, for all people and at all times in life, human agency is dependent upon interpersonal relationships. It is therefore imperative to examine intersections of agency and linked lives in order to more fully and accurately understand life course dynamics in diverse populations. Human agency is profoundly affected by interpersonal relationships and other social factors. Because agency and linked lives are inseparable, agency cannot be conceptualized as an individual characteristic of 'independent' actors. We conclude by discussing how life course research can more fully attend to the relationship between agency and linked lives.

Heterogeneity in age at death for adults with developmental disability

BACKGROUND

Although increased attention has been devoted to mortality trends for adults with developmental disability, research has not accounted for possible differences in age at death between disability types. We examine whether heterogeneity is present in age at death between adults with different types of developmental disability.

METHODS

Data were from the 2012-2016 U.S. Multiple Cause-of-Death Mortality files. Mean age at death and age at death distributions were analysed for adults, aged 18-126, with and without developmental disability collectively and then stratified by biological sex.

RESULTS

There were 33 154 decedents with and 13 026 759 without developmental disability. Compared with adults without developmental disability, age at death was lower for all decedents with developmental disability but varied markedly by disability type and biological sex. Among adults with developmental disability, those with intellectual disability had the highest age at death, and those with cerebral palsy or other rare developmental disabilities, especially if co-morbid for a second developmental disability, had the lowest age at death.

CONCLUSION

Research on age at death for adults with developmental disability must account for heterogeneity among disability types in order to ensure reliable estimates. Failure to do so conceals important differences between disability types, which can misguide public health and preventive care efforts to reduce premature mortality and/or provide aging-related supports.

COMPARISON OF AGE AND BIOLOGICAL SEX MORTALITY TRENDS BETWEEN ADULTS WITH AND WITHOUT DOWN SYNDROME

Distinct mortality trends emerge from comparisons of mean and median age at death and specific causes of death between adults with and without cerebral palsy. We compare standardized mortality odds ratios (SMORs) for 20 leading causes of death for 11,895 adults with cerebral palsy and 13,047,988 without cerebral palsy in the US between 2012 and 2016. Male and female decadents with cerebral palsy died significantly younger than male and female decadents without cerebral palsy, and were more likely to die from respiratory diseases, choking, and unknown causes. Public health and preventive care efforts should account for respiratory, swallowing, and nutrition risks, as well as mortality trends’ variation across age and biological sex. The CDC and WHO could better surveil this population’s health and mortality by disallowing certifiers from using cerebral palsy as the underlying cause of death as the practice leads to high rates of unknown causes of death.

VETERAN MORTALITY DISADVANTAGE AMONG RURAL, SUBURBAN, AND URBAN RESIDENTS

Although veterans tend to have higher mortality rates than non-veterans, recent research suggests there is substantial heterogeneity in veteran mortality on the basis of various characteristics such as race, period of service, type of health insurance coverage, and service-connected disability status. This analysis extends the extant literature by using the 1978-2014 General Social Survey linked to the National Death Index (GSS-NDI) to examine veteran status differences in mortality by geographic location. We estimate a series of Cox regression models predicting death for male veterans and nonveterans, controlling for age, race/ethnicity, education, income, and work status. Separate models are presented for rural, suburban, and urban residents. All models are weighted and include robust standard errors. The results indicate that rural veterans have higher mortality risk than rural non-veterans, particularly among older adults. There are no significant differences in mortality risk between veteran and non-veterans living in suburban and urban areas.

COMPARISON OF AGE AND BIOLOGICAL SEX MORTALITY TRENDS BETWEEN ADULTS WITH AND WITHOUT DOWN SYNDROME

Age at death and cause of death comparisons between adults with and without Down syndrome reveal distinct mortality trends that can be utilized to inform preventive care efforts to reduce premature mortality in this population. We compare mean and median age at death, and standardized mortality odds ratios (SMORs) for 20 leading causes of death for 9,564 decedents with and 13,050,319 without Down syndrome in the U.S. between 2012 and 2016. Decedents with Down syndrome, on average, were substantially younger than those without Down syndrome, and were more likely to die from Alzheimer disease and dementia at younger ages. In addition, adults with Down syndrome also had higher risk of choking related deaths. Efforts to reduce premature mortality through public health and preventive care interventions for this population should be cognizant of these increased risk factors, as well as variation in age and biological sex mortality trends.

THE HEALTH OF MALE VETERANS IN LATER LIFE

Veterans have the opportunity to accrue health-promoting “military capital,” but they are also at risk of experiencing a “military hazard” effect that undermines later-life health and mortality outcomes. Given these possibly competing effects, there is substantial heterogeneity in physical and mental health among older male veterans. The health and mortality outcomes of older veterans who were not substantially harmed during military service appear to be just as good as, if not better than, those of nonveterans. However, older veterans who served in-theater, were exposed to combat or hazardous chemicals, and/or were physically or psychologically harmed during service tend to have worse health and higher mortality than non¬veterans. Some older veterans with these experiences struggle with life-long or late-onset PTSD, while others exhibit resilience and posttraumatic growth. Additional population-level, life-course research is needed on specific war-era cohorts to identify the mechanisms that shape veteran status differences in late-life health and mortality.

Trend Change in the Intellectual Disability Nursing Home Census From 1977 to 2004

The Omnibus Budget Reconciliation Act (OBRA) of 1987 was expected to reduce inappropriate residential placements of persons with intellectual disability (ID) in nursing homes. Utilizing the nationally representative 1977, 1985, 1995, and 2004 National Nursing Home Surveys (NNHS), we estimate trend change in the ID nursing home census pre- and post-OBRA. We find a marked decrease in number and percentage, and a shift in the age distribution of the ID nursing home census, most pronounced between 1985 and 1995. We contend that these trend changes, concurrent with growth in the overall nursing home population, provide empirical evidence that policy changes that occurred during the OBRA enactment period were successful in reducing inappropriate residential placements of persons with ID in nursing homes.

Obscuring effect of coding developmental disability as the underlying cause of death on mortality trends for adults with developmental disability: a cross-sectional study using US Mortality Data from 2012 to 2016

OBJECTIVE

To determine whether coding a developmental disability as the underlying cause of death obscures mortality trends of adults with developmental disability.

DESIGN

National Vital Statistics System 2012-2016 US Multiple Cause-of-Death Mortality files.

SETTING

USA.

PARTICIPANTS

Adults with a developmental disability indicated on their death certificate aged 18 through 103 at the time of death. The study population included 33 154 adults who died between 1 January 2012 and 31 December 2016.

PRIMARY OUTCOME AND MEASURES

Decedents with a developmental disability coded as the underlying cause of death on the death certificate were identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code for intellectual disability, cerebral palsy, Down syndrome or other developmental disability. Death certificates that coded a developmental disability as the underlying cause of death were revised using a sequential underlying cause of death revision process.

RESULTS

There were 33 154 decedents with developmental disability: 7901 with intellectual disability, 11 895 with cerebral palsy, 9114 with Down syndrome, 2479 with other developmental disabilities and 1765 with multiple developmental disabilities. Among all decedents, 48.5% had a developmental disability coded as the underlying cause of death, obscuring higher rates of choking deaths among all decedents and dementia and Alzheimer's disease among decedents with Down syndrome.

CONCLUSION

Death certificates that recorded the developmental disability in Part I of the death certificate were more likely to code disability as the underlying cause of death. While revising these death certificates provides a short-term corrective to mortality trends for this population, the severity and extent of this problem warrants a long-term change involving more precise instructions to record developmental disabilities only in Part II of the death certificate.

Racial–Ethnic Differences in Turnover Intent Among Home Health Aides

Home health aides are crucial to ensuring quality services for the growing older adult population needing home-based care in the United States. We utilize data from the nationally representative 2007 National Home Health Aide Survey ( N = 3,344) to analyze racial–ethnic disparity in turnover intent. Non-Hispanic Black and non-Hispanic Other home health aides had higher all-cause turnover intent than Non-Hispanic Whites. Cause-specific turnover intent varied by race–ethnicity. Compared with non-Hispanic White home health aides, (a) non-Hispanic Black home health aides were more likely to leave due to low pay and educational/advancement opportunities; (b) Hispanic home health aides were more likely to leave due to a perceived lack of respect or difficulty with their supervisor/agency; and (c) non-Hispanic home health aides were more likely to leave due to an impending move. Findings suggest that efforts to address high levels of turnover intent among home health aides should account for differences in race–ethnic groups.

The Intellectual Disability Mortality Disadvantage: Diminishing With Age?

On average, adults with intellectual disability (ID) have higher mortality risk than their peers in the general population. However, the effect of age on this mortality disadvantage has received minimal attention. Using data from the 1986-2011 National Health Interview Survey-Linked Mortality Files (NHIS-LMF), discrete time hazard models were used to compare mortality risk for adults with and without ID by age and gender. Increased mortality risk was present for all adults with ID, but was most pronounced among younger age females. The mortality differential between those with and without ID diminished with increased age for both females and males. Findings support the argument that heterogeneity of frailty may explain differences in mortality risk between those with and without ID.

The Association between Education and Mortality for Adults with Intellectual Disability

Although the relationship between education and mortality is well documented in the general population, it has not been examined for adults with intellectual disability. Informed by fundamental cause theory, I explore the association between education and mortality in a sample of 4,241 adults with intellectual disability from the 1986-2009 National Health Interview Survey with Linked Mortality Files through 2011. Cox regression models were utilized to analyze the predictive effect of education on mortality risk while taking into account birth cohort differences. Increased education was associated with lower mortality risk for adults with intellectual disability, and this relationship strengthened in later birth cohorts who had greater access to the public education system. Comparison with a sample of 21,205 adults without intellectual disability demonstrates that the association between education and mortality risk was not as robust for adults with intellectual disability and highlights the ongoing socioeconomic challenges faced by this population.

Attention Deficit Hyperactivity Disorder and adult mortality

This study examines the relationship between self-reported ADHD and adult mortality over a four-year period, and whether ADHD is associated with underlying cause of death (accidents versus all others). If ADHD increases mortality risk through accidents, then interventions may be designed and implemented to reduce risk and prevent premature death. We estimate descriptive statistics and multivariate logistic regression models using data from the 2007 U.S. National Health Interview Survey (NHIS) Sample Adult File linked to National Death Index (NDI) data through 2011 (N=23,352). Analyses are weighted and standard errors are adjusted for the complex sampling design. We find that the odds of dying are significantly higher among those with ADHD than among those without ADHD net of exogenous sociodemographic controls (adjusted odds ratio=1.78, 95% confidence interval=1.01, 3.12). Although marginally non-significant, accidental death is more common among those with ADHD than among those without ADHD (13.2% versus 4.3%, p=0.052). Few population-representative studies examine the relationship between ADHD and adult mortality due to data limitations. Using NHIS data linked to the NDI, we are only able to observe a few deaths among adults with ADHD. However, ADHD is associated with significantly higher odds of dying for adults and results suggest that accidents may be an underlying cause of death more often for decedents with ADHD. Future research should further examine the mechanisms linking ADHD to adult mortality and the extent to which mortality among persons with ADHD is preventable. Regular measurement of ADHD among adults in the NHIS is warranted.

Childhood adversity, midlife generativity, and later life well-being

OBJECTIVES

Prior studies confirm that after experiencing childhood adversity, resilient adults can recover and engage in generative growth. This study explored the long-term effects of childhood adversity (assessed as harsh parenting and/or childhood poverty) on successful aging for individuals who either achieved or failed to achieve Erikson's psychosocial developmental stage of generativity in midlife.

METHOD

The study utilized a sample of 636 men from the Harvard Sample and Inner City Cohort of the 73-year longitudinal Study of Adult Development. Nested ordinary least squares regression models were used to test the mediating and moderating effects of midlife generativity on later life health and adjustment to aging.

RESULTS

Men who experienced childhood adversity were less likely than men with no childhood adversity to achieve generativity in midlife. Although achievement of generativity was associated with better later life health and adjustment to aging, it neither mediated nor moderated the negative relation between childhood poverty and later life health outcomes. However, for men who experienced an adversarial childhood, achievement of generativity mediated and moderated adjustment to aging.

DISCUSSION

Results suggest that psychosocial growth in adulthood can compensate for the long-term negative effects of an adversarial childhood on adjustment to aging, but not for later life health.

Death by mental retardation? The influence of ambiguity on death certificate coding error for adults with intellectual disability

BACKGROUND

Although the coding of mental retardation as underlying cause of death has been recognised by previous researchers as erroneous, factors influencing this inaccuracy have not been sufficiently analysed. This study explores the effects of diagnostic ambiguity on risk of mental retardation being coded as underlying cause of death on US death certificates from 2004.

METHODS

Utilising all US death certificates from 2004 that included a cause of death code for mental retardation, logistic regression analysis provided estimates of the likelihood of having mental retardation erroneously coded as the underlying cause of death. Estimators used to measure ambiguity included the number of multiple causes of death, the place of death, and ICD-10 diagnostic Chapter codes.

RESULTS

A total of 2278 US death certificates from 2004 included a cause of death code for mental retardation. Of these death certificates, 20% erroneously coded mental retardation as the underlying cause of death. Reflecting the negative impact of diagnostic ambiguity on death certificate coding accuracy, mental retardation was more likely to be coded as underlying cause of death for decedents who: (1) had a death certificate that provided less information on co-morbid disease processes; (2) died in an outpatient or emergency room setting; or (3) had either abnormal symptomatology or death by injury, accident or other external cause.

CONCLUSIONS

Findings from this study, as well as prior research, demonstrate that attempts to understand mortality trends for this population must attend to frequent underlying cause of death coding errors which threaten accuracy of cause of death data. Furthermore, inquiry is warranted into the impetus behind US death certificate coding policy that continues to allow the erroneous coding of 'death by mental retardation'.

Deliberating death

Utilizing a particular case study of a woman attempting to come to terms with her death, this article explores the difficult metaphors of death present within the Christian tradition. Tracing a Christian understanding of death back to the work of Augustine, the case study is utilized to highlight the difficulties presented by past and present theology embracing ideas of punishment within death. Following the trajectory of the case study, alternative understandings of death present in recent Christian theology and within Native American spirituality are presented in an attempt to find room for a fuller meaning of death post-reconciliation, but premortem.