Use of death certificates to study ethnic-specific mortality

Heat-related fatalities in North Carolina 1999-2017

OBJECTIVES

Research shows the highest rates of occupational heat-related fatalities among farm laborers and among Black and Hispanic workers in North Carolina (NC). The Hispanic population and workforce in NC have grown substantially in the past 20 years. We describe the epidemiology of heat-related fatal injuries in the general population and among workers in NC.

METHODS

We reviewed North Carolina death records and records of the North Carolina Office of the Chief Medical Examiner to identify heat-related deaths (primary International Classification of Diseases, Tenth Revision diagnosis code: X30 or T67.0-T67.9) that occurred between January 1, 1999, and December 31, 2017. Decedent age, sex, race, and ethnicity were extracted from both the death certificate and the medical examiner's report as well as determinations of whether the death occurred at work.

RESULTS

In NC between 1999 and 2017, there were 225 deaths from heat-related injuries, and 25 occurred at work. The rates of occupational heat-related deaths were highest among males, workers of Hispanic ethnicity, workers of Black, multiple, or unknown race, and in workers aged 55-64. The highest rate of occupational heat-related deaths occurred in the agricultural industry.

CONCLUSIONS

Since the last report (2001), the number of heat-related fatalities has increased, but fewer were identified as workplace fatalities. Rates of occupational heat-related deaths are highest among Hispanic workers. NC residents identifying as Black are disproportionately burdened by heat-related fatalities in general, with a wider apparent disparity in occupational deaths.

Pre-pandemic trends and Black:White inequities in life expectancy across the 30 most populous U.S. cities: a population-based study

BACKGROUND

Racial inequities in life expectancy, driven by structural racism, have been documented at the state and county levels; however, less information is available at the city level where local policy change generally happens. Furthermore, an assessment of life expectancy during the decade preceding COVID-19 provides a point of comparison for life expectancy estimates and trends post COVID-19 as cities recover.

METHODS

Using National Vital Statistics System mortality data and American Community Survey population estimates, we calculated the average annual city-level life expectancies for the non-Hispanic Black (Black), non-Hispanic White (White), and total populations. We then calculated the absolute difference between the Black and White life expectancies for each of the 30 cities and the U.S. We analyzed trends over four time periods (2008-2010, 2011-2013, 2014-2016, and 2017-2019).

RESULTS

In 2017-2019, life expectancies ranged from 72.75 years in Detroit to 83.15 years in San Francisco (compared to 78.29 years for the U.S.). Black life expectancy ranged from 69.94 years in Houston to 79.04 years in New York, while White life expectancy ranged from 75.18 years in Jacksonville to 86.42 years in Washington, DC. Between 2008-2010 and 2017-2019, 17 of the biggest cities experienced a statistically significant improvement in life expectancy, while 9 cities experienced a significant decrease. Black life expectancy increased significantly in 14 cities and the U.S. but decreased significantly in 4 cities. White life expectancy increased significantly in 17 cities and the U.S. but decreased in 8 cities. In 2017-2019, the U.S. and all but one of the big cities had a significantly longer life expectancy for the White population compared to the Black population. There was more than a 13-year difference between Black and White life expectancies in Washington, DC (compared to 4.18 years at the national level). From 2008-2010 to 2017-2019, the racial gap decreased significantly for the U.S. and eight cities, while it increased in seven cities.

CONCLUSION

Urban stakeholders and equity advocates need data on mortality inequities that are aligned with city jurisdictions to help guide the allocation of resources and implementation of interventions.

Mexican Americans agree to participate in longitudinal clinical research more than non-Hispanic whites

BACKGROUND

The National Institutes of Health has advocated for improved minority participation in clinical research, including clinical trials and observational epidemiologic studies since 1993. An understanding of Mexican Americans (MAs) participation in clinical research is important for tailoring recruitment strategies and enrollment techniques for MAs. However, contemporary data on MA participation in observational clinical stroke studies are rare. We examined differences between Mexican Americans (MAs) and non-Hispanic whites (NHWs) participation in a population-based stroke study.

METHODS

We included 3,594 first ever stroke patients (57.7% MAs, 48.7% women, median [IQR] age 68 [58-79]) from the Brain Attack Surveillance in Corpus Christi Project, 2009-2020 in Texas, USA, who were approached and invited to participate in a structured baseline interview. We defined participation as completing a baseline interview by patient or proxy. We used log-binomial models adjusting for prespecified potential confounders to estimate prevalence ratios (PR) of participation comparing MAs with NHWs. We tested interactions of ethnicity with age or sex to examine potential effect modification in the ethnic differences in participation. We also included an interaction between year and ethnicity to examine ethnic-specific temporal trends in participation.

RESULTS

Baseline participation was 77.0% in MAs and 64.2% in NHWs (Prevalence Ratio [PR] 1.20; 95% CI, 1.14-1.25). The ethnic difference remained after multivariable adjustment (1.17; 1.12-1.23), with no evidence of significant effect modification by age or sex (Pinteraction by age = 0.68, Pinteraction by sex = 0.83). Participation increased over time for both ethnic groups (Ptrend < 0.0001), but the differences in participation between MAs and NHWs remained significantly different throughout the 11-year time period.

CONCLUSION

MAs were persistently more likely to participate in a population-based stroke study in a predominantly MA community despite limited outreach efforts towards MAs during study enrollment. This finding holds hope for future research studies to be inclusive of the MA population.

The accuracy of race & ethnicity data in US based healthcare databases: A systematic review

BACKGROUND

The availability and accuracy of data on a patient's race/ethnicity varies across databases. Discrepancies in data quality can negatively impact attempts to study health disparities.

METHODS

We conducted a systematic review to organize information on the accuracy of race/ethnicity data stratified by database type and by specific race/ethnicity categories.

RESULTS

The review included 43 studies. Disease registries showed consistently high levels of data completeness and accuracy. EHRs frequently showed incomplete and/or inaccurate data on the race/ethnicity of patients. Databases had high levels of accurate data for White and Black patients but relatively high levels of misclassification and incomplete data for Hispanic/Latinx patients. Asians, Pacific Islanders, and AI/ANs are the most misclassified. Systems-based interventions to increase self-reported data showed improvement in data quality.

CONCLUSION

Data on race/ethnicity that is collected with the purpose of research and quality improvement appears most reliable. Data accuracy can vary by race/ethnicity status and better collection standards are needed.

Racial/Ethnic disparities in the chains of morbid events leading to death: network analysis of US multiple cause of death data

Multiple-cause-of-death data have not yet been applied to the study of racial/ethnic differences in causal chains of events leading to death, nor they have been used to examine racial/ethnic disparities in cause-of-death certification. We use publicly available 2019 US death certificate data to reassemble chains of morbid events leading to death. From them, we construct and analyze directed multiple cause of death networks by race and sex of deaths aged 60+. Three perspectives to measure disparities are employed: (i) relative prevalence of cause-of-death-pairs, (ii) strength of associations between diseases, (iii) similarities in transition matrices. Non-Hispanic Blacks (NHB) had overall lower prevalence of cause of death pairs, Hispanics (HIS) were burdened more by alcohol-related mortality and Asian and Pacific Islanders (API) exceeded in transitions to cerebrovascular diseases. Lower similarity was observed in transitions to external causes of death, dementia and Alzheimer's disease, pulmonary heart diseases, interstitial respiratory diseases, and diseases of the liver. After excluding rare diseases, the similarity further decreased for ill-defined conditions, diabetes mellitus, other cardiovascular diseases, diseases of the pleura, and anemia. To sum up, races/ethnicities not only vary in structure and timing of death but they differ in morbid processes leading to death as well.

Trends and ethnic differences in stroke recurrence and mortality in a biethnic population, 2000-2019: a novel application of an illness-death model

PURPOSE

To estimate temporal trends in post-stroke outcomes in Mexican Americans (MAs) and non-Hispanic whites (NHWs).

METHODS

We included first-ever ischemic strokes from a population-based study in South Texas (n = 5343, 2000-2019). We applied an illness-death model with three jointly specified Cox-type models to estimate ethnic differences and ethnic-specific temporal trends in recurrence (first stroke to recurrence), recurrence-free mortality (first stroke to death without recurrence), recurrence-affected mortality (first stroke to death with recurrence), and postrecurrence mortality (recurrence to death).

RESULTS

MAs had higher rates of postrecurrence mortality than NHWs in 2019 but lower rates in 2000. One-year risk of this outcome increased in MAs and decreased in NHWs, resulting in ethnic differences changing from -14.9% (95% CI -35.9%, -2.8%) in 2000 to 9.1% (1.7%, 18.9%) in 2018. For recurrence-free mortality, lower rates were observed in MAs until 2013. Ethnic differences in 1-year risk changed from -3.3% (95% CI -4.9%, -1.6%) in 2000 to -1.2% (-3.1%, 0.8%) in 2018. For stroke recurrence and recurrence-affected mortality, significant ethnic disparities persisted over the study period.

CONCLUSIONS

An ethnic disparity in postrecurrence mortality was newly identified, driven by the increasing trend in MAs but a decreasing trend in NHWs.

Challenges with misclassification of American Indian/Alaska Native race and Hispanic ethnicity on death records in North Carolina occupational fatalities surveillance

As frequently segregated and exploitative environments, workplaces are important sites in driving health and mortality disparities by race and ethnicity. Because many worksites are federally regulated, US workplaces also offer opportunities for effectively intervening to mitigate these disparities. Development of policies for worker safety and equity should be informed by evidence, including results from research studies that use death records and other sources of administrative data. North Carolina has a long history of Black/white disparities in work-related mortality and evidence of such disparities is emerging in Hispanic and American Indian/Alaska Native (AI/AN) worker populations. The size of Hispanic and AI/AN worker populations have increased in North Carolina over the last decade, and North Carolina has the largest AI/AN population in the eastern US. Previous research indicates that misidentification of Hispanic and AI/AN identities on death records can lead to underestimation of race/ethnicity-specific mortality rates. In this commentary, we describe problems and complexities involved in determining AI/AN and Hispanic identities from North Carolina death records. We provide specific examples of misidentification that are likely introducing bias to occupational mortality disparity documentation, and offer recommendations for improved data collection, analysis, and interpretation. Our primary recommendation is to build and maintain relationships with local community leadership, so that improvements in the ascertainment of race and ethnicity are grounded in the lived experience of workers from communities of color.

Evaluation of State Cannabis Laws and Rates of Self-harm and Assault

Importance

State cannabis laws are changing rapidly. Research is inconclusive about their association with rates of self-harm and assault. Existing studies have not considered variations in cannabis commercialization across states over time.

Objective

To evaluate the association of state medical and recreational cannabis laws with self-harm and assault, overall and by age and sex, while considering varying degrees of commercialization.

Design, Setting, and Participants

Using a cohort design with panel fixed-effects analysis, within-state changes in claims for self-harm and assault injuries before and after changes in cannabis laws were quantified in all 50 US states and the District of Columbia. Comprehensive claims data on commercial and Medicare Advantage health plan beneficiaries from January 1, 2003, to December 31, 2017, grouped by state and month, were evaluated. Data analysis was conducted from January 31, 2020, to January 21, 2021.

Exposures

Categorical variable that indexed the degree of cannabis legalization in each state and month based on law type (medical or recreational) and operational status of dispensaries (commercialization).

Main Outcomes and Measures

Claims for self-harm and assault injuries based on International Classification of Diseases codes.

Results

The analysis included 75 395 344 beneficiaries (mean [SD] age, 47 [22] years; 50% female; and median follow-up, 17 months [interquartile range, 8-36 months]). During the study period, 29 states permitted use of medical cannabis and 11 permitted recreational cannabis. Point estimates for populationwide rates of self-harm and assault injuries were higher in states legalizing recreational cannabis compared with states with no cannabis laws, but these results were not statistically significant (adjusted rate ratio [aRR] assault, recreational dispensaries: 1.27; 95% CI, 0.79-2.03;self-harm, recreational dispensaries aRR: 1.15; 95% CI, 0.89-1.50). Results varied by age and sex with no associations found except for states with recreational policies and self-harm among males younger than 40 years (aRR <21 years, recreational without dispensaries: 1.70; 95% CI, 1.11-2.61; aRR aged 21-39 years, recreational dispensaries: 1.46; 95% CI, 1.01-2.12). Medical cannabis was generally not associated with self-harm or assault injuries populationwide or among age and sex subgroups.

Conclusions and Relevance

Recreational cannabis legalization appears to be associated with relative increases in rates of claims for self-harm among male health plan beneficiaries younger than 40 years. There was no association between cannabis legalization and self-harm or assault, for any other age and sex group or for medical cannabis. States that legalize but still constrain commercialization may be better positioned to protect younger male populations from unintended harms.

Comparison of All-Cause Mortality Rates and Inequities Between Black and White Populations Across the 30 Most Populous US Cities

IMPORTANCE

To address elevated mortality rates and historically entrenched racial inequities in mortality rates, the United States needs targeted efforts at all levels of government. However, few or no all-cause mortality data are available at the local level to motivate and guide city-level actions for health equity within the country's biggest cities.

OBJECTIVES

To provide city-level data on all-cause mortality rates and racial inequities within cities and to determine whether these measures changed during the past decade.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used mortality data from the National Vital Statistics System and American Community Survey population estimates to calculate city-level mortality rates for the non-Hispanic Black (Black) population, non-Hispanic White (White) population, and total population from January 2016 to December 2018. Changes from January 2009 to December 2018 were examined with joinpoint regression. Data were analyzed for the United States and the 30 most populous US cities. Data analysis was conducted from February to November 2020.

EXPOSURE

City of residence.

MAIN OUTCOMES AND MEASURES

Total population and race-specific age-standardized mortality rates using 3-year averages, mortality rate ratios between Black and White populations, excess Black deaths, and annual average percentage change in mortality rates and rate ratios.

RESULTS

The study included 26 295 827 death records. In 2016 to 2018, all-cause mortality rates ranged from 537 per 100 000 population in San Francisco to 1342 per 100 000 in Las Vegas compared with the overall US rate of 759 per 100 000. The all-cause mortality rate among Black populations was 24% higher than among White populations nationally (rate ratio, 1.236; 95% CI, 1.233 to 1.238), resulting in 74 402 excess Black deaths annually. At the city level, this ranged from 6 excess Black deaths in El Paso to 3804 excess Black deaths every year in Chicago. The US rate remained constant during the study period (average annual percentage change, -0.10%; 95% CI, -0.34% to 0.14%; P = .42). The racial inequities in rates for the US decreased between 2008 and 2019 (annual average percentage change, -0.51%; 95% CI, -0.92% to -0.09%; P =0.02). Only 14 of 30 cities (46.7%) experienced improvements in overall mortality rates during the past decade. Racial inequities increased in more cities (6 [20.0%]) than in which it decreased (2 [6.7%]).

CONCLUSIONS AND RELEVANCE

In this study, mortality rates and inequities between Black and White populations varied substantially among the largest US cities. City leaders and other health advocates can use these types of local data on the burden of death and health inequities in their jurisdictions to increase awareness and advocacy related to racial health inequities, to guide the allocation of local resources, to monitor trends over time, and to highlight effective population health strategies.

Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites

BACKGROUND AND PURPOSE

Stroke incidence and mortality are declining rapidly in developed countries. Little data on ethnic-specific stroke recurrence trends exist. Fourteen-year stroke recurrence trend estimates were evaluated in Mexican Americans and non-Hispanic whites in a population-based study.

METHODS

Recurrent stroke was ascertained prospectively in the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in Texas, between 2000 and 2013. Incident cases were followed forward to determine 1- and 2-year recurrence. Fine & Gray subdistribution hazard models were used to estimate adjusted trends in the absolute recurrence risk and ethnic differences in the secular trends. The ethnic difference in the secular trend was examined using an interaction term between index year and ethnicity in the models adjusted for age, sex, hypertension, diabetes mellitus, smoking, atrial fibrillation, insurance, and cholesterol and relevant interaction terms.

RESULTS

From January 1, 2000 to December 31, 2013 (N=3571), the cumulative incidence of 1-year recurrence in Mexican Americans decreased from 9.26% (95% CI, 6.9%-12.43%) in 2000 to 3.42% (95% CI, 2.25%-5.21%) in 2013. Among non-Hispanic whites, the cumulative incidence of 1-year recurrence in non-Hispanic whites decreased from 5.67% (95% CI, 3.74%-8.62%) in 2000 to 3.59% (95% CI, 2.27%-5.68%) in 2013. The significant ethnic disparity in stroke recurrence existed in 2000 (risk difference, 3.59% [95% CI, 0.94%-6.22%]) but was no longer seen by 2013 (risk difference, -0.17% [95% CI, -1.96% to 1.5%]). The competing 1-year mortality risk was stable over time among Mexican Americans, while for non-Hispanic whites it was decreasing over time (difference between 2000 and 2013: -4.67% [95% CI, -8.72% to -0.75%]).

CONCLUSIONS

Mexican Americans had significant reductions in stroke recurrence despite a stable death rate, a promising indicator. The ethnic disparity in stroke recurrence present early in the study was gone by 2013.

Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest

Importance

Previous studies have found marked differences in survival after in-hospital cardiac arrest by race. Whether racial differences in survival have narrowed as overall survival has improved remains unknown.

Objectives

To examine whether racial differences in survival after in-hospital cardiac arrest have narrowed over time and if such differences could be explained by acute resuscitation survival, postresuscitation survival, and/or greater temporal improvement in survival at hospitals with higher proportions of black patients.

Design, Setting, and Participants

In this cohort study from Get With the Guidelines-Resuscitation, performed from January 1, 2000, through December 31, 2014, a total of 112 139 patients with in-hospital cardiac arrest who were hospitalized in intensive care units or general inpatient units were studied. Data analysis was performed from April 7, 2015, to May 24, 2017.

Exposure

Race (black or white).

Main Outcomes and Measures

The primary outcome was survival to discharge. Secondary outcomes were acute resuscitation survival and postresuscitation survival. Multivariable hierarchical (2-level) regression models were used to calculate calendar-year rates of survival for black and white patients after adjusting for baseline characteristics.

Results

Among 112 139 patients with in-hospital cardiac arrest, 30 241 (27.0%) were black (mean [SD] age, 61.6 [16.4] years) and 81 898 (73.0%) were white (mean [SD] age, 67.5 [15.2] years). Risk-adjusted survival improved over time in black (11.3% in 2000 and 21.4% in 2014) and white patients (15.8% in 2000 and 23.2% in 2014; P for trend <.001 for both), with greater survival improvement among black patients on an absolute (P for trend = .02) and relative scale (P for interaction = .01). A reduction in survival differences between black and white patients was attributable to elimination of racial differences in acute resuscitation survival (black individuals: 44.7% in 2000 and 64.1% in 2014; white individuals: 47.1% in 2000 and 64.0% in 2014; P for interaction <.001). Compared with hospitals with fewer black patients, hospitals with a higher proportion of black patients with in-hospital cardiac arrest achieved larger survival gains over time.

Conclusions and Relevance

A substantial reduction in racial differences in survival after in-hospital cardiac arrest has occurred that has been largely mediated by elimination of racial differences in acute resuscitation survival and greater survival improvement at hospitals with a higher proportion of black patients. Further understanding of the mechanisms of this improvement could provide novel insights for the elimination of racial differences in survival for other conditions.

Unpacking Hispanic Ethnicity-Cancer Mortality Differentials Among Hispanic Subgroups in the United States, 2004-2014

Introduction: National data on the epidemiology of cancer are commonly reported by broad racial/ethnic categories, such as "Hispanic." However, few studies have disaggregated Hispanic groups and explored mortality differentials in this heterogeneous population. This paper aims to further examine cancer mortality differentials among Hispanic subgroups in the U.S. Materials and Methods: The study examined cancer deaths in the United States from 2004 to 2014 among decedents classified as Mexican, Puerto Rican, Cuban, Dominican, Central/South American and non-Hispanic white on the death certificate among those who were 20 years or older at the time of death. Data were obtained from the National Vital Statistics System. Sex-specific age-adjusted mortality rates were computed for a 10-year period and each individual year, for all cancers combined. Differences by age group, cancer sites, and age distribution were also assessed. Results: A total of 296,486 Hispanic cancer deaths were identified. Mortality rates of the Hispanic subgroups compare favorably with those of non-Hispanic whites. The mortality rates for Mexicans are very similar to those of all Hispanics combined, whereas the rates for Cuban and Puerto Ricans are higher. Dominicans and Central/South Americans had the overall lowest mortality rates. Statistically significant decreases in cancer mortality rates were noted in some sub-groups, but rates increased among Dominican women. Age-adjusted mortality rates by cancer site varied among Hispanics subgroups and gender. Among Cubans, only 5% of cancer deaths occurred before the age of 50 compared to 16% of cancer deaths among Central/South American. Conclusion: While it is common to present data on the burden of cancer among Hispanics as an aggregate group, this study illustrates that the burden of cancer varies by Hispanic subgroups. The disaggregation of Hispanics by ancestry/country of origin allows for a clearer understanding of the health status of this growing population and is needed if health disparities are to be adequately identified, understood and addressed.

In-State and Interstate Associations Between Gun Shows and Firearm Deaths and Injuries: A Quasi-experimental Study

BACKGROUND

Gun shows are an important source of firearms, but no adequately powered studies have examined whether they are associated with increases in firearm injuries.

OBJECTIVE

To determine whether gun shows are associated with short-term increases in local firearm injuries and whether this association differs by the state in which the gun show is held.

DESIGN

Quasi-experimental.

SETTING

California.

PARTICIPANTS

Persons in California within driving distance of gun shows.

MEASUREMENTS

Gun shows in California and Nevada between 2005 and 2013 (n = 915 shows) and rates of firearm-related deaths, emergency department visits, and inpatient hospitalizations in California.

RESULTS

Compared with the 2 weeks before, postshow firearm injury rates remained stable in regions near California gun shows but increased from 0.67 injuries (95% CI, 0.55 to 0.80 injuries) to 1.14 injuries (CI, 0.97 to 1.30 injuries) per 100 000 persons in regions near Nevada shows. After adjustment for seasonality and clustering, California shows were not associated with increases in local firearm injuries (rate ratio [RR], 0.99 [CI, 0.97 to 1.02]) but Nevada shows were associated with increased injuries in California (RR, 1.69 [CI, 1.16 to 2.45]). The pre-post difference was significantly higher for Nevada shows than California shows (ratio of RRs, 1.70 [CI, 1.17 to 2.47]). The Nevada association was driven by significant increases in firearm injuries from interpersonal violence (RR, 2.23 [CI, 1.01 to 4.89]) but corresponded to a small increase in absolute numbers. Nonfirearm injuries served as a negative control and were not associated with California or Nevada gun shows. Results were robust to sensitivity analyses.

LIMITATION

Firearm injuries were examined only in California, and gun show occurrence was not randomized.

CONCLUSION

Gun shows in Nevada, but not California, were associated with local, short-term increases in firearm injuries in California. Differing associations for California versus Nevada gun shows may be due to California's stricter firearm regulations.

PRIMARY FUNDING SOURCE

National Institutes of Health; University of California, Berkeley; and Heising-Simons Foundation.

Spatial Proximity to Incidents of Community Violence Is Associated with Fewer Suicides in Urban California

Suicide is a leading cause of premature mortality. Aspects of the social environment such as incidents of violence in the community may induce psychological distress and affect suicidality, but these determinants are not well understood. We conducted an ecological study using California vital statistics records, geocoded to address of the decedent, to examine whether proximity to homicide was associated with the occurrence of suicide in urban census tracts. For each urban tract (N = 7194) and each month in 2012, we assessed homicides in the tract or within buffer zones around the tract with a 1-month lag. We estimated two risk difference parameters that capture how suicide risk is related to differences in homicide exposure. Proximity to homicides was negatively associated with suicide occurrence after controlling for demographic factors, seasonality, and other confounders. Estimates suggest that the absence of homicides would be associated with a 4.2 % higher number of tract-months with one or more suicides (95 % confidence interval 2.2-6.0). This relationship was stronger in tracts that were wealthier, older, and less civically engaged. Results were robust to a wide variety of sensitivity tests. Contrary to expectations, we identified a consistent negative association of proximity to homicide with suicide occurrence. It may be that a homicide deters or distracts from suicidality or that aggression or hopelessness may be expressed as inward or outward directed violence in different settings. Further investigation is needed to identify the drivers of this association.

Prevalence of pre-stroke sleep apnea risk and short or long sleep duration in a bi-ethnic stroke population

BACKGROUND

The ethnic disparity in ischemic stroke between Mexican Americans (MAs) and non-Hispanic whites (NHWs) may be partly attributable to disparities in sleep and its disorders. We therefore assessed whether pre-stroke sleep apnea symptoms (SA risk) and pre-stroke sleep duration differed between MAs and NHWs.

METHODS

MA and NHW ischemic stroke survivors in the Brain Attack Surveillance in Corpus Christi (BASIC) project reported sleep duration and SA symptoms on the validated Berlin questionnaire, both with respect to their pre-stroke baseline. Log binomial and linear regression models were used to test the unadjusted and adjusted (demographics and vascular risk factors) associations of high-risk Berlin scores and sleep duration with ethnicity.

RESULTS

Among 862 subjects, 549 (63.7%) were MA and 514 (59.6%) had a high risk of pre-stroke SA. The MA and NHW subjects showed no ethnic difference, after adjustment for potential confounders, in pre-stroke SA risk (risk ratio (95% confidence interval (CI)): 1.06 (0.93, 1.20)) or in pre-stroke sleep duration (on average MAs slept 2.0 fewer minutes than NHWs, 95% CI: -18.8, 14.9 min).

CONCLUSIONS

Pre-stroke SA symptoms are highly prevalent, but ethnic differences in SA risk and sleep duration appear unlikely to explain ethnic stroke disparities.

Loss of the Mexican American survival advantage after ischemic stroke

BACKGROUND AND PURPOSE

Mexican Americans (MAs) were previously found to have lower mortality after ischemic stroke than non-Hispanic whites. We studied mortality trends in a population-based design.

METHODS

Active and passive surveillance were used to find all ischemic stroke cases from January 2000 to December 2011 in Nueces County, TX. Deaths were ascertained from the Texas Department of Health through December 31, 2012. Cumulative 30-day and 1-year mortality adjusted for covariates was estimated using log-binomial models with a linear term for year of stroke onset used to model time trends. Models used data from the entire study period to estimate adjusted mortality among stroke cases in 2000 and 2011 and to calculate projected ethnic differences.

RESULTS

There were 1974 ischemic strokes among non-Hispanic whites and 2439 among MAs. Between 2000 and 2011, model estimated mortality declined among non-Hispanic whites at 30 days (7.6% to 5.6%; P=0.24) and 1 year (20.8% to 15.5%; P=0.02). Among MAs, 30-day model estimated mortality remained stagnant at 5.1% to 5.2% (P=0.92), and a slight decline from 17.4% to 15.3% was observed for 1-year mortality (P=0.26). Although ethnic differences in 30-day (P=0.01) and 1-year (P=0.06) mortality were apparent in 2000, they were not so in 2011 (30-day mortality, P=0.63; 1-year mortality, P=0.92).

CONCLUSIONS

Overall, mortality after ischemic stroke has declined in the past decade, although significant declines were only observed for non-Hispanic whites and not MAs at 1 year. The survival advantage previously documented among MAs vanished by 2011. Renewed stroke prevention and treatment efforts for MAs are needed.

Persistent ischemic stroke disparities despite declining incidence in Mexican Americans

OBJECTIVE

To determine trends in ischemic stroke incidence among Mexican Americans and non-Hispanic whites.

METHODS

We performed population-based stroke surveillance from January 1, 2000 to December 31, 2010 in Corpus Christi, Texas. Ischemic stroke patients 45 years and older were ascertained from potential sources, and charts were abstracted. Neurologists validated cases based on source documentation blinded to ethnicity and age. Crude and age-, sex-, and ethnicity-adjusted annual incidence was calculated for first ever completed ischemic stroke. Poisson regression models were used to calculate adjusted ischemic stroke rates, rate ratios, and trends.

RESULTS

There were 2,604 ischemic strokes in Mexican Americans and 2,042 in non-Hispanic whites. The rate ratios (Mexican American:non-Hispanic white) were 1.94 (95% confidence interval [CI] = 1.67-2.25), 1.50 (95% CI = 1.35-1.67), and 1.00 (95% CI = 0.90-1.11) among those aged 45 to 59, 60 to 74, and 75 years and older, respectively, and 1.34 (95% CI = 1.23-1.46) when adjusted for age. Ischemic stroke incidence declined during the study period by 35.9% (95% CI = 25.9-44.5). The decline was limited to those aged ≥60 years, and happened in both ethnic groups similarly (p > 0.10), implying that the disparities seen in the 45- to 74-year age group persist unabated.

INTERPRETATION

Ischemic stroke incidence rates have declined dramatically in the past decade in both ethnic groups for those aged ≥60 years. However, the disparity between Mexican American and non-Hispanic white stroke rates persists in those <75 years of age. Although the decline in stroke is encouraging, additional prevention efforts targeting young Mexican Americans are warranted.

Quality and integration of public health information systems: A systematic review focused on immunization and vital records systems

OBJECTIVES

Public health professionals rely on quantitative data for the daily practice of public health as well as organizational decision making and planning. However, several factors work against effective data sharing among public health agencies in the US. This review characterizes the reported barriers and enablers of effective use of public health IS from an informatics perspective.

METHODS

A systematic review of the English language literature for 2005 to 2011 followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. The review focused on immunization information systems (IIS) and vital records information systems (VRIS). Systems were described according to the structural aspects of IS integration and data quality.

RESULTS

Articles describing IIS documented issues pertaining to the distribution of the system, the autonomy of the data providers, the heterogeneous nature of information sharing as well as the quality of the data. Articles describing VRIS were focused much more heavily on data quality, particularly whether or not the data were free from errors.

CONCLUSIONS

For state and local practitioners to effectively utilize data, public health IS will have to overcome the challenges posed by a large number of autonomous data providers utilizing a variety of technologies.

The Latino adolescent male mortality peak revisited: attribution of homicide and motor vehicle crash death

OBJECTIVE

The Latino Epidemiologic Paradox describes favourable health profiles for Latinos compared to non-Latino whites despite poverty, low education, and low access to healthcare. The objective of this study was to determine if the anomaly to the Latino Epidemiological Paradox and the Latino Adolescent Male Mortality Peak in California mortality data persists.

METHODS

Cases were California residents (1999-2006) of any race and ethnicity that died (N = 1,866,743) in California from any cause of death. Mortality rates and rate ratios were calculated according to causes of death for 5 year age groups.

RESULTS

For males and females combined, age adjusted mortality rates were 509 for Latinos and 681 for non-Latino whites per 100,000/year. Latino male mortality rate ratios exceeded 1.0 compared to non-Latino white males only for age groups 15-19 years (1.41, 95% CI 1.35 to 1.49) and 20-24 years (1.24, 95% CI 1.19 to 1.29). Latinas had lower mortality rates than non-Latino white females for all ages over 15 years. Male homicide rates for Latinos increased over the study period, but did not reach the rates reported for the years 1989-1997. Both male homicide and motor vehicle crash mortality rates were higher for Latinos than non-Latino whites and peaked at 20-24 years. The Latino crash mortality rate exceeded the rate for non-Latino whites overall and for each year 2003-2006. Crash mortality for males aged 15-24 years increased from 2000 to 2006.

CONCLUSION

The anomaly and the mortality peak persist, with notable attribution to homicide and crashes. Without homicide, the mortality peak would not exist. Mortality disparities for Latino adolescent males from these two causes of death in California appear to be growing.

Widening gap in age at muscular dystrophy-associated death between blacks and whites, 1986-2005

BACKGROUND

Muscular dystrophies (MDs), characterized by progressive muscle wasting, are associated with 1 in 2,500 deaths in the United States. Although treatments slow the progression, these disorders lead to early death, usually due to cardiac or respiratory failure.

METHODS

We analyzed death record data from 18,315 MD-associated deaths that occurred in the United States in 1986 through 2005 to assess trends in the age at death of people with MDs.

RESULTS

From 1986 through 2005, the MD-associated mortality rate did not change among blacks, whites, males, or females. The median age at death among white females with MDs was 12 years higher than among black females. The frequency of reported cardiomyopathy increased among white but not black male decedents with MDs, although cardiomyopathy remained more commonly reported among black males. Among white males, the median age at death increased by 0.2 annually for those with and 1.3 for those without indications of cardiomyopathy. Among black males, the median age at death increased 0.3 years annually among those without reported cardiomyopathy. Among white males, the frequencies of pulmonary failure and pulmonary infection decreased significantly over time.

CONCLUSIONS

Changes in age at death and reported clinical comorbidities reflect improvements in the treatment of MDs. White males with MDs have shown a greater increase in age at death over time than black males. Contributing factors to this difference might include differences in types of MDs, rates of genetic and environmental modifiers, natural history, socioeconomic factors, and access to and use of treatment options.

Race/Ethnicity, Quality of Care, and Outcomes in Ischemic Stroke

Background— Prior studies suggest differences in stroke care associated with race/ethnicity. We sought to determine whether such differences existed in a population of black, Hispanic, and white patients hospitalized with stroke among hospitals participating in a quality-improvement program.

Methods and Results— We analyzed in-hospital mortality and 7 stroke performance measures among 397 257 patients admitted with ischemic stroke to 1181 hospitals participating in the Get With The Guidelines-Stroke program 2003 through 2008. Relative to white patients, black and Hispanic patients were younger and more often had diabetes mellitus and hypertension. After adjustment for both patient- and hospital-level variables, black patients had lower odds relative to white patients of receiving intravenous thrombolysis (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.77 to 0.91), deep vein thrombosis prophylaxis (OR, 0.88; 95% CI, 0.83 to 0.92), smoking cessation (OR, 0.85; 95% CI, 0.79 to 0.91), discharge antithrombotics (OR, 0.88; 95% CI, 0.84 to 0.92), anticoagulants for atrial fibrillation (OR, 0.84; 95% CI, 0.75 to 0.94), and lipid therapy (OR, 0.91; 95% CI, 0.88 to 0.96), and of dying in-hospital (OR, 0.90; 95% CI, 0.85 to 0.95). Hispanic patients received similar care as their white counterparts on all 7 measures and had similar in-hospital mortality. Black (OR, 1.31; 95% CI, 1.28 to 1.35) and Hispanic (OR, 1.16; 95% CI, 1.11 to 1.20) patients had higher odds of exceeding the median length of hospital stay relative to whites. During the study, quality of care improved in all 3 race/ethnicity groups.

Conclusions— Black patients with stroke received fewer evidence-based care processes than Hispanic or white patients. These differences could lead to increased risk of recurrent stroke. Quality of care improved substantially in the Get With The Guidelines-Stroke Program over time for all 3 racial/ethnic groups.

Non-English speakers attend gastroenterology clinic appointments at higher rates than English speakers in a vulnerable patient population

GOALS

We sought to identify factors associated with gastroenterology clinic attendance in an urban safety net healthcare system.

BACKGROUND

Missed clinic appointments reduce the efficiency and availability of healthcare, but subspecialty clinic attendance among patients with established healthcare access has not been studied.

STUDY

We performed an observational study using secondary data from administrative sources to study patients referred to, and scheduled for an appointment in, the adult gastroenterology clinic serving the safety net healthcare system of San Francisco, CA. Our dependent variable was whether subjects attended or missed a scheduled appointment. Analysis included multivariable logistic regression and classification tree analysis. A total of 1833 patients were referred and scheduled for an appointment between May 2005 and August 2006. Prisoners were excluded. All patients had a primary care provider.

RESULTS

Six hundred eighty-three patients (37.3%) missed their appointment; 1150 patients (62.7%) attended. Language was highly associated with attendance in the logistic regression; non-English speakers were less likely than English speakers to miss an appointment [adjusted odds ratio 0.42 (0.28, 0.63) for Spanish, 0.56 (0.38, 0.82) for Asian language, P<0.001]. Other factors were also associated with attendance, but classification tree analysis identified language to be the most highly associated variable.

CONCLUSIONS

In an urban safety net healthcare population, among patients with established healthcare access and a scheduled gastroenterology clinic appointment, not speaking English was most strongly associated with higher attendance rates. Patient-related factors associated with not speaking English likely influence subspecialty clinic attendance rates, and these factors may differ from those affecting general healthcare access.

Fatalities in the landscape and horticultural services industry, 1992-2001

BACKGROUND

Although landscape and horticultural services workers have high injury and illness rates, little is known about fatalities in this industry.

METHODS

Census of Fatal Occupational Injuries and Current Population Survey data were analyzed to determine fatality rates and causes of landscaping deaths from 1992 to 2001.

RESULTS

There were 1,101 fatalities during the 10-year period and the average fatality rate was 13.50 deaths per 100,000 full-time employees. In 2001, the landscaping fatality rate was 3.33 (95% CI 2.84-3.91) times the all industry rate. The leading causes of death were transportation incidents (27%), contact with objects or equipment (27%), falls (24%), exposure to harmful substances and environments (18%), and assaults and violent acts (4%). The fatality rate for African American landscapers was 1.51 (95% CI 1.25-1.83) times the rate for white workers. Fatalities were also common among self-employed, small business, and young landscapers.

CONCLUSIONS

Landscaping workers are at increased risk of fatal injury. Further research is needed to characterize industry hazards.

Ethnic disparities in stroke and hypertension among women: the BASIC project

BACKGROUND

Little data exist on stroke burden in Mexican-American (MA) women. The objective of this study was to characterize the burden of stroke in MA and non-Hispanic white (NHW) women and to compare this burden across ethnic groups.

METHODS

Cases of ischemic stroke and intracerebral hemorrhage among women (January 2000-December 2006) were identified as part of the Brain Attack Surveillance in Corpus Christi (BASIC) Project, a stroke surveillance study in a biethnic Texas community. Cumulative incidence of stroke among women was compared by ethnicity and age. Logistic regression was used to compare risk factors and age-adjusted use of antihypertensives between MA and NHW female stroke cases.

RESULTS

MA women had elevated stroke risk compared with NHW women at younger ages (ages 45-59: relative risk (RR) = 2.00 (95% confidence interval (CI): 1.54-2.58); ages 60-74: RR = 1.57 (95% CI: 1.31-1.87); ages > or =75: RR = 1.13 (95% CI: 0.98-1.29)). Stroke severity and stroke type did not differ between ethnic groups. MA female stroke cases were more likely to have hypertension (odds ratio (OR) = 1.41 (95% CI: 1.11-1.80)), diabetes (OR = 3.54 (95% CI: 2.82-4.45)), and the presence of both risk factors (OR = 3.31 (95% CI: 2.61-4.21)) compared with NHW female stroke cases and were more likely to report use of antihypertensives (OR = 1.51 (95% CI: 1.10-2.06)). There was a trend toward greater hypertension awareness among MA female stroke cases (OR = 1.37 (95% CI: 0.98-1.91)).

CONCLUSIONS

MA women have increased risk of stroke at younger ages compared with NHW women. Reasons for this ethnic disparity, including an increased prevalence of hypertension and diabetes, should be explored.

Increased mortality in African Americans with idiopathic pulmonary arterial hypertension

BACKGROUND

Idiopathic pulmonary arterial hypertension (IPAH) is a progressive disorder that usually culminates in right ventricular failure and death without treatment.

OBJECTIVE

To assess mortality trends by race and gender for idiopathic pulmonary arterial hypertension in the United States from 1994-1998.

METHODS

The U.S. National Center for Health Statistics data for the years 1994-1998 was reviewed for deaths in which the underlying cause was primary pulmonary hypertension (ICD-9 code 416.0), now known as IPAH. The age, gender, race and state of residence of the deceased were abstracted from the Centers for Disease Control Wonder System (http://wonder.cdc.gov). Average annual age-adjusted region-, race- and gender-specific rates were then calculated.

RESULTS

African-American women demonstrated the highest mortality rates for IPAH across all age groups compared to other racial and gender groups. No geographical differences in mortality rates were noted. An increase in mortality rates with advancing age was observed in all racial and gender groups, with the highest mortality rates for IPAH noted in the elderly.

DISCUSSION

African Americans with IPAH exhibit a substantially increased mortality compared with Caucasians, particularly African-American women.

Occupation recorded on certificates of death compared with self-report: the Atherosclerosis Risk in Communities (ARIC) Study

Background

Death certificates are a potential source of sociodemographic data for decedents in epidemiologic research. However, because this information is provided by the next-of-kin or other proxies, there are concerns about validity. Our objective was to assess the agreement of job titles and occupational categories derived from death certificates with that self-reported in mid and later life.

Methods

Occupation was abstracted from 431 death certificates from North Carolina Atherosclerosis Risk in Communities Study participants who died between 1987 and 2001. Occupations were coded according to 1980 Bureau of Census job titles and then grouped into six 1980 census occupational categories. This information was compared with the self-reported occupation at midlife as reported at the baseline examination (1987–89). We calculated percent agreement using standard methods. Chance-adjusted agreement was assessed by kappa coefficients, with 95% confidence intervals.

Results

Agreement between death certificate and self-reported job titles was poor (32%), while 67% of occupational categories matched the two sources. Kappa coefficients ranged from 0.53 for technical/sales/administrative jobs to 0.68 for homemakers. Agreement was lower, albeit nonsignificant, for women (kappa = 0.54, 95% Confidence Interval, CI = 0.44–0.63) than men (kappa = 0.62, 95% CI = 0.54–0.69) and for African-Americans (kappa = 0.47, 95% CI = 0.34–0.61) than whites (kappa = 0.63, 95% CI = 0.57–0.69) but varied only slightly by educational attainment.

Conclusion

While agreement between self- and death certificate reported job titles was poor, agreement between occupational categories was good. This suggests that while death certificates may not be a suitable source of occupational data where classification into specific job titles is essential, in the absence of other data, it is a reasonable source for constructing measures such as occupational SES that are based on grouped occupational data.

Mortality of foreign-born and US-born Hispanic adults at younger ages: a reexamination of recent patterns

OBJECTIVES

We sought to determine whether mortality rates among immigrant and US-born Hispanic young adults were higher or lower compared with non-Hispanic Whites. We also sought to identify which causes of death accounted for the differences in mortality rates between groups. Measures. We used Texas and California vital registration data from 1999 to 2001 linked to 2000 census denominators. We calculated cause-specific, indirectly standardized rates and ratios and determined excess/deficit calculations comparing mortality rates among US- and foreign-born Hispanic men and women with rates among non-Hispanic White men and women.

RESULTS

Mortality rates were substantially lower among Hispanic immigrant men (standardized mortality ratio [SMR]=0.79) and women (SMR=0.59) than among non-Hispanic White men and women. Most social and behavioral and chronic disease causes in Texas and California other than homicide were noteworthy contributors to this pattern. Mortality rates among US-born Hispanics were similar to or exceeded those among non-Hispanic Whites (male SMR=1.17, female SMR=0.91).

CONCLUSIONS

Mortality rates among younger Hispanic immigrants in Texas and California were lower than rates among non-Hispanic Whites. This pattern was not observed among US-born Hispanics, however.