Ethnic Differences In Mortality Research Articles

The impact of race and ethnicity on the outcome of carotid interventions in the United States

ObjectivePrevious studies have demonstrated an adverse impact of African American race and Hispanic ethnicity on the outcomes of carotid endarterectomy (CEA), although little is known about the influence of race and ethnicity on the outcome of carotid angioplasty and stenting (CAS). The present study was undertaken to examine the influence of race and ethnicity on the outcomes of CEA and CAS in contemporary practice. MethodsThe nationwide inpatient sample (2005–2008) was queried using International Classification of Diseases-9 codes for CEA and CAS in patients with carotid artery stenosis. The primary outcomes were postoperative death or stroke. Multivariate analysis was performed adjusting for age, gender, race, comorbidities, high-risk status, procedure type, symptomatic status, year, insurance type, and hospital characteristics. ResultsOverall, there were 347,450 CEAs and 47,385 CASs performed in the United States over the study period. After CEA, Hispanics had the greatest risk of mortality (P < 0.001), whereas black patients had the greatest risk of stroke (P = 0.02) compared with white patients on univariate analysis. On multivariable analysis, Hispanic ethnicity remained an independent risk factor for mortality after CEA (relative risk 2.40; P < 0.001), whereas the increased risk of stroke in black patients was no longer significant. After CAS, there were no racial or ethnic differences in mortality. On univariate analysis, the risk of stroke was greatest in black patients after CAS (P = 0.03). However, this was not significant on multivariable analysis. ConclusionHispanic ethnicity is an independent risk factor for mortality after CEA. While black patients had an increased risk of stroke after CEA and CAS, this was explained by factors other than race. Further studies are warranted to determine if Hispanic ethnicity remains an independent risk factor for mortality after discharge.

Racial and Ethnic Differences in Mortality among Individuals with Chronic Kidney Disease: Results from the Kidney Early Evaluation Program (KEEP)

Racial and Ethnic Differences in Mortality among Individuals with Chronic Kidney Disease: Results from the Kidney Early Evaluation Program (KEEP)

Term Pregnancy

To estimate the trend of maternal racial and ethnic differences in mortality for early-term (37 0/7 to 38 6/7 weeks of gestation) compared with full-term births (39 0/7 to 41 6/7 weeks of gestation). We analyzed 46,329,018 singleton live births using the National Center for Health Statistics U.S. period-linked birth and infant death data from 1995 to 2006. Infant mortality rates, neonatal mortality rates, and postneonatal mortality rates were calculated according to gestational age, race and ethnicity, and cause of death. Overall, infant mortality rates have decreased for early-term and full-term births between 1995 and 2006. At 37 weeks of gestation, Hispanics had the greatest decline in infant mortality rates (35.4%; 4.8 per 1,000 to 3.1 per 1,000) followed by 22.4% for whites (4.9 per 1,000 to 3.8 per 1,000); blacks had the smallest decline (6.8%; 5.9 per 1,000 to 5.5 per 1,000) as a result of a stagnant neonatal mortality rate. At 37 weeks compared with 40 weeks of gestation, neonatal mortality rates increase. For Hispanics, the relative risk is 2.6 (95% confidence interval [CI] 2.0-3.3); for whites, the relative risk is 2.6 (95% CI 2.2-3.1); and for blacks, the relative risk is 2.9 (95% CI 2.2-3.8). Neonatal mortality rates are still increased at 38 weeks of gestation. At both early- and full-term gestations, neonatal mortality rates for blacks are 40% higher than for whites and postneonatal mortality rates 80% higher, whereas Hispanics have a reduced postneonatal mortality rate when compared with whites. Early-term births are associated with higher neonatal, postneonatal, and infant mortality rates compared with full-term births with concerning racial and ethnic disparity in rates and trends.

The effect of race and ethnicity on outcomes among patients in the intensive care unit: a comprehensive study involving socioeconomic status and resuscitation preferences.

We sought to determine whether race or ethnicity is independently associated with mortality or intensive care unit length of stay among critically ill patients after accounting for patients' clinical and demographic characteristics including socioeconomic status and resuscitation preferences. Historical cohort study of patients hospitalized in intensive care units. Adult intensive care units in 35 California hospitals during the years 2001-2004. A total of 9,518 intensive care unit patients (6,334 white, 655 black, 1,917 Hispanic, and 612 Asian/Pacific Islander patients). The primary outcome was risk-adjusted mortality and a secondary outcome was risk-adjusted intensive care unit length of stay. Crude hospital mortality was 15.9% among the entire cohort. Asian patients had the highest crude hospital mortality at 18.6% and black patients had the lowest at 15.0%. After adjusting for age and gender, Hispanic and Asian patients had a higher risk of death compared to white patients, but these differences were not significant after additional adjustment for severity of illness. Black patients had more acute physiologic derangements at intensive care unit admission and longer unadjusted intensive care unit lengths of stay. Intensive care unit length of stay was not significantly different among racial/ethnic groups after adjustment for demographic, clinical, and socioeconomic factors and do-not-resuscitate status. In an analysis restricted only to those who died, decedent black patients averaged 1.1 additional days in the intensive care unit (95% confidence interval, 0.26-2.6) compared to white patients who died, although this was not statistically significant. Hospital mortality and intensive care unit length of stay did not differ by race or ethnicity among this diverse cohort of critically ill patients after adjustment for severity of illness, resuscitation status, socioeconomic status, insurance status, and admission type. Black patients had more acute physiologic derangements at intensive care unit admission and were less likely to have a do-not-resuscitate order. These results suggest that among intensive care unit patients, there are no racial or ethnic differences in mortality within individual hospitals. If disparities in intensive care unit care exist, they may be explained by differences in the quality of care provided by hospitals that serve high proportions of minority patients.

Racial and Ethnic Differences in Mortality of Hemodialysis Patients: Role of Dietary and Nutritional Status and Inflammation

Background: Racial/ethnic disparities prevail among hemodialysis patients. We hypothesized that significant differences exist between Black and non-Hispanic and Hispanic White hemodialysis patients in nutritional status, dietary intake and inflammation, and that they account for racial survival disparities. Methods: In a 6-year (2001–2007) cohort of 799 hemodialysis patients, we compared diet and surrogates of nutritional-inflammatory status and their mortality-predictabilities between 279 Blacks and 520 Whites using matched and regression analyses and Cox with cubic splines. Results: In age-, gender- and diabetes-matched analyses, Blacks had higher lean body mass and serum prealbumin, creatinine and homocysteine levels than Whites. In case-mix-adjusted analyses, dietary intakes in Blacks versus Whites were higher in energy (+293 ± 119 cal/day) and fat (+18 ± 5 g/day), but lower in fiber (–2.9 ± 1.3 g/day) than Whites. In both races, higher serum albumin, prealbumin and creatinine were associated with greater survival, whereas CRP and IL-6, but not TNF-α, were associated with increased mortality. The highest (vs. lowest) quartile of IL-6 was associated with a 2.4-fold (95% CI: 1.3–3.8) and 4.1-fold (2.2–7.2) higher death risk in Blacks and Whites, respectively. Conclusions: Significant racial disparities exist in dietary, nutritional and inflammatory measures, which may contribute to hemodialysis outcome disparities. Testing race-specific dietary and/or anti-inflammatory interventions is indicated.

Racial and Ethnic Differences in Mortality in Children Awaiting Heart Transplant in the United States

Racial differences in outcomes are well known in children after heart transplant (HT) but not in children awaiting HT. We assessed racial and ethnic differences in wait-list mortality in children <18 years old listed for primary HT in the United States during 1999-2006 using multivariable Cox models. Of 3299 listed children, 58% were listed as white, 20% as black, 16% as Hispanic, 3% as Asian and 3% were defined as 'Other'. Mortality on the wait-list was 14%, 19%, 21%, 17% and 27% for white, black, Hispanic, Asian and Other children, respectively. Black (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.3, 1.9), Hispanic (HR 1.5, CI 1.2, 1.9), Asian (HR, 2.0, CI 1.3, 3.3) and Other children (HR 2.3, CI 1.5, 3.4) were all at higher risk of wait-list death compared to white children after controlling for age, listing status, cardiac diagnosis, hemodyamic support, renal function and blood group. After adjusting additionally for medical insurance and area household income, the risk remained higher for all minorities. We conclude that minority children listed for HT have significantly higher wait-list mortality compared to white children. Socioeconomic variables appear to explain a small fraction of this increased risk.

Established risk factors account for most of the racial differences in cardiovascular disease mortality.

BackgroundCardiovascular disease (CVD) mortality varies across racial and ethnic groups in the U.S., and the extent that known risk factors can explain the differences has not been extensively explored.MethodsWe examined the risk of dying from acute myocardial infarction (AMI) and other heart disease (OHD) among 139,406 African-American (AA), Native Hawaiian (NH), Japanese-American (JA), Latino and White men and women initially free from cardiovascular disease followed prospectively between 1993–1996 and 2003 in the Multiethnic Cohort Study (MEC). During this period, 946 deaths from AMI and 2,323 deaths from OHD were observed. Relative risks of AMI and OHD mortality were calculated accounting for established CVD risk factors: body mass index (BMI), hypertension, diabetes, smoking, alcohol consumption, amount of vigorous physical activity, educational level, diet and, for women, type and age at menopause and hormone replacement therapy (HRT) use.ResultsEstablished CVD risk factors explained much of the observed racial and ethnic differences in risk of AMI and OHD mortality. After adjustment, NH men and women had greater risks of OHD than Whites (69% excess, P<0.001 and 62% excess, P = 0.003, respectively), and AA women had greater risks of AMI (48% excess, P = 0.01) and OHD (35% excess, P = 0.007). JA men had lower risks of AMI (51% deficit, P<0.001) and OHD (27% deficit, P = 0.001), as did JA women (AMI, 37% deficit, P = 0.03; OHD, 40% deficit, P = 0.001). Latinos had underlying lower risk of AMI death (26% deficit in men and 35% in women, P = 0.03).ConclusionKnown risk factors explain the majority of racial and ethnic differences in mortality due to AMI and OHD. The unexplained excess in NH and AA and the deficits in JA suggest the presence of unmeasured determinants for cardiovascular mortality that are distributed unequally across these populations.

Environmental Exposure to Trace Elements and Prostate Cancer in Three New Zealand Ethnic Groups

A stratified random sample of 176 men was taken from a larger community prostate study group of 1405 eligible subjects from three ethnic groups in the Wellington region of New Zealand, in order to examine ethnic differences in exposure to cadmium (Cd), selenium (Se) and zinc (Zn) and possible associations of blood levels of Cd, Se and Zn with the prevalence of elevated serum Prostate Specific Antigen (PSA); a marker of prostate cancer. Maori and Pacific Islands men were found likely to have higher Cd exposure than New Zealand Europeans through diet, occupation and smoking. However, there was no significant difference between ethnic groups in mean blood Cd levels. Pacific Islands men had significantly higher levels of blood Se than both New Zealand European men and Maori men. Maori men had significantly higher levels of blood Zn than both New Zealand European men and Pacific Islands men. A positive association was found between blood Cd and total serum PSA. Se and Zn levels were not associated with elevated PSA. Maori and Pacific Islands men have higher prostate cancer mortality rates than New Zealand European men. Ethnic differences in mortality could be contributed to by differences in rates of disease progression, influenced by exposure and/or deficiency to trace elements. However, results did not reflect a consistent ethnic trend and highlight the complexity of the risk/protective mechanisms conferred by exposure factors. Further research is needed to ascertain whether the associations found between Cd and PSA levels are biologically important or are merely factors to be considered when interpreting PSA results clinically.

Ethnic Differences in Mortality, End-Stage Complications, and Quality of Care Among Diabetic Patients

To determine the influence of ethnic differences in diabetes care on inequalities in mortality and prevalence of end-stage complications among diabetic patients. The following questions were examined: 1) Are there ethnic differences among diabetic patients in mortality and end-stage complications and 2) are there ethnic differences among diabetic patients in quality of care? A review of the literature on ethnic differences in the prevalence of complications and mortality among diabetic patients and in the quality of diabetes care was performed by systematically searching articles on Medline published from 1987 through October 2004. A total of 51 studies were included, mainly conducted in the U.S. and the U.K. In general, after adjusting for confounders, diabetic patients from ethnic minorities had higher mortality rates and higher risk of diabetes complications. After additional adjustment for risk factors such as smoking, socioeconomic status, income, years of education, and BMI, in most instances ethnic differences disappear. Nevertheless, blacks and Hispanics in the U.S. and Asians in the U.K. have an increased risk of end-stage renal disease, and blacks and Hispanics in the U.S. have an increased risk of retinopathy. Intermediate outcomes of care were worse in blacks, and they were inclined to be worse in Hispanics. Likewise, ethnic differences in quality of care in the U.S. exist: process of care was worse in blacks. Given the fact that there are ethnic differences in diabetes care and that ethnic differences in some diabetes complications persist after adjustment for risk factors other than diabetes care, it seems the case that ethnic differences in diabetes care contribute to the more adverse disease outcomes of diabetic patients from some ethnic minority groups. Although no generalizations can be made for all ethnic groups in all regions for all kinds of complications, the results do implicate the importance of quality of care in striving for equal health outcomes among ethnic minorities.

The Deadly Triad

The Deadly Triad

Identifying Hispanics in Existing Databases

This study compares death certificate designations to other methods of identifying Hispanics. Three methods of identifying Hispanics—death certificate, U.S. census Spanish-surname list, and a revised surname list—were applied to death certificates of the 1,516,465 White Califor nians who died during 1987 through 1994. Data were compared using frequencies, rates, and rate ratios (RR). Whether death certificate designation or the revised Spanish-surname list identifies the most Hispanics depends on age, gender, and cause of death. RRs comparing Hispanic and non-Hispanic Whites produce conflicting results for some groups. The most discrepant RRs were for homicides of 15- to 34-year-old males. These findings illustrate how ethnic differences in mortality are shaped by the method used to identify ethnicity. In the absence of a gold standard for identifying persons of Hispanic ethnicity in official government records, intermittent if not ongoing comparison of the available identification methods merits serious consideration.

Ethnic differences in rates of infant mortality and sudden infant death in Sweden, 1978-1990

This study examined ethnic differences in infant mortality rates (IMRs) and rates of sudden infant death syndrome (SIDS) among Swedish and immigrant women between 1978 and 1990 in Sweden. The study population comprised 1,265,942 single live births to women between the ages of 15 and 44 years in Sweden. Data from 3 registers In Sweden were linked to obtain medical and sociodemographic information for each mother and child in the study. Logistic regression analyses were employed to assess ethnic differences in infant mortality and SIDS while controlling for relevant confounders. This study revealed no ethnic differences in IMRs. There were also no ethnic differences in the mortality rates due to SIDS, except for immigrant women from Southeast Asia and the Pacific Islands who experienced significantly higher rates of SIDS than Swedish women. This study shows that, in general, the IMRs and mortality rates due to SIDS are not a serious public health problem among immigrant women in Sweden and suggests several reasons why this is the case.

Demographic, Socioeconomic, and Behavioral Factors Affecting Ethnic Mortality by Cause

This article examines ethnic differences in total and cause-specific mortality. We employ the linked National Health Interview Survey-National Death Index (NHIS-NDI) to examine ethnic differences in mortalityfrom a combination of demographic, socioeconomic, and health characteristic perspectives. Wefind that Asian American mortality is low in part because of healthy behaviors and socioeconomic advantages; that Caucasian American mortality is higher partly because of high prevalence and quantity of cigarette smoking; and that Mexican, Native, and African American mortality is higher partly from socioeconomic disadvantages. These results give us added insight into the demographic, social, and health mechanisms that lead us to persevere or to perish. Most mortality research has focused on how demographic characteristics - age, sex, and ethnicity - affect total and cause-specific mortality. But to properly conceptualize the multiple and interacting proximate determinants of mortality by ethnicity, researchers must extend the traditional demographic framework of mortality analysis to a more complete, though more complex, multivariate model that also incorporates social characteristics - marital status, education, and income (see Mosley & Chen 1984; Rosenwaike 1988). Moreover, health behaviors have cultural dimensions and therefore can also affect ethnic differences in mortality. A new file, the linked National Health Interview Survey-National Death Index (NHIS-NDI), allows us to disentangle some of the effects of demographic, socioeconomic, and behavioral health characteristics on ethnic differences in total and cause-specific mortality.

Ethnic differences in mortality from cardiovascular disease in the UK: do they persist in people with diabetes?

To determine whether ethnic differences in cardiovascular disease mortality persist in people with non-insulin-dependent diabetes mellitus. This was an ecological study in which routine mortality data from 1985-86, which coded all mentioned causes of death, provided the numerator. The UK population derived from 1981 census formed the denominator. United Kingdom. Records of all deaths in people aged 45 years and above were extracted if diabetes was mentioned anywhere on the death certificate. The denominator was aged five years to approximate to the 1986 population. Mortality rates where a cardiovascular underlying cause was given were compared between South Asians, African-Caribbeans, and those born in England and Wales. The latter group formed the standard for directly standardised rate ratios. Mortality from heart disease was approximately three times higher in diabetic South Asian born men and women than in those with diabetes born in England and Wales. This ethnic difference was greatest in the younger age group. Conversely, stroke mortality rates in African-Caribbeans were 3.5-4 times higher than those in the England and Wales population. Despite this high mortality from stroke, ischaemic heart disease death rates were not high in African-Caribbean men. Ethnic differences in cardiovascular mortality persisted and were greater in those with diabetes. Thus the high risk of heart disease should be targeted for intervention in South Asians, and the high rates of stroke targeted in African-Caribbeans.

Economic Status as a Determinant of Mortality Among Black and White Older Men: Does Poverty Kill?

The evidence presented in this paper shows that differential mortality by economic status is strongly present in the United States today, and that this relationship is monotonic, with men's death rates being lower among the wealthier. Also, the greater the number of spells of poverty, the higher the death rate. These data suggest that differential mortality rates by economic status are being confused with the well-known ethnic differences in mortality. An implication of this paper, therefore, is that ethnic differences in mortality are, in large part, a consequence of poverty or permanent low income, as opposed to genotype. Consequently, it may be just as valid, or even more so, to publish mortality tables by income as by race. A policy implication of this paper is that the redistributive effects of longevity-based transfer systems, such as social security (public pensions), may be less ‘progressive’ than has been assumed, since would-be poorer recipients are either less likely to live long enough to coll...

Ethnic differences in mortality from sudden infant death syndrome in New Zealand.

To examine the factors which might explain the higher mortality from sudden infant death syndrome in Maori infants (7.4/1000 live births in 1986 compared with 3.6 in non-Maori children). A large nationwide case control study. New Zealand. 485 infants who died of sudden infant death syndrome were compared with 1800 control infants. There were 229 Maori and 240 non-Maori cases of sudden infant death syndrome (16 cases unassigned) and 353 Maori and 1410 non-Maori controls (37 unassigned). Maori infants had 3.81 times the risk (95% confidence interval 3.06 to 4.76) of sudden infant death syndrome compared with non-Maori infants. The risk factors for sudden infant death syndrome within groups were remarkably similar. When Maori and non-Maori controls were compared the prevalence of many of the known risk factors was higher in Maori infants. In particular, mothers were socioeconomically disadvantaged, younger, and more likely to smoke and their infants were of lower birth weight and more likely to share a bed with another person. Multivariate analysis controlling for potential confounders found that simply being Maori increased the risk of sudden infant death syndrome by only 1.37 (95% CI = 0.95 to 2.01), not statistically significantly different from 1. Population attributable risk was calculated for prone sleeping position, maternal smoking, not breast feeding, and infants sharing a bed with another person. In total these four risk factors accounted for 89% of deaths from sudden infant death syndrome in Maori infants and 79% in non-Maori infants. The high rate of sudden infant death syndrome among Maori infants is based largely on the high prevalence in the Maori population of the major risk factors. Other risk factors, not related to ethnicity, probably explain remaining differences between Maori and non-Maori children.

Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales.

To examine mortality from ischaemic heart disease and cerebrovascular disease in England and Wales by country of birth of the deceased. Standardised mortality ratios were computed by country of birth groups for ischaemic heart disease and cerebrovascular disease for 1979-83 and 1970-2 by using the five year age-sex specific rates for England and Wales for 1979-83 as standard. England and Wales 1970-2 and 1979-83. In 1979-83 mortality from ischaemic heart disease was highest in men and women born in the Indian subcontinent (standardised mortality ratio 136 and 146 respectively). Young Indian men suffered the greatest excess (313 at ages 20-29). Other groups with raised mortality included Irish, Scottish, and Polish born immigrants. Those born in the Caribbean, the old Commonwealth, west Europe, and the United States had low death rates. In England and Wales mortality from ischaemic heart disease declined by 5% in men and 1% in women between 1970-2 and 1979-83, with greatest percentage declines in immigrants born in the United States, South Africa, the old Commonwealth, the Caribbean, and France. immigrant groups with raised mortality in the earlier period showed little improvement, and mortality from ischaemic heart disease increased among Indians (6% in men and 13% in women). In 1979-83 mortality from cerebrovascular disease was highest in Caribbeans (standardised mortality ratios 176 in men and 210 in women), followed by Africans, Indians, and Irish. Rates were low in west Europeans. Mortality from stroke declined by 28% overall in this period, a rate of decline shared by most groups. Men from the Indian subcontinent showed a decline of only 3%. In the 1980s mortality from ischaemic heart disease and cerebrovascular disease differed significantly between ethnic groups in England and Wales. In general, ethnic groups that experienced lower mortality from ischaemic heart disease in the 1970s showed the greatest improvement over the following decade.

Racial inequalities in childhood asthma

Mortality and hospital admission rates for asthma are higher in Maoris and Pacific Islander children than in European children. These ethnic differences are not explained by ethnic differences in asthma prevalence, the characteristics of the disease or admission criteria. There are major ethnic differences in asthma drug management both in the community and at the time of discharge from hospital. In particular Polynesians were less likely to receive prophylactic therapy and this factor probably accounts for ethnic differences in mortality and admission rates. Possible explanations for the ethnic differences in medical management are discussed.

Ethnic differences in mortality from ischemic heart disease: A study of migrant and native populations

The population of Manitoba, by virtue of their various ethnic background, provide a good opportunity to investigate the extent to which the occurrence of ischemic heart disease (IHD) or its risk factors is determined by genetic or by environmental factors. Mortality from this disease has been measured and compared between ethnic groups of the immigrants and their descendants. Of a total of 6029 deaths from IHD in this province during 1960–1962, 3487 were foreign-born (outside Canada) and 2542 were Canadian-born. These along with 2880 deaths in 1961 from diseases other than cardiovascular (used as controls) were analyzed. The standardized mortality ratios from IHD and the relative risk (for some groups) were computed and compared between different ethnic groups and between the Canadian-born and the foreign-born subjects of the corresponding ethnic groups. A higher risk of mortality from IHD than the expected was found among the Jews, English, and Scottish; and a lower risk was found among the native Indians, Austrians, Germans and Ukrainians. In some groups a varying pattern of risk was found between the foreign-born and the Canadian-born subjects of the same ethnic background. The data suggest that both genetic and environmental factors operate in the development of IHD. However, some of the findings are consistent with the hypothesis that the environmental factors play a dominant role, and manipulations of these factors may therefore lead to successful prevention.