National Center For Health Statistics Research Articles

Changes in cancer mortality rates after Medicaid expansion under the Affordable Care Act and the role of changes in stage at diagnosis.

74 Background: Medicaid expansion is associated with earlier cancer diagnoses and improved cancer survival. However, it is unclear if the expansion-associated survival benefits are driven primarily by early detection leading to improved prognosis and/or increased access to appropriate cancer care. A nationwide analysis was performed to determine the degree to which expansion-associated changes in cancer mortality rates can be explained by changes in stage at diagnosis. Methods: State-level cancer incidence and mortality data from 2001-2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results and National Program of Cancer Registries databases (incidence) and the National Center for Health Statistics (mortality), which cover the 50 US States and Washington DC. Difference-in-differences analyses were conducted to compare changes in localized and distant stage cancer incidence rates and cancer mortality rates from pre- vs. post-2014 in expansion vs. non-expansion states. We utilized generalized estimating equations to account for autocorrelation within states and adjusted for age, race, sex, year, state, early Medicaid expansion effects, and state-level covariates (unemployment, education, poverty, race/ethnicity, and insurance). Analyses were conducted overall and by cancer site subtype. Mediation analyses were utilized to assess whether local and/or distant stage diagnosis rates were mediators of the changes in cancer mortality rates. Results: The data consisted of 16,470 state-year observations stratified by age, sex and race. In our adjusted analyses with all cancer sites combined, there were decreases in the distant stage cancer incidence rate (OR: 0.966, 95% CI = 0.942 - 0.991, P=.009) and cancer mortality rate (OR: 0.974, 95% CI = 0.950 - 0.999, P=.041) after Medicaid expansion in expansion relative to non-expansion states. There were no expansion-associated changes in localized cancer incidence rates (OR: 0.989, P=.45). Changes in distant stage cancer incidence mediated 26% of the expansion-associated change in cancer mortality ( P=.013). By cancer site, there were Medicaid expansion-associated decreases in cancer mortality rates for breast (OR: 0.954, P<.001), cervical (OR: 0.934, P=.020), and colorectal (OR: 0.945, P=.045) cancers, though local or distant stage incidence rates were not found to be statistically significant mediators. Conclusions: Medicaid expansion was associated with decreased metastatic stage cancer incidence and decreased overall cancer mortality. Approximately 25% of the improvements in cancer mortality can be attributed to decreases in metastatic diagnoses suggesting increased rates of curative-intent treatment, amongst other factors. Remaining survival benefits may reflect access to timely, quality cancer care not captured in this analysis.

Disparities in place of death from prostate cancer revealed by disaggregation of Asian race.

187 Background: Place of death (PoD) is a surrogate determinant of health care inequity in patients with cancer. Aggregation of Asian Americans, a diverse group, may mask significant health disparities in end-of-life care. Methods: De-identified death certificate data were obtained via the National Center for Health Statistics. All adult (> 18 years of age) prostate cancer deaths from 2018 to 2019 were included. Multinomial logistic regression was used to test for differences in place of death associated with sociodemographic variables. Results: From 2018 through 2019, 81,292 adults died from prostate cancer. Overall, most Asians were less likely to die at home (p < 0.05) or nursing facility (p < 0.05) compared to White patients. Significant differences in nursing facility use was noted in disaggregated analysis, with Samoan patients 12.44 times more likely to die in a hospice facility compared to hospital (CI 2.89, 53.6; p < 0.001) and Chinese patients 100 times less likely to die in a hospice facility (CI 0.01, 0.02; p < 0.001) to give two notable examples. Chinese (OR 0.26), Guamanian (OR 0.2), and Vietnamese race (OR 0.05) had the lowest likelihood of dying at home, with odds ratio lower than Black race (OR 0.3) (Table). Conclusions: Increased attention to PoD over recent years has highlighted issues around equity in end-of-life care. Overall, our data underscore important differences among Asian subpopulations and possible barriers to quality end of life care that would otherwise be masked with data aggregation. It is well known that resources are needed to allow death at home or at a nursing facility. Further qualitative work is planned to investigate culture differences contributing to PoD differences for patients with cancer through the lens of the social determinants of health.

Excess deaths after tropical cyclones in the United States

Background and aim In the US, hurricanes and other tropical cyclones have a devastating impact on society and are an important public health concern. Knowledge of excess deaths is essential for understanding the true public health burden of climate-related disasters. However, methodology to calculate post-tropical cyclone deaths has been hitherto inconsistent; even estimates for the same tropical cyclone can vary greatly, such as for Hurricane Maria in 2017, for which official death counts were up to seventy times lower than the total number of excess deaths. Methods We used mortality data from the National Center for Health Statistics and a comprehensive record of tropical cyclone occurrence in the US over 31 years (1988 – 2018). For each tropical cyclone, we formulated a Bayesian ensemble of forecasting models to estimate monthly all-cause and cause-specific death rates for the six months after exposure of tropical cyclone-impacted counties—defined as counties with a sustained maximal wind speed ≥34 knots—for the counterfactual scenario that these counties were not exposed to the tropical cyclone. We compared actual death rates to counterfactual rates and used population estimates to calculate excess deaths. We also examined how excess deaths varied by age group, sex, and social vulnerability. Results There were 106 named tropical cyclones which contributed to US exposures in 1,206 counties during 1988 – 2018. In initial estimates, we found that for Hurricane Sandy in 2012, there were 172 [95%CrI,125–226] post-tropical cyclone excess deaths; the official figure is 72. For Hurricane Katrina in 2005, there were 1,793 [95%CrI,1,559–2,105] post-tropical cyclone excess deaths; the official figure is 1,836. Conclusions A full cataloguing of excess deaths by cause, age group, sex, and social vulnerability with a consistent methodology improves understanding of the true public health burden of hurricanes and other tropical cyclones.

Type of household firearm ownership and firearm suicide among adolescents, 1976–2018

After declining steadily for almost two decades, the rate of firearm suicide among adolescents (aged 15–19 years) has increased nearly every year since 2007. At the same time, overall levels of household firearm ownership have been declining. In this paper, we examined whether and how types of firearms in the homes of adolescents have changed over time, and the extent to which such changes are associated with trends in firearm suicides among adolescents. Our analyses focused on understanding these trends among Black and White male and female adolescents to better understand longstanding race-gender differences in firearm ownership and firearm suicide. With combined data from the General Social Survey (GSS) and the National Center for Health Statistics (NCHS), the findings show that handgun ownership in Black and White households increased over the last four decades, while overall levels of firearm ownership declined. Increases in handgun ownership were predictive of increased firearm suicide rates among White adolescents, especially among males. We found no significant relationship between firearm suicide among Black adolescents and firearm ownership among Black households, regardless of gun type, which is potentially unsurprising given that firearm ownership is substantially lower in Black households compared to White households. Possibly reflecting race and gender differences in household gun ownership, our findings also show that rates of firearm suicide were lower for Black and female adolescents and highest for White male adolescents. Taken together, these findings provide new evidence on the relationship between trends in firearm ownership and adolescent firearm suicide and address important questions about the influence of race and gender for understanding firearm suicide among adolescents.

Variation in and Factors Associated With US County-Level Cancer Mortality, 2008-2019

The association between cancer mortality and risk factors may vary by geography. However, conventional methodological approaches rarely account for this variation. To identify geographic variations in the association between risk factors and cancer mortality. This geospatial cross-sectional study used county-level data from the National Center for Health Statistics for individuals who died of cancer from 2008 to 2019. Risk factor data were obtained from County Health Rankings & Roadmaps, Health Resources and Services Administration, and Centers for Disease Control and Prevention. Analyses were conducted from October 2021 to July 2022. Conventional random forest models were applied nationwide and by US region, and the geographical random forest model (accounting for local variation of association) was applied to assess associations between a wide range of risk factors and cancer mortality. The study included 7 179 201 individuals (median age, 70-74 years; 3 409 508 women [47.5%]) who died from cancer in 3108 contiguous US counties during 2008 to 2019. The mean (SD) county-level cancer mortality rate was 177.0 (26.4) deaths per 100 000 people. On the basis of the variable importance measure, the random forest models identified multiple risk factors associated with cancer mortality, including smoking, receipt of Supplemental Nutrition Assistance Program (SNAP) benefits, and obesity. The geographical random forest model further identified risk factors that varied at the county level. For example, receipt of SNAP benefits was a high-importance factor in the Appalachian region, North and South Dakota, and Northern California; smoking was of high importance in Kentucky and Tennessee; and female-headed households were high-importance factors in North and South Dakota. Geographic areas with certain high-importance risk factors did not consistently have a corresponding high prevalence of the same risk factors. In this cross-sectional study, the associations between cancer mortality and risk factors varied by geography in a way that did not correspond strictly to risk factor prevalence. The degree to which other place-specific characteristics, observed and unobserved, modify risk factor effects should be further explored, and this work suggests that risk factor importance may be a preferable paradigm for selecting cancer control interventions compared with risk factor prevalence.

A Dynamic Visualization Tool of Local Trends in Heart Disease and Stroke Mortality in the United States.

Efforts in the US to prevent and treat cardiovascular disease (CVD) contributed to large decreases in death rates for decades; however, in the last decade, progress has stalled, and in many counties, CVD death rates have increased. Because of these increases, there is heightened urgency to disseminate high-quality data on the temporal trends in CVD mortality. The Local Trends in Heart Disease and Stroke Mortality Dashboard is an online, interactive visualization of US county-level death rates and trends for several CVD outcomes across stratifications of age, race and ethnicity, and sex. This powerful visualization tool generates national maps of death rates and trends, state maps of death rates and trends, county-level line plots of annual death rates, and bar charts of percentage changes. County-level death rates and trends were estimated by applying a Bayesian spatiotemporal model to data obtained from the National Vital Statistics System of the National Center for Health Statistics and US Census bridged-race intercensal estimates for the years 1999 through 2019. The Local Trends in Heart Disease and Stroke Mortality Dashboard makes it easy for public health practitioners, health care providers, and community leaders to monitor county-level spatiotemporal trends in CVD mortality by age group, race and ethnicity, and sex and provides key information for identifying and addressing local health inequities in CVD mortality trends.

Impact of fruit and vegetable benefits on pregnancy outcomes among WIC participants: a natural experiment.

Proper nutrition is critical for maternal and neonatal health. In January 2017, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in San Francisco, California, began providing an additional $40 per month in fruit and vegetable (F&V) benefits to pregnant clients with the goal of improving food security and nutrition-related outcomes. We evaluated whether pregnant women on WIC who received this additional F&V benefit exhibited better perinatal and birth outcomes compared with those who received standard WIC benefits. We used 2010-2019 birth certificate data from the National Center for Health Statistics. The intervention group consisted of WIC participants living in San Francisco (SF) County (intervention county) and whose first trimester started after January 2017. We used a quasi-experimental synthetic control method to compare trends between the intervention and control groups (a weighted sample of other California counties that did not distribute additional F&V benefits). Outcomes included low birth weight, preterm birth, small-for-gestational-age, gestational diabetes, and gestational weight gain. No significant differences in maternal and neonatal outcomes among WIC recipients in SF and synthetic control group were observed after the F&V benefits were distributed. Prior studies have shown that additional F&V benefits have positive effects on maternal and infant outcomes, indicating that F&V vouchers are a promising strategy for supporting equitable health outcomes. Our null results suggest that more rigorous research is needed to determine their optimal dose and duration, especially in high-cost-of-living areas, and to examine more upstream and structural interventions.

Question evaluation for real-time surveys: Lessons from COVID-19 data collection

The need for high-quality, real-time data has never presented itself as clearly as it did during the COVID-19 pandemic. Responding to the COVID-19 pandemic, from both a policy and a public health perspective, required timely, accurate data about the public's attitudes and behaviors from health surveillance, monitoring, and public opinion surveys. The uniqueness of the COVID-19 pandemic also created particular challenges for survey data collection, specifically, how to develop high quality survey questions on topics that had never been previously fielded. To account for this challenge, the National Center for Health Statistics adopted an iterative, two-component, mixed-method approach to question design and evaluation. The first, a cognitive interviewing study using virtual, online interviews was used to produce interpretative schemata of the response processes underlying the survey questions. The second, a two-round, mixed method survey using a statistically-sampled panel, was designed to further develop the interpretive schemata and to allow for detailed subgroup analyses. To increase the usefulness of the survey's second round, cognitive interview findings and results from the survey's first round were used to develop both open- and close-ended embedded probes. Taken together, the studies reveal the specific problems for question-design during such a novel, quickly-evolving event: 1) a lack of shared understanding of novel concepts and vocabulary, 2) the shifting reference period respondents use to think about attitudes and behaviors during a multi-year event, 3) the pervasive nature of the event that therefore frames how respondents conceptualize and process questions about unrelated topics. This iterative approach to understanding question-design problems not only allowed for the continuing improvement of COVID-19 survey items, going forward, it also provided a methodological foundation for question development for high quality, real-time data collection.

Exploring inequalities in life expectancy and lifespan variation by race/ethnicity and urbanicity in the United States: 1990 to 2019

Background/ObjectiveInvestigating trends in life expectancy and lifespan variation can highlight disproportionate mortality burdens among population subgroups. We examined inequalities in life expectancy and lifespan variation by race/ethnicity and by urbanicity in the US from 1990 to 2019. MethodsUsing vital registration data for 322.0 million people in 3,141 counties from the National Center for Health Statistics, we obtained life expectancy at birth and lifespan variation for 16 race/ethnicity-gender-urbanicity combinations in six 5-year periods (1990–1994 to 2015–2019). Race/ethnicity was categorized as Hispanic, and non-Hispanic White, Black, and Asian/Pacific Islander. Urbanicity was categorized as metropolitan vs nonmetropolitan areas, or in six further detailed categorizations. Life expectancy and lifespan variation (coefficient of variation) were computed using life tables. ResultsIn 2015–2019, residents in metropolitan areas had higher life expectancies than their nonmetropolitan counterparts (79.6 years compared to 77.0 years). The widest inequality in life expectancy occurred between Asian/Pacific Islander women and Black men, with a 17.7-year gap for residents in metropolitan areas and a 16.9-year gap for residents in nonmetropolitan areas. Nonmetropolitan areas had greater dispersion around average age at death. Black individuals had the highest lifespan variations in both metropolitan and nonmetropolitan areas. Until the mid-2010s, life expectancy increased while lifespan variation decreased; however, recent trends show stagnation in life expectancy and increases in lifespan variation. Metropolitan-nonmetropolitan inequalities in both life expectancy and lifespan variation widened over time. ConclusionDespite previous improvements in longevity, life expectancy is now stagnating while lifespan variation is increasing. Our results highlight that early-life deaths (i.e., young- and middle-age mortality) disproportionately affect Black individuals, who not only live the shortest lifespans but also have the most variability with respect to age at death.

Prescribing Narcotics for Pain: Reconsider the Fifth Vital Sign.

Prescribing Narcotics for Pain: Reconsider the Fifth Vital Sign.

Abstract P022: The Geographic Variations In Hypertension Medication Adherence

Objective: Hypertension (HTN) affects 47% of adults in the United States (US). Medication adherence is difficult to achieve due to its benign course. This study aims to characterize the difference in HTN medication adherence between major regions of the US and the incongruity between urban and rural areas. Methods: This is a cross-sectional study consisting of 11,494 persons, representing over 71 million adults in the US, with a diagnosis of HTN. Data was obtained from the National Health Interview Survey in 2020. Variables include HTN medication adherence, access to regular care, household region, and urban-rural classification as defined by the National Center for Health Statistics. Chi-square test and logistic regression was used to compare the study groups. Results: HTN medication adherence was 75.6% in large urban (LU), 81.5% in large fringe urban (FU), 81.1% in medium urban (MU), and 83.3% in nonmetro (NM) areas [p < 0.001]. Using urban as the baseline comparison for a logistic regression model, a statistically significant difference was observed between LU and each individual group [p < 0.001] . This association remained significant when adjusting for covariates of BMI, marital status, insurance status, race, and age [p < 0.001]. Also, patients in LU were least likely to have a regular healthcare provider at 94.7% followed by 95.9% in FU, and 97.0% in MU and NM [p < 0.01]. Adherence across U.S. regions, defined as Northeast, South, Midwest, and West was statistically significant [p <0.01]. On logistic regression, West had a significantly lower adherence rate at 76.6% when compared to other regions [OR 0.69; 95% CI 0.56, 0.85; p < 0.05]. The odds increased further when adjusting for covariates of BMI, marital status, insurance status, race, and age [AOR 0.74; 95% CI 0.58, 0.95; p < 0.05]. Conclusion: Urban areas are associated with lower rates of HTN medication adherence with increasing adherence in smaller communities. Additionally, Western US is correlated with a lower adherence rate compared to other regions. Further investigation into sources for this discrepancy is warranted, including potential differences in public health campaigns, prescribing practices, and follow up care. This knowledge could assist in the development of targeted solutions.

Lesion-Specific Congenital Heart Disease Mortality Trends in Children: 1999 to 2017.

Congenital heart disease (CHD) is a leading cause of premature death in infants and children. Currently limited data are available regarding lesion specific mortality over time. Our study aimed to describe pediatric mortality trends by CHD lesion in the United States. We conducted a 19 year analysis (1999 to 2017) of publicly available, deidentified multiple cause of death data compiled and produced by the National Center for Health Statistics. Analysis was stratified by CHD diagnosis and age using 3 age categories (infants, 1 to 4 years, and 5 to 17 years). Temporal trends of CHD mortality and the effect of contributing risk factors were analyzed by using joinpoint regression. Mortality was highest for in infants for all CHD lesions, in particular for total anomalous pulmonary venous return. Significant declines in infant CHD mortality occurred for most other lesions. Contributing risk factors, including prematurity, extracardiac birth defects, and genetic conditions, occurred in 19% of infant CHD deaths and demonstrated worse mortality trends in the majority of lesions. Mortality rates remained highest for single ventricle lesions in all ages, with an infant mortality rate plateau in the later half of the study and progressive increasing mortality rates for children 5 to 17 years. CHD mortality is decreasing for most lesions. Because of the heterogenicity of CHD lesions, there is expected variability in mortality trends by lesion and age group. Single ventricle lesions continue to contribute most heavily to premature death because of CHD demonstrated by significant increases in mortality rate for children aged 5 to 17 years.

Relationship between Infant Mortality, Household Income and Race in Maryland Counties: A Short Communication

We used the data collected by the Centers for Disease Control and Prevention, National Center for Health Statistics to analyze infant crude death rate data in Maryland counties between 1999 and 2020 and compared this data to household income data collected by the US Census in the same Maryland counties. We found a significant inverse relationship and correlation between infant deaths and household income in Maryland counties. It is likely that low income plays a role in low birth weight in these infants and therefore may be related to the major cause of infant mortality.

Lost on the frontline, and lost in the data: COVID-19 deaths among Filipinx healthcare workers in the United States.

BackgroundFilipinx Americans working in healthcare are at risk for COVID-19 death but lack consistent mortality data on healthcare worker deaths. The lack of disaggregated data for Asian subgroups proliferates anti-Asian structural racism as the needs of high-risk groups are systematically undetected to merit a proper public health response. We work around this aggregated data problem by examining how the overrepresentation of Filipinxs in healthcare contributes to COVID-19 mortality among Asian American populations.MethodsTo overcome the lack of COVID-19 mortality data among Filipinx American healthcare workers, we merged data from several sources: Kanlungan website (the only known public-facing source of systematically reported mortality data on Filipinx healthcare workers nationally and globally), National Center for Health Statistics, and 2014–2018 American Community Survey. We examined county-level associations using t-tests, scatterplots, and linear regression.FindingsA higher percentage of Filipinxs among Asian Americans was correlated with a higher percentage of COVID-19 decedents who are Asian Americans (r = 0.24, p = 0.01). The percentage of Filipinx in healthcare remained a strong predictor of COVID-19 deaths among Asian Americans even after adjusting for age, poverty, and population density (coef = 1.0, p < 0.001). For every 1% increase in Filipinx among the healthcare workforce, the percentage of Asian American COVID-19 decedents increased by 1%.InterpretationOur study shows that the overrepresentation of Filipinxs in healthcare contributes to COVID-19 mortality disparities among Asian Americans. Our findings advocate for systems change by practicing anti-racist data agendas that collect and report on Asian subgroups for effective real-time targeted approaches against health inequities.

Income Inequality and Pregnancy-Associated Homicide in the US: A Longitudinal, State-Level Analysis.

Pregnancy-associated homicide remains an understudied yet critical issue. Using restricted use mortality files provided by the National Center for Health Statistics and the National Violent Death Reporting System, annual state-level pregnancy-associated homicide ratios were estimated as the count of deaths divided by the number of live births. The exposure, the state Gini index, was categorized into tertiles to compare states by levels of income inequality. In the final adjusted longitudinal linear model, those who experienced the greatest amount of income inequality had a significant 1.28 per 100,000 homicide rate when compared to the lowest income inequality tertile.

Saving light, losing lives: How daylight saving time impacts deaths from suicide and substance abuse.

This paper estimates the impact of Daylight Saving Time (DST) on deaths from suicide and substance abuse in the United States. Using Multiple Cause-of-Death Mortality Data from the National Vital Statistics System of the National Center for Health Statistics from 1979 to 1988, the effect is identified in two ways: a regression discontinuity design that exploits discrete time changes in the Spring and Fall; and a fixed effects model that uses a policy change and a switching mechanism that introduces random variation to DST's start and end dates. This is one of the first attempts to estimate the impact of DST on deaths due to suicide and substance abuse and the first to use either identification strategy. The results from both methods suggest that the sleep disruptions during the Spring transition cause the suicide rate to rise by 6.25 percent and the death rate from suicide and substance abuse combined to increase by 6.59 percent directly after the time change. There is no evidence for any change in these outcomes during the Fall transition. The contrasting results from Spring to Fall suggest the entire effect can be attributed to disruptions in sleep patterns rather than changes in ambient light exposure.

A Female Career in Research

After a long career at the National Center for Health Statistics, I retired and joined the Stanford Prevention Research Center as an unpaid associate. I was once described by a former US Food and Drug Administration commissioner as "one of the great epidemiologists." The chair of the Harvard nutrition department, speaking on National Public Radio, once described my research as "rubbish." Both may be exaggerations. Here I address some of the events that led to these contrasting descriptions. I also address the extent to which the so-called Matilda effect may have influenced my career. Are women in science on an equal footing with men? The Matilda effect suggests not. Unlike the Matthew effect for scientists, whereby those of higher prestige accrue a disproportionate share of recognition and rewards, the Matilda effect proposes that women scientists are systematically undervalued and underrecognized. I could never get a faculty job and was often treated like an underling. Nonetheless I persevered to publish highly cited research on several high-profile and sometimes controversial topics. Though overt sexism in science and workplaces has diminished over the course of my career, progress toward eliminating unconscious bias has been slower. The Matthew and Matilda effects are still powerful forces that distort incentives and rewards in science.

The association between Toxoplasma infection and mortality: the NHANES epidemiologic follow-up study

BackgroundToxoplasma gondii has been reported to be associated with higher mortality in patients with schizophrenia. This study aimed to explore the relationship between T. gondii infection and 25-year mortality based on data from the Third National Health and Nutrition Examination Survey (NHANES III) database.MethodsCases with serum T. gondii antibody test results were included in this study and the corresponding mortality dataset was obtained from the US National Center for Health Statistics (NCHS). Propensity score matching (PSM) was used to match age and sex between groups. The Cox proportional hazards model was used to evaluate the effect of T. gondii infection on mortality.ResultsA total of 14,181 cases were included in the analysis, of which 3831 (27.0%) were seropositive for T. gondii antibody. The median follow-up time of the whole cohort was 22.5 (interquartile range 16.3, 24.5) years. A total of 5082 deaths were observed in this cohort, a mortality rate of 35.8%. All-cause mortality was significantly higher in the seropositive group than in the seronegative group (50.0% vs 30.6%, P < 0.001). Kaplan–Meier analysis showed a significant difference in the survival time between two groups before and after PSM. Multivariate analysis showed that T. gondii infection was independently associated with higher all-cause mortality after adjusting for potential confounders.ConclusionsToxoplasma gondii infection is associated with higher mortality in general population.Graphical

Racial Differences in Firearms Used and Autopsies Following Gun Deaths Exist

IntroductionDisparities in gun violence across race are well documented. Studying these disparities is essential to reduce preventable gun deaths. This study evaluates the relationship between sociodemographic factors and firearms used in gun deaths. Materials and methodsThis retrospective cohort study of firearm mortalities from 2009 to 2018 used the Mortality Multiple Cause-of-Death Public Use Record from the National Center for Health Statistics. The primary outcome was the type of firearm used and the secondary outcome was autopsy status. Factors of interest include race, ethnicity, gender, marital status, age, education, and place of death. Factors significantly associated with outcomes in univariate analyses were included in separate multivariate logistic regression models for assaults, intentional self-harm, and accidents. ResultsA total of 276,127 firearm deaths from 2009 to 2018 were analyzed. Compared to White victims, Black victims were less likely to die from handguns (accident: odds ratio [OR] = 0.70, P < 0.05; self-harm: OR = 0.84, P < 0.001; assault: OR = 0.58, P < 0.001) and rifles, shotguns, or large firearms (accident: OR = 0.30, P < 0.001; self-harm: OR = 0.37, P < 0.001; assault: OR = 0.28, P < 0.001). Black decedents were more likely to undergo autopsy than White decedents (accident: OR = 2.14, P < 0.001; intentional self-harm: OR = 2.02, P < 0.001; assault: OR = 2.02, P < 0.001). Ethnicity, gender, marital status, age, education, and other racial identities were also associated with firearms used and autopsy rates (P < 0.05). ConclusionsDifferences in firearms used and autopsy rates following gun deaths exist by race, ethnicity, gender, marital status, age, and education. Future studies should investigate the relationship between sociodemographic factors and firearms used and autopsy status following gun deaths.

Deprescribing: What About Vitamins, Minerals, and Other Nutritional Supplements?

Deprescribing: What About Vitamins, Minerals, and Other Nutritional Supplements?