Race Mortality Research Articles

Esophageal cancer mortality disparities between Black and White adults in the United States, 1999-2020: insights from CDC-WONDER.

Esophageal cancer significantly contributes to US cancer mortality, with notable racial disparities. This study aims to provide updated esophageal cancer mortality trends among Black and White adults from 1999 to 2020. CDC-WONDER was used to identify Black and White adults in the United States from 1999 to 2020. We calculated age-standardized mortality rates, absolute rate differences, and rate ratios to compare the mortality differences between these populations. From 1999 to 2020 in the United States, there were 303 267 esophageal cancer deaths, with significant racial disparities. The age-adjusted mortality rate for Black adults fell from 6.52 to 2.62 per 100 000, while for White adults, it declined from 4.19 to 3.97 per 100 000, narrowing the racial mortality gap. Gender-wise, the study showed a decrease in the mortality rate from 3.31 to 2.29 per 100 000 in Black women, but an increase from 1.52 to 1.99 per 100 000 in White women. Among young men, the rate dropped in Black men from 12.82 to 6.26 per 100 000 but rose in White men from 9.90 to 10.57 per 100 000. Regionally, Black adults in the Midwest and South initially had higher mortality rates than Whites, but this gap reduced over time. By 2020, Black men had lower mortality rates across all regions. Over the last two decades, age-adjusted esophageal cancer mortality decreased in Black adults but stabilized in White adults, reflecting distinct cancer trends and risk factors. The study highlights the importance of tailored public health strategies for healthcare access and risk factor management.

“Racial mortality inversion”: Black-white disparities in mortality among people experiencing homelessness in the United States

Disparities in mortality between Black and White people have long been observed. These disparities persist at all income levels. However, similar patterns in racial mortality disparities are not observed among people experiencing homelessness. Instead, studies in a handful of cities show a reversal in the Black-White mortality disparity in the United States: Black people experiencing homelessness are less likely to die compared to White people experiencing homelessness. We propose a theory of “racial mortality inversion” and test whether inverted Black-White mortality patterns are observable in homeless populations throughout the United States. Using a novel dataset of 18,618 homeless decedents in 20 localities across 10 states and the District of Columbia, we find consistent evidence for “racial mortality inversion” across time and place. Between 2015 and 2020, the aggregate White homeless mortality rate was 67.8%–138.4% higher than the rate for the Black homeless population. Inverted racial mortality rates were observed in all 20 localities and in nearly every year. Across the entire sample, higher average ages of death were also observed for Black people compared to White people experiencing homelessness in 5 of 6 years, though racial inversion in age was not consistent across localities. These findings offer novel insight into racial health disparities among people experiencing homelessness and may inform policies and programs that seek to prevent homelessness and homeless mortality across racial groups.

Credit Markets and Racial Mortality Inequality

Credit Markets and Racial Mortality Inequality

Impact of interventions to reduce racial disparities in receipt of breast cancer guideline-concordant treatment: A statewide simulation analysis.

160 Background: Inequities in the receipt of guideline-concordant treatment contribute to worse survival in Black breast cancer (BCa) patients. Inequity reduction interventions (e.g., navigation, bias training, and real-time treatment tracking) may close such treatment gaps. However, evidence to date has been derived from small-scale interventional studies, and the potential impact of these interventions on population-level disparities is unclear. The aim of this study was to simulate the effect of implementing inequity reduction interventions on observed racial inequities in treatment and downstream outcomes after BC diagnosis. Methods: We used data from the North Carolina (NC) Cancer Information and Population Health Resource - which links multi-payer claims to state cancer registry data, for women diagnosed with BCa in 2004-2017 - to calculate Black/non-Black inequities in the receipt of chemotherapy (CTx) within 4 months for women ages <70 with hormone receptor-negative stage Ib-III BCa (n=2,223) and endocrine therapy (ET) within 12 months for stage I-III hormone receptor-positive BCa (n=16,220) in NC. Using effect estimates from trials of inequity-reducing interventions, we simulated the potential increase in the proportion of patients receiving CTx or ET if such interventions were implemented statewide. We estimated the effect of this potential increase in CTx and ET receipt on 10-year BCa mortality by building cohort-, race-, and treatment receipt-stratified simulation Markov models. We report confidence bounds representing 95% of simulation results. Results: Only 70.7% and 72.9% of Black patients in our cohorts received guideline-recommend ET and CTx, respectively, in 2004-2017 (versus 74.3 and 79.4% of non-Black patients, respectively; p<.005). Statewide implementation of inequity reduction interventions could increase ET and CTx receipt among Black patients to 84.3% (79.1-89.3%) and 86.8% (81.5-91.9%), respectively. This would be expected to reduce 10-year BCa mortality among Black patients from 14.2% to 13.6% (13.3-13.9%) in the ET cohort and from 29.4% to 28.7% (28.3-29.1%) in the CTx group. As a result, the racial mortality gap would decrease from 5.7 to 5.2 (4.9-5.5) from 7.0 to 6.6 (6.2-6.9) in the CTx cohorts, respectively. Conclusions: Implementation of interventions designed to reduce treatment inequities are likely to improve cancer care equity. However, increases intreatment receipt alone will not close the BCa mortality gap. Inequities at other points on the cancer continuum, such as in pre-diagnostic risk factors, screening, diagnostic work-up, and post-treatment factors, may explain residual gaps which will require more comprehensive interventions to achieve full equity in breast cancer outcomes.

The Enduring Effects of Racial Discrimination on Income and Health

We investigate the effect of income on the long-standing racial mortality gap in the United States by using evidence from White and Black Civil War veterans who went on to receive postwar pensions. To circumvent endogeneity, we propose an exogenous source of variation in pension income: the judgment of the doctors who certified disability. We find large effects of pension income on longevity; large enough to close the Black–White mortality gap, in principle. However, because physicians discriminated against Blacks when evaluating the existence and severity of disabilities, Blacks received reduced pension benefits that failed to eliminate racial mortality gaps in practice. Our findings shed light on the role of beliefs about race, as opposed to racial animus, in contributing to racial differentials in well-being. (JEL H55, I12, I14, I24, J15, N31)

Life Expectancy Gaps Among Black and White Persons and Contributing Causes of Death in 3 Large US Cities, 2018-2019

US cities have substantial, but varying, levels of racial mortality inequities, a consequence of structural racism. As committed partners increasingly pledge to eliminate health inequities, local data are required to focus and unify efforts. To analyze the contributions of 26 cause-of-death categories to Black to White life expectancy gaps within 3 large US cities. In this cross-sectional study, data were extracted from the 2018 and 2019 National Vital Statistics System Multiple Cause of Death Restricted Use data files for deaths by race, ethnicity, sex, age, place of residence, and underlying and contributing causes of death in Baltimore, Maryland; Houston, Texas; and Los Angeles, California. Life expectancy at birth was calculated for non-Hispanic Black and non-Hispanic White populations overall and by sex using abridged life tables with 5-year age intervals. Data analysis was performed from February to May 2022. Using the Arriaga method, the proportion of the Black to White life expectancy gap was calculated overall and by sex for each city that was attributable to 26 cause-of-death categories defined using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for underlying and contributing causes of death. A total of 66 321 death records from 2018 to 2019 were analyzed, with 29 057 individuals (44%) were identified as Black, 34 745 (52%) as male, and 46 128 (70%) as aged 65 years and older. Black to White life expectancy gaps were 7.60 years for Baltimore, 8.06 years for Houston, and 9.57 years for Los Angeles. Circulatory diseases, cancer, injuries, and diabetes and endocrine disorders were top contributors to the gaps, although the order and magnitude varied by city. The contribution of circulatory diseases was 11.3 percentage points higher in Los Angeles than in Baltimore (3.76 years [39.3%] vs 2.12 years [28.0%]). The contribution of injuries to Baltimore's racial gap (2.22 years [29.3%]) was twice as large as in Houston (1.11 years [13.8%]) and Los Angeles (1.36 years [14.2%]). By assessing the composition of Black to White life expectancy gaps for 3 large US cities and categorizing deaths at a more granular level than past studies, this study provides insight into the differing underpinnings of urban inequities. This type of local data can support local resource allocation that more effectively addresses racial inequities.

S110 Racial Differences in the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP) in Acute Cholangitis: A Nationwide Time Trend Analysis, 2008-2018

Introduction: Black race was shown to have high mortality from acute cholangitis (AC) previously (1998-2009) and to undergo less endoscopic retrograde cholangiopancreatography (ERCP) (2009-2012). We conducted a longitudinal racial breakdown of ERCP performed in AC in the USA over 11 years (2008-2018). Methods: This is a retrospective longitudinal trend analysis using National Inpatient Sample. Adult patients (≥18 years old) with AC were identified. Multivariate linear or logistic regression was performed when appropriate. To control for the severity of AC, we also included severe sepsis, septic shock, systemic inflammatory response syndrome with acute organ dysfunction, acute renal failure, acute respiratory failure, thrombocytopenia, altered mental status, and abnormal coagulation in the regression model. Stata (v.14.2) was used to perform analyses considering a 2-sided P-value< 0.05 as statistically significant. Results: A total of 312,849 patients with AC were included in the analysis. Before 2015, the longitudinal trend for the overall total and early ERCPs performed in Whites and Hispanics was increasing (P< 0.01) (Table). The trend was stable in Asians but in Blacks, even though the trend for early ERCP was increasing (P< 0.01) but the overall ERCPs performed for AC remained the same (P=0.07). After 2015, the trends for both early and total ERCPs remained stable for all races (P >0.05). However, upon examining the proportion of early ERCPs among total ERCPs performed, Blacks represented the racial category with the lowest numbers (Figure). Even though the trend of proportions for all racial categories was increasing (P< 0.01) however, the rate of increase was lowest for Blacks (per year increase for Whites was 1.37%, Blacks 1.18%, Hispanics 1.47%, and 1.37 for Asians). Racial mortality comparison showed that compared to Whites, Blacks had the highest odds of mortality (for Blacks, adjusted odds ratio (aOR) 1.86, P< 0.01, Hispanics aOR 1.29, P< 0.01, Asians aOR 1.30, P=0.01). Conclusion: The modification in International Classification of Diseases (ICD) coding in 2015 resulted in an apparent sharp change in the proportion of ERCPs performed due to coding change. Even though the trend for the performance of early ERCP for AC is on the rise in all races, there still exists a racial disparity in the use of early ERCP. The black population was at risk of receiving lower rates of early ERCP (calculated as a fraction of total ERCP), which may impart higher mortality.Figure 1.: Trend for the proportion of early ERCP comparing to total ERCP (ERCP: endoscopic retrograde cholangiopancreatography, AC: acute cholangitis, %: percentage, ICD: International Classification of Diseases) Table 1. - Trends for early and total ERCP performance in acute cholangitis Year 2008 2010 2012 2014 P value a,b 2016 2018 P value a,b White Total ERCP, % 47.58 48.75 50.21 50.55 < 0.01 33.42 32.55 0.37 Early ERCP, % 24.43 25.60 28.38 29.01 < 0.01 18.89 18.90 0.99 Black Total ERCP, % 41.20 39.75 43.59 43.45 0.07 30.97 30.21 0.72 Early ERCP, % 17.34 18.09 22.58 21.93 < 0.01 13.96 14.72 0.66 Hispanic Total ERCP, % 53.87 53.85 56.36 58.14 < 0.01 35.61 35.51 0.96 Early ERCP, % 28.70 27.64 31.94 34.36 < 0.01 17.64 20.28 0.13 Asians Total ERCP, % 54.34 52.86 55.28 53.04 0.84 35.08 37.58 0.39 Early ERCP, % 31.69 27.32 33.45 33.18 0.31 17.16 22.33 0.27 ERCP: endoscopic retrograde cholangiopancreatography.aLinear P trend values.bTime-interrupted trends (before and after 2015) were obtained due to International Classification of Diseases (ICD) coding change from ICD-9 to ICD-10 in 2015.

In-Hospital Mortality Disparities Among American Indian and Alaska Native, Black, and White Patients With COVID-19

American Indian and Alaska Native populations have some of the highest COVID-19 hospitalization and mortality rates in the US, with those in Mississippi being disparately affected. Higher COVID-19 mortality rates among Indigenous populations are often attributed to a higher comorbidity burden, although examinations of these associations are scarce, and none were believed to have included individuals hospitalized in Mississippi. To evaluate whether racial mortality differences among adults hospitalized with COVID-19 are associated with differential comorbidity experiences. The described cross-sectional study used retrospective hospital discharge data from the Mississippi Inpatient Outpatient Data System. All adult (aged ≥18 years) Mississippians of a known racial identity and who had been hospitalized with COVID-19 from March 1 to December 31, 2020, in any of the state's 103 nonfederal hospitals were included. Data were abstracted on June 17, 2021. Racial identity. In-hospital mortality as indicated by discharge status. A total of 18 731 adults hospitalized with a COVID-19 diagnosis and known racial identity were included (median age, 66 [IQR, 53-76] years; 10 109 [54.0%] female; 225 [1.2%] American Indian and Alaska Native; 9191 [49.1%] Black; and 9121 [48.7%] White). Pooling across comorbidity risk groups, odds of in-hospital mortality among Black patients were 75% lower than among American Indian and Alaska Native patients (odds ratio [OR], 0.25 [95% CI, 0.18-0.34]); odds of in-hospital death among White patients were 77% lower (OR, 0.23 [95% CI, 0.16-0.31]). Within comorbidity risk group analyses, Indigenous patients with the lowest risk (Elixhauser Comorbidity Index score ≤0) had an adjusted probability of in-hospital death of 0.10 compared with 0.03 for Black patients (OR, 0.29 [95% CI, 0.10-0.82]) and 0.04 for White patients (OR, 0.37 [95% CI, 0.13-1.07]). Probability of in-hospital death at the highest comorbidity risk levels (Elixhauser Comorbidity Index score ≥16) was 0.69 for American Indian and Alaska Native patients compared with 0.28 for Black patients (OR, 0.16 [95% CI, 0.08-0.32]) and 0.25 for White patients (OR, 0.14 [95% CI, 0.07-0.27]). This cross-sectional study of US adults hospitalized with COVID-19 found that American Indian and Alaska Native patients had lower comorbidity risk scores than those observed among Black or White patients. Despite empirical associations between reduced comorbidity risk scores and reduced odds of inpatient mortality, American Indian and Alaska Native patients were significantly more likely to die in the hospital of COVID-19 than Black or White patients at every level of comorbidity risk. Alternative factors that may contribute to high mortality rates among Indigenous populations must be investigated.

Abstract 12877: National Trends of Atrial Fibrillation/Atrial Flutter Mortality in the United States From 1999 to 2019: Regional, Racial, and Gender Variations

Introduction: There is an emerging need to evaluate Atrial Fibrillation/Atrial Flutter (AF/AFL) mortality trends in different races and genders in different regions across the US. Methods: In an observational study utilizing the CDC WONDER database, age-adjusted mortality rates (AAMR) per 100,000 people for AF/AFL between 1999 and 2019 were investigated. Trends in AAMR were determined by evaluating average annual percentage changes (AAPC)s with Joinpoint regression analysis. Results: In the total US population from 1999 to 2019, AAMR due to AF/AFL has increased from 3.1 to 6.5 per 100,000 population. AF/AFL-related mortality rates have nearly doubled in all racial groups, ranging from an 84% increase in Black males (2.5 to 4.6 per 100,000) to a 123% increase in White males (3.1 to 6.9 per 100,000). AF/AFL-related mortality relative increase was highest in the West (140%) followed by Midwest (124%) and South (103%) while North East (81%) came last. Comparing white race mortality rates in different census regions, West demonstrated the highest increase in AAMR in the white population [170% in males, 138% in females]. Meanwhile, Midwest had the highest increase in the Black/African American population with a 111% increase in Females and 130% increase in Males. The Northeast showed the least increase in AAMR in both blacks and whites. Joinpoint analysis demonstrated that AF/AFL-related mortality rate has plateaued for black females and white males since 2017; the same plateau occurrence can be seen for white females since 2015 (Figure 1). Conclusion: The greatest increases in mortality occurred among white men and women and in Western states. AAMR increase has plateaued recently in white males as well as black and white females. AAPCs demonstrate that the rates of increases in AF mortality are greatest in Caucasians, followed by Asian and Black Americans.

What accounts for the racial disparity in survival from estrogen receptor-positive, axillary node-negative breast cancer in the United States? An analysis of the SEER-Oncotype database.

6534 Background: In a previous analysis of the SEER-Oncotype database (Hoskins, et al. JAMA Oncol, 2021), we reported that among women with estrogen receptor (ER)-positive, axillary node-negative breast cancer (BC), Black women were more likely than non-Hispanic White (White) women to have a high risk Oncotype Recurrence Score (RS), and the adjusted hazard for BC-specific death was 1.5-2.5 times higher for Black than for White women within each RS risk category. In this study we examined the role of health insurance, census tract socioeconomic status and tumor biology in the racial disparity in ER-positive BC mortality among US women. Methods: We obtained BC-specific survival data from the SEER-Oncotype database for women diagnosed with first primary, stages I-II, ER-positive, node-negative BC between 1/1/2004 -12/31/2015 who had an Oncotype Recurrence Score (RS) through Genomic Health Laboratory. The racial (Black:White) BC mortality disparity was estimated as a disparity hazard ratio (HR) from a series of Cox proportional hazards models of time to BC death. The baseline model adjusted for SEER registry and age at diagnosis (included in all models). We estimated the disparity HR after controlling for variable domains one at a time, as well as cumulatively in this order: neighborhood SES index (a composite measure including census tract education, income and poverty) and insurance (none, public, private); tumor biology (RS, PR status, tumor grade); tumor size; and treatment (surgery type, initiation of radiation and chemotherapy). Results: The analysis included 57,428 White and 6,003 Black women with node-negative, ER-positive BC (median follow-up = 54 months). The total disparity HR for BC death was 1.67 (95% CI: 1.37, 2.02). Tract SES and insurance together accounted for 21% of the disparity HR (adjusted HR 1.52, 95% CI: 1.22, 1.88); most of this was due to differences in insurance status, with tract SES accounting for 7% of the disparity when considered in isolation. Tumor biology (RS, PR status and grade) accounted for 30% of the disparity (adjusted HR = 1.41, 95% CI:1.14, 1.75); together, the domains of social determinants and tumor biology accounted for 50% of the disparity HR (adjusted HR = 1.30, 95% CI: 1.04, 1.62). Tumor size and treatment initiation each explained roughly 10% of the disparity HR when considered in isolation but did not account for any of the disparity once other factors were accounted for. Results obtained from additional methods for mediation analyses, including a method of rescaled coefficients and structural equation modeling (SEM) applied to discrete-time survival analysis will also be presented. Conclusions: In this study of node-negative, ER-positive BC, much of the BC survival disparity among US women could be explained by racial differences in measured tumor biology and social determinants of health.

Insurance pricing discrimination and Aristotelian equality: an application to annuity pricing

International courts often apply the social justice standard of Aristotelian equality—treating like people alike and unlike people differently—to cases involving insurance pricing discrimination. This article examines whether the use of insurance pricing variables like gender and race results in discriminatory pricing categories consisting of heterogeneous policyowners, in violation of Aristotelian equality. This article applies this discrimination standard to the pricing of annuities, drawing from studies investigating the racial mortality crossover, findings that show that the mortality rate of Black Americans falls below the rate of White Americans at advanced ages. Based on the crossover literature, this study demonstrates how race-based annuity pricing would be discriminatory because it results in heterogeneous pricing within racial pricing categories, but that insurers can control for this heterogeneity by using the wider variety of annuity pricing data (e.g., medical history, diseases, and smoking) developed in the enhanced annuity submarket. The article demonstrates how the increased use of data analytics in insurance pricing to control for heterogeneity is consistent with Aristotelian equality.

Abstract 1177: Insurance status and racial disparities in mortality for black and white head and neck cancer patients in the United States

Abstract Historically, and currently, black males have the highest mortality rates of any demographic group defined by race plus gender. Even though incidence has dropped for all demographic groups, and survival has improved as well, black males still bare a disproportionate burden of mortality. It has been reported that even when controlling for variables associated with prognosis, including socioeconomic status, black males still die at higher rates than white males. The question is whether this is true when one focuses on patients in lower socioeconomic groups where baseline health is poor for both blacks and whites. We hypothesized that patients in the lowest socioeconomic tertile would have a life expectancy that was significantly reduced compared to those of higher socioeconomic tertiles regardless of race, tumor grade, age at diagnosis, insurance status, anatomic subsite of the cancer and HPV status (all factors associated with prognosis). Towards answering this question, we analyzed de-identified data from a customized head and neck cancer dataset with HPV status, additional cancer treatment fields and census tract SES subset recode, from the Surveillance, Epidemiology and End Results (SEER) database that tracked patients diagnosed with HNSCC from 2010-2016. This retrospective cohort multivariate analysis utilized survival analysis methods such as Kaplan-Meier survival, hazard curves, regression, and the hypertabastic survival method, to analyze the survival time of our patients. Cross-tabulation between the registry SES tertile and race shows significance (p&amp;lt;0.001) with the majority of blacks (58%) in the lowest socioeconomic tertile compared to 21.9% of whites. Blacks significantly differ from whites for categories age at diagnosis (p&amp;lt;4.8E-16), subsite hypopharynx (p&amp;lt;2.6E-4), subsite oropharynx (p&amp;lt;1.5E-7), subsite tongue (p&amp;lt;4.5E-4), HPV status (p&amp;lt;3.4E-28), and presence in uninsured insurance category (p&amp;lt;4.2E-7). Individuals in the lowest SES tertile and the uninsured groups died at higher rates than their wealthier insured peers. Proportional hazards regression reveals that across all insurance groups (Insured, Uninsured, Medicaid, and Unknown), blacks had significantly shorter survival than whites. So, regardless of whether we used SES tertile rank or insurance status as proxies for SES, and despite the idea that low SES would level the mortality playing field for black and white HNSCC patients, this preliminary analysis showed otherwise. Additionally, the association of black race with additional variables associated with poor prognosis continues to confound the interpretation of these outcomes. Determining that the racial mortality disparity exists regardless of socioeconomic tertile or insurance status can guide future research to focus on biological factors that may impact survival outcome. Citation Format: Dana R. Marshall, Joycemary Amponsem, Billy R. Ballard, Mohammed A. El Kadmiri, Young J. Kim, Derek Wilus, Mohammad A. Tabatabai. Insurance status and racial disparities in mortality for black and white head and neck cancer patients in the United States [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1177.

Assessment of Racial Disparities in Mortality Rates Among Older Adults Living in US Rural vs Urban Counties From 1968 to 2016

Population-based mortality rates are important indicators of overall health status. Mortality rates may reflect underlying disparities in access to health care, quality of care, racial and geographical variations, and other socioeconomic factors associated with health. However, there is limited information on historical trends in mortality rates between older Black and White adults living in urban compared with rural communities. To examine historical trends of mortality rates among White adults compared with Black adults and among rural residents compared with urban residents by comparing sex-specific age-adjusted all-cause mortality rates between older adults of both races who reside in rural and urban counties in the US. In this county-level cross-sectional longitudinal study of US counties from January 1, 1968, to December 31, 2016, mortality data were obtained from the CDC WONDER database of the Centers for Disease Control and Prevention, and socioeconomic characteristics were obtained from the Area Health Resources Files of the US Health Resources and Services Administration. The study population included older adults (≥65 years) of Black and White ancestry living in 3131 rural and urban counties in the US. Using ordinary least squares regression analyses, race- and sex-specific trends in mortality rates with 95% CIs were examined, and trends adjusted by county-level socioeconomic characteristics using year and county fixed-effects were calculated. Data were analyzed from March 24 to May 10, 2020. Three geographic regions were examined: urban counties, rural counties adjacent to an urban county (rural-adjacent counties), and rural counties not adjacent to an urban county (rural-nonadjacent counties). All-cause age-adjusted mortality rates of Black and White adults 65 years and older. For 1968, a total of 3076 counties (19 240 437 adults ≥65 years; 11 100 000 women [57.69%]; 1 484 747 Black individuals [7.74%]) were identified; of those, 1138 counties were urban, 1018 counties were rural adjacent, and 922 counties were rural nonadjacent. For 2016, a total of 3087 counties (46 400 000 adults ≥65 years; 25 800 000 women [55.72%]; 4 447 733 Black individuals [9.60%]) were identified; of those, 1163 counties were urban, 1020 counties were rural adjacent, and 904 counties were rural nonadjacent. Between 1968 and 2016, mortality rates per 100 000 persons decreased from 9063 to 4896 deaths (46%) among White men and from 6175 to 3760 deaths (39%) among White women. During the same period, mortality rates decreased from 8801 to 5477 deaths (38%) among Black men and from 6380 to 3960 deaths (38%) among Black women. However, the racial mortality gap increased among men living in rural counties after 1980. From 1968 to 2016, the mortality rate among White men decreased from 9063 to 4751 deaths (48%) in urban counties, from 9113 to 5338 deaths (41%) in rural-adjacent counties, and from 8971 to 5229 deaths (42%) in rural-nonadjacent counties. The mortality rate among Black men during the same period decreased from 8715 to 5368 deaths (38%) in urban counties, from 8924 to 6458 deaths (28%) in rural-adjacent counties, and from 9500 to 6941 deaths (27%) in rural-nonadjacent counties. Rural and urban socioeconomic differences were associated with mortality rate disparities among both White and Black women. However, rural vs urban disparities in mortality rates among men remained significant, especially among Black men living in rural counties. Notably, the current mortality rate of Black men living in rural areas is similar to that of White men living in urban and rural areas in the mid-1980s. Understanding the intersectional factors associated with health disparities may help to inform public health and clinical interventions.

Independent and joint contributions of economic, social and physical environmental characteristics to mortality in the Detroit Metropolitan Area: A study of cumulative effects and pathways.

Previous studies have demonstrated associations between race-based residential segregation, neighborhood socioeconomic and physical environmental characteristics, and mortality. Relatively few studies have examined independent and joint effects of these multiple neighborhood characteristics and mortality, including potential mediating pathways. In this study we examine the extent to which associations between race-based residential segregation and all-cause mortality may be explained by multiple socioeconomic indicators and exposure to air pollutants. Drawing on data from multiple sources, we assessed bivariate associations between race-based residential segregation (operationalized as percent non-Hispanic Black), education (percent with graduate equivalency degree), poverty (percent below poverty), income inequality (GINI coefficient) and air pollution (ambient PM2.5) and age adjusted all-cause, all race mortality (henceforth all cause mortality) at the census tract level in the Detroit Metropolitan Area. We used inequality curves to assess the (in)equitable distribution of economic and environmental characteristics by census tract racial composition. Finally, we used generalized estimating equations (GEE) to examine independent and joint associations among percent NHB, education, income inequality, and air pollution to all-cause mortality, and test for mediating effects. Bivariate associations between racial composition, education, poverty, income inequality, PM2.5 and all-cause mortality were statistically significant. Census tracts with higher concentrations of NHB residents had significantly lower educational attainment, higher poverty, and greater exposure to PM2.5. In multivariate models, education, income inequality and PM2.5 fully attenuated associations between racial composition and all-cause mortality. Results are consistent with the hypothesis that race-based residential segregation is associated with heightened all-cause mortality, and that those effects are mediated by education, income inequality, and exposure to air pollution at the census tract level. Public health and cross-sector interventions to eliminate race-based residential segregation or to eliminate the maldistribution of educational and economic resources, and environmental exposures, across census tracts could substantially reduce regional inequities in all-cause mortality.

Racial disparities in mortality in the adult hispanic population.

ObjectiveWe addressed three research questions: (1) Are there racial mortality disparities in the adult Hispanic population that resemble those observed in the non-Hispanic population in the US? (2) Does nativity mediate the race-mortality relationship in the Hispanic population? and (3) What does the Hispanic mortality advantage relative to the non-Hispanic white population look like when Hispanic race is considered?MethodsWe estimated a series of parametric hazard models on eight years of mortality follow-up data and calculated life expectancy estimates using the Mortality Disparities in American Communities database.ResultsHispanic white adults experience lower mortality than their Hispanic black, American Indian and Alaska Native, Some Other Race, and multiple race counterparts. This Hispanic white advantage is found mostly among the US born. The Hispanic advantage relative to the non-Hispanic white population operates for most Hispanic race groups among the foreign born but either disappears or converts to a disadvantage for most of the non-white Hispanic groups among the US born.ContributionOur study extends the literature on the Hispanic Mortality Paradox by revealing that the adult Hispanic population experiences racial mortality disparities that closely resemble those observed in the non-Hispanic population. The Hispanic mortality advantage is mediated not only by nativity but by race. These results indicate that race is a critical factor that should be considered in any study with the goal of understanding the health and mortality profiles of the Hispanic population in the US.

Structural racism, economic opportunity and racial health disparities: Evidence from U.S. counties.

In this study, we introduce the ‘racial opportunity gap’ as a place-based measure of structural racism for use in population health research. We first detail constructing the opportunity gap using race-sex specific estimates of intergenerational economic mobility outcomes for a recent cohort. We then illustrate its utility in examining spatial variation in the racial mortality gap. First we demonstrate a correlation between the racial opportunity gap and the racial mortality gap across U.S. counties; where the gap in the adult earnings of black and white children born to families at the same income level is greater so, too, is the gap in mortality. Second, we show in a multivariable framework that the racial opportunity gap is associated with the racial mortality gap net of differences in the socioeconomic composition of the two groups. In so doing, we aim to provide population health researchers with a new empirical tool and analytic framework for examining the role of structural racism in generating racial health disparities.

Racial disparities in guideline-concordant cancer care and mortality in the United States

PurposeWe identified the frequency of racial disparities in guideline-concordant cancer care for select common disease sites in the United States and the impact of guideline concordance on mortality disparities. Methods and materialsUsing Surveillance, Epidemiology, and End Results Medicare data, we evaluated patients age >65 years of black or non-Hispanic white race who were diagnosed with stage III breast (n = 3607), stage I (n = 14,605) or III (n = 15,609) non-small cell lung, or stage III prostate (n = 3548) cancer between 2006 and 2011. Chemotherapy, surgery, and radiation therapy (RT) treatments were identified using claims data. Pearson χ2 was used to test the associations between race and guideline concordance on the basis of National Comprehensive Cancer Network curative treatment guidelines. Mortality risks were modeled using Cox proportional hazards. ResultsBlack patients were less likely to receive guideline-concordant curative treatment than non-Hispanic white patients for stage III breast cancer postmastectomy RT (53% black, 61% white; P = .0014), stage I non-small cell lung cancer stereotactic radiation or surgery (61% black, 75% white; P < .0001), stage III non-small cell lung cancer chemotherapy in addition to RT or surgery (36% black, 41% white; P = .0001), and stage III prostate cancer RT or prostatectomy (82% black, 95% white; P < .0001). Disparities in guideline concordance impacted racial mortality disparities. Specifically, hazard ratios that demonstrated elevated all-cause mortality risks in black patients were lowered (and more closely approached hazard ratio of 1.00) after adjusting for guideline concordance. A similar impact for cause-specific mortality was observed. ConclusionsRacial disparities in the receipt of curative cancer therapy impacted racial mortality disparities across multiple cancer sites. Benchmarking adherence to guideline-concordant care could represent an opportunity to stimulate improvements in disparities in cancer treatment and survival.

Disparity in breast cancer mortality by age and geography in 10 racially diverse US cities

ObjectivesAssess geographic variation in breast cancer racial mortality disparity by age cohorts in US and ten cities with large African American populations. MethodsNon-Hispanic Black (NHB) and Non-Hispanic White (NHW) female breast cancer mortality rates and NHB:NHW rate ratio (RR) (disparity) were calculated by four age group categories: <40, 40–49, 50–64 and 65+ with time period 1999–2013. ResultsIn all 10 cities and the US, the most pronounced breast cancer disparities, measured by RR, were seen among younger women. In age group <40, the RR ranges from 1.71 in Houston to 5.37 in Washington, DC. For age group 50–64, the disparity was less pronounced, ranging from 1.24 in New York to 1.72 in Chicago. For 65+ age group, there was wide city to city variation in breast cancer mortality disparity. Three cities had higher mortality for NHW compared to NHB; Baltimore 0.78, Washington DC 0.94 and New York 0.98. One city had no statistically significant racial variation in breast cancer mortality in this age group and six cities had increased NHB: NHW mortality disparities. ConclusionsWhile the mortality rate for breast cancer is lower among younger women, the NHB:NHW disparities, as measured by rate ratios, are most pronounced in these age groups. Given the absence of available data regarding incidence, stage and subtypes, further research is necessary and such research is important, given the possible policy implications of these results with respect to screening guidelines and coverage for mammography and breast cancer treatment in particular for younger NHB women.

Segregation and mortality over time and space

Few studies have been able to measure the evolution of segregation on health disparities or assess whether those disparities existed in rural communities prior to the Great Migration of African Americans to urban centers. We use a newly developed measure of historical racial residential segregation based on individual-level data. The measure exploits complete census manuscript files to identify the races of next-door neighbors. This measure is the first and only measure of historical segregation for rural communities, allowing us to greatly extend the empirical analysis of the effects of racial segregation on health over space and time. Using this comprehensive measure of racial residential segregation, we estimate the historical relationship between racial segregation and mortality. We find that conditional on racial composition, racially segregated environments had higher mortality rates and it was not always the case that the outcomes for blacks were worse than those of whites. These effects of segregation on health differed between urban and rural locations. We conclude by noting how comprehensive measures of segregation can extend the analysis of structural factors in racial health disparities to rural residents and to the historical evolution of health disparities.

Can States Simultaneously Improve Health Outcomes and Reduce Health Outcome Disparities?

IntroductionReducing racial health disparities is often stated as a population health goal, but specific targets for such improvement are seldom set. It is often assumed that improving overall health outcomes will be linked to disparity reduction, but this is not necessarily the case.MethodsWe compared the annual change from 1999 through 2013 in combined-race (black and white) mortality with the annual change in absolute and relative racial mortality disparities for US states.ResultsMedian annual improvement in combined-race mortality was 1.08% per year. Annual overall mortality rate reductions ranged from 0.24% per year in Oklahoma to 1.83% per year in Maryland. For disparities, the median for the black–white absolute gap was 3.60% per year, and the median for the relative black-to-white ratio was 1.19% per year. There was no significant correlation between the combined-race measure and either the absolute (0.03) or relative disparity measure reductions (−0.17).ConclusionFor mortality in US states over a recent period, improvement in the population mean and disparity reduction do not usually occur together. The disparity reduction rates observed may provide realistic guidance for public and private policy makers in setting goals for reducing population health disparity and creating investment priorities. As a starting point for discussion, the observed national median annual percentage improvement of 1.1 per year combined, 3.6% per year absolute gap reduction, and 1.2% per year relative gap reduction would be modest and reasonable goals.