Social Determinants and the Classification of Disease: Descriptive Epidemiology of Selected Socially Mediated Disease Constellations

Background Most major diseases have important social determinants. In this context, classification of disease based on etiologic or anatomic criteria may be neither mutually exclusive nor optimal. Methods and Findings Units of analysis comprised large metropolitan central and fringe metropolitan counties with reliable mortality rates – (n = 416). Participants included infants and adults ages 25 to 64 years with selected causes of death (1999 to 2006). Exposures included that residential segregation and race-specific social deprivation variables. Main outcome measures were obtained via principal components analyses with an orthogonal rotation to identify a common factor. To discern whether the common factor was socially mediated, negative binomial multiple regression models were developed for which the dependent variable was the common factor. Results showed that infant deaths, mortality from assault, and malignant neoplasm of the trachea, bronchus and lung formed a common factor for race-gender groups (black/white and men/women). Regression analyses showed statistically significant, positive associations between low socio-economic status for all race-gender groups and this common factor. Conclusions Between 1999 and 2006, deaths classified as “assault” and “lung cancer”, as well as “infant mortality” formed a socially mediated factor detectable in population but not individual data. Despite limitations related to death certificate data, the results contribute important information to the formulation of several hypotheses: (a) disease classifications based on anatomic or etiologic criteria fail to account for social determinants; (b) social forces produce demographically and possibly geographically distinct population-based disease constellations; and (c) the individual components of population-based disease constellations (e.g., lung cancer) are phenotypically comparable from one population to another but genotypically different, in part, because of socially mediated epigenetic variations. Additional research may produce new taxonomies that unify social determinants with anatomic and/or etiologic determinants. This may lead to improved medical management of individuals and populations

Using a Participatory Research Process to Address Disproportionate Hispanic Cancer Burden

Community-based participatory research (CBPR) offers great potential for increasing the impact of research on reducing cancer health disparities. This article reports how the Community Outreach Core (COC) of the Meharry–Vanderbilt–Tennessee State University (TSU) Cancer Partnership has collaborated with community partners to develop and implement CBPR. The COC, Progreso Community Center, and Nashville Latino Health Coalition jointly developed and conducted the 2007 Hispanic Health in Nashville Survey as a participatory needs assessment to guide planning for subsequent CBPR projects and community health initiatives. Trained community and student interviewers surveyed 500 Hispanic adults in the Nashville area, using a convenience sampling method. In light of the survey results, NLHC decided to focus in the area of cancer on the primary prevention of cervical cancer. The survey led to a subsequent formative CBPR research project to develop an intervention, then to funding of a CBPR pilot intervention study to test the intervention

Rural congestive heart failure mortality among US elderly, 1999–2013: Identifying counties with promising outcomes and opportunities for implementation research

Objective Describe modern trends in congestive heart failure (CHF) among elderly (\u3e65 years of age) in the United States, to identify potentially successful rural areas. Compare CHF mortality using multiple- (MCOD) versus underlying-(UCOD) cause of death data. Methods U.S. Centers for Disease Control and Prevention mortality files (WONDER internet site). Results Using MCOD data, overall mortality rates/100,000 population (and 95% confidence intervals) for CHF among persons \u3e65 years of age (1999–2013) were 482.0 (481.2–482.8) for large central and large fringe metropolitan (LCLF) counties, 549.6 (548.6–550.7) in small and medium metropolitan (SM) counties, and 652.6 (650.9–654.0) in micropolitan and non-core, non-metropolitan (MNCNM) counties. Twenty positive deviance NCNM counties (collectively including 198,581 residents \u3e65 years of age) had an overall CHF rate of 300.9 (275.0–326.9) in 2013. This was significantly lower than the LCLF rate for 2013 (482.0 [481.2–482.8]), and represented a reduction of 47% since 1999. Overall CHF occurrence as estimated with MCOD was 3.4-fold higher than that obtained with UCOD. Conclusion These data illustrate underestimation of CHF by UCOD data and the importance of correct death certification. Rural CHF mortality rates are higher than urban rates, but some positive deviance counties demonstrate that this is not inevitable. Further research is needed to understand the relative contribution of research innovation, medical care, and public health to rural-urban disparities and the relative success of positive deviance counties

Lack of validity of self-reported mammography data

This qualitative literature review aimed to describe the totality of peer-reviewed scientific evidence from 1990 to 2017 concerning validity of self-reported mammography. This review included articles about mammography containing the words accuracy, validity, specificity, sensitivity, reliability or reproducibility; titles containing self-report, recall or patient reports, and breast or ‘mammo’; and references of identified citations focusing on evaluation of 2-year self-reports. Of 45 publications meeting the eligibility criteria, 2 conducted in 1993 and 1995 at health maintenance organisations in Western USA which primarily served highly educated whites provided support for self-reports of mammography over 2 years. Methodological concerns about validity of self-reports included (1) telescoping, (2) biased overestimates particularly among black women, (3) failure to distinguish screening and diagnostic mammography, and (4) failure to address episodic versus consistent mammography use. The current totality of evidence supports the need for research to reconsider the validity of self-reported mammography data as well as the feasibility of alternative surveillance data sources to achieve the goals of the Healthy People Initiative

Smoking, depression, and hospital costs of respiratory cancers: Examining race and sex variation

Objective To investigate the effect of smoking and depression on hospital costs for lung cancer (LC). Methods We extracted data on depression, smoking history, demographics, and hospital charges for patients with respiratory cancers (ICD-9 codes 161–163, 165) from the 2008 Tennessee Hospital Discharge Data System. The sample (n=6665) was mostly white (86%) and male (57%). Age-adjusted rates were developed in accordance with Centers for Disease Control and Prevention methods, and hospital costs were compared for patients with LC with versus without depression and a smoking history. Results Three findings (P\u3c0.001) emerged: (1) the LC rate was higher among blacks than among whites, and higher among men than among women; (2) while 66% of LC patients smoked (more men than women without racial variation), 24% had depression (more females and whites were depressed); (3) the LC hospital cost was 54% higher than the non-LC hospital cost, and this cost doubled for patients with LC with depression and smoking versus those without such characteristics. Conclusion While LC is more prevalent among blacks and men, depression is higher among female and white patients. Since depression with higher costs existed among LC patients, our findings point to (1) the possibility of cost savings by diagnosing and treating depression among LC patients, and (2) implementation of proven smoking cessation programs to reduce LC morbidity and hospital costs

Depression effects on hospital cost of heart failure patients in California: An analysis by ethnicity and gender

Background: Depression often interferes with self-management and treatment of medical conditions. This may result in serious medical complications and escalated health-care cost. Objectives: Study distribution of heart failure (HF) cases estimates the prevalence of depression and its effects on HF-related hospital costs by ethnicity and gender. Methods: Secondary data files of California Hospital Discharge System for he year 2010 were examined. For patients with a HF diagnosis, details regarding depression, demographics, comorbid conditions, and hospital costs were studied. Age-adjusted HF rates and depression were examined for whites, blacks, Hispanics, and Asians/Pacific Islanders (AP) by comparing HF patients with depression (HF +D) versus HF without depression (HFND). Results: HF cases (n = 62,685; average age: 73) included nearly an equal number of males and females. HF rates were higher (P < 0.001) among blacks compared to Hispanics, AP, and whites and higher among males than females. One-fifth of HF patients had depression, higher among females and whites compared to males and other ethnic groups. Further, HF hospital costs for blacks and AP were higher (P < 0.001) compared to other groups. The cost for HF +D was 22% higher compared to HFND, across all gender and ethnic groups, largely due to higher comorbidities, more admissions, and longer hospitalization. Conclusion: Depression, ethnicity, and gender are all associated with increased hospital costs of HF patients. The higher HF and HF +D costs among blacks, AP, and males reflect additional burden of comorbidities (hypertension and diabetes). Prospective studies to assess if selective screening and treating depression among HF patients can reduce hospital costs are warranted