Widening educational disparities in premature death rates in twenty six States in the United States, 1993-2007

Background

Eliminating socioeconomic disparities in health is an overarching goal of the U.S. Healthy People decennial initiatives. We present recent trends in mortality by education among working-aged populations.

Methods and Findings

Age-standardized death rates and their average annual percent change for all-cause and five major causes (cancer, heart disease, stroke, diabetes, and accidents) were calculated from 1993 through 2007 for individuals aged 25–64 years by educational attainment as a marker of socioeconomic status, using national vital registration data for 26 states with consistent educational information on the death certificates. Rate ratios and rate differences were used to assess disparities (≤12 versus ≥16 years of education) for 1993 through 2007. From 1993 through 2007, relative educational disparities in all-cause mortality continued to increase among working-aged men and women in the U.S., due to larger decreases of mortality rates among the most educated coupled with smaller decreases or even worsening trends in the less educated. For example, the rate ratios of all-cause mortality increased from 2.5 (95% confidence interval (CI), 2.4–2.6) in 1993 to 3.6 (95% CI, 3.5–3.7) in 2007 in men and from 1.9 (95% CI, 1.8–2.0) to 3.0 (95% CI, 2.9–3.1) in women. Generally, the rate differences (per 100,000 persons) of all-cause mortality increased from 415.5 (95% CI, 399.1–431.9) in 1993 to 472.7 (95% CI, 460.2–485.2) in 2007 in men and from 165.4 (95% CI, 154.5–176.2) to 256.2 (95% CI, 248.3–264.2) in women. Disparity patterns varied largely across the five specific causes considered in this study, with the largest increases of relative disparities for accidents, especially in women.

Conclusions

Relative educational differentials in mortality continued to widen among men and women despite emphasis on reducing disparities in the U.S. Healthy People decennial initiatives.     

Chickenpox in Canada, 1924-87.

Because of the lack of an effective vaccine and the difficulty in implementing any effective control measures, physicians and public health practitioners have paid little attention to understanding the epidemiologic features of chickenpox. No data on the incidence rate in Canada are available for 1959-85. However, Ontario data suggest an overall decrease in the annual rate during the 1960s and a stable rate since the mid-1970s. High incidence rates are expected among children 5 to 9 years of age because of their susceptibility and their greater exposure in school. Low incidence rates among older age groups are expected, because most of these people have already been exposed to the virus. The disease is more serious among infants than among other children. The risk of death from chickenpox is also highest among infants. More patient-specific information and improved collection of incidence data are required to measure any impact from future control procedures, including the use of vaccines currently being developed.     

Time required for approval of new drugs in Canada,Australia, Sweden,the United Kingdom and the United States in 1996-1998

BACKGROUND: The timeliness with which national regulatory agencies approve new drugs for marketing affects health care professionals and patients. An unnecessarily long approval process delays access to new medications that may improve patients'' health status. The author compared drug approval times in Canada, Australia, Sweden, the United Kingdom and the United States. METHODS: Application and approval dates of new chemical or biological substances (excluding diagnostic products, and new salts, esters, dosage forms and combinations of previously approved substances) approved for marketing in the 5 countries from January 1996 to December 1998 were requested from the relevant pharmaceutical companies. Data on new drug approvals during the study period were also obtained from the national drug regulatory agencies in Canada, Australia and Sweden and from publications of the US Food and Drug Administration. RESULTS: A total of 219 new drugs were identified as being approved in at least one of the countries during the study period: 23 (10.5%) in all 5 countries, 23 (10.5%) in 4, 27 (12.3%) in 3, 42 (19.2%) in 2, and 104 (47.5%) in 1 country. By individual nation, 97 drugs were identified as being approved in Canada, 94 in Australia, 107 in Sweden, 55 in the UK and 123 in the US. Approval times in Canada and Australia were similar (medians 518 and 526 days respectively), but both countries had significantly longer approval times than Sweden (median 371 days), the UK (median 308 days) and the US (median 369 days). This pattern was consistent across all 3 years and for the 23 new drugs approved in all 5 countries during the 3-year period. Median approval times in Canada were similar in all of the reviewing divisions of Health Canada''s Therapeutic Product Program (539-574 days) except the Central Nervous System Division (428 days) and the Bureau of Biologics and Radiopharmaceuticals (698 days). INTERPRETATION: Median drug approval times during 1996-1998 decreased by varying amounts from the 1995 values in all 5 countries. However, the median approval time in Canada continues to be significantly longer than the times achieved in Sweden, the UK and the US, and it remains considerably longer than Canada''s own target of 355 days for all new drugs.     

Aboriginal mortality in Canada, the United States and New Zealand

Indigenous populations in New World nations share the common experience of culture contact with outsiders and a prolonged history of prejudice and discrimination. This historical reality continues to have profound effects on their well-being, as demonstrated by their relative disadvantages in socioeconomic status on the one hand, and in their delayed demographic and epidemiological transitions on the other. In this study one aspect of aboriginals' epidemiological situation is examined: their mortality experience between the early 1980s and early 1990s. The groups studied are the Canadian Indians, the American Indians and the New Zealand Maori (data for Australian Aboriginals could not be obtained). Cause-specific death rates of these three minority groups are compared with those of their respective non-indigenous populations using multivariate log-linear competing risks models. The empirical results are consistent with the proposition that the contemporary mortality conditions of these three minorities reflect, in varying degrees, problems associated with poverty, marginalization and social disorganization. Of the three minority groups, the Canadian Indians appear to suffer more from these types of conditions, and the Maori the least.     

National Trends in the Ambulatory Treatment of Hypertension in the United States, 1997-2012

Importance

Hypertension is common and costly. Over the past decade, new antihypertensive therapies have been developed, several have lost patent protection and additional evidence regarding the safety and effectiveness of these agents has accrued.

Objective

To examine trends in the use of antihypertensive therapies in the United States between 1997 and 2012.

Design, Setting and Participants

We used nationally representative audit data from the IMS Health National Disease and Therapeutic Index to examine the ambulatory pharmacologic treatment of hypertension.

Outcome Measures

Our primary unit of analysis was a visit where hypertension was a reported diagnosis and treated with a pharmacotherapy (treatment visit). We restricted analyses to the use of six therapeutic classes of antihypertensive medications among individuals 18 years or older.

Results

Annual hypertension treatment visits increased from 56.9 million treatment visits (95% confidence intervals [CI], 53.9–59.8) in 1997 to 83.3 million visits (CI 79.2–87.3) in 2008, then declined steadily to 70.9 million visits (CI 66.7–75.0) by 2012. Angiotensin receptor blocker utilization increased substantially from 3% of treatment visits in 1997 to 18% by 2012, whereas calcium channel blocker use decreased from 27% to 18% of visits. Rates of diuretic and beta-blocker use remained stable and represented 24%–30% and 14–16% of visits, respectively. Use of direct renin inhibitor accounted for fewer than 2% of annual visits. The proportion of visits treated using fixed-dose combination therapies increased from 28% to 37% of visits.

Conclusions

Several important changes have occurred in the landscape of antihypertensive treatment in the United States during the past decade. Despite their novel mechanism of action, the adoption rate of direct renin inhibitors remains low.     

Increased rates of illness and death from asthma in Canada.

Recent rates of illness and death from asthma in Canada and rates of hospital admission/separation for asthma were examined by age group and region. The death rates were higher in 1982-84 than in 1970-72, especially among those aged 15 to 34 years. Increases were also noted in hospital admission/separation rates, especially among those less than 15 years of age. Hospital admission/separation rates were highest in the Maritime provinces and Saskatchewan, whereas death rates were highest in Alberta and Saskatchewan. Examination of death certificates for coding errors and recoding of certificates to a single (8th) revision of the International Classification of Diseases indicated that changes in disease coding and errors in coding did not account for the significant increase in rates of death from asthma for those aged 15 to 34 years. These increases in rates of illness and death from asthma are unexplained and warrant further investigation.     

Trends in Educational Attainment by Race/Ethnicity, Nativity, and Sex in the United States, 1989-2005

Despite the importance of education for shaping individuals' life chances, little research has examined trends and differences in educational attainment for detailed demographic subpopulations in the United States. We use labor market segmentation and cohort replacement theories, linear regression methods, and data from the National Health Interview Survey to understand educational attainment by race/ethnicity, nativity, birth cohort, and sex between 1989 and 2005 in the United States. There have been significant changes in educational attainment over time. In support of the cohort replacement theory, we find that across cohorts, females have enjoyed greater gains in education than men, and for some race/ethnic groups, recent cohorts of women average more years of education than comparable men. And in support of labor market segmentation theories, foreign-born Mexican Americans continue to possess relatively low levels of educational attainment. Our results can aid policymakers in identifying vulnerable populations, and form the base from which to better understand changing disparities in education.