The Roles of Health Condition, Health Behaviors and Socioeconomic Factors in Racial Disparities in Sepsis Mortality
Table 6a: Mediation Analyses for Age- and Sex-Adjusted Hazard for Black Mortality from Sepsis, Influenza and Pneumonia
Jordan A. Kempker, MD, MSc
2017-03-14
Introduction
Project Overview
Our goals are to: 1) examine the social and health determinants of racial disparities in sepsis mortality; 2) test the hypothesis that socioeconomic factors, health behaviors and health status will explain the racial disparity in sepsis mortality; and 3) examine if healthcare utilization is associated with decreased sepsis mortality in fully adjusted multivariate, multivariable models. We will use Cox Proportional Hazards modeling strategies to examine and rank the effects of each socioeconomic and health variable on all-cause and cause-specific age- and sex-adjusted mortality. Then each variable will be assessed for its confounding and/or mediation effects the Black race risk ratio for all-cause and cause-specific mortality. Finally, these analyses will inform the development of multivariate, multivariable models. The results will fill a critical knowledge gap in the field of sepsis epidemiology by providing the first and largest nation-level longitudinal cohort study examining the risk factors for sepsis mortality and the racial disparity in sepsis mortality. This will address an important US public health concern by potentially identifying modifiable risk factors for this prevalent disease.
Dataset
We utilize the 1999-2005 National Health Interview Surveys (NHIS) linked at the individual-level to outcomes in the National Death Index (NDI), years 1999-2011. The outcomes of interest in this analysis is combined septicemia and influenza/pneumonia mortality, defined using the National Vital Statistics ICD-10 coding schema. these codes can occur in any position on the death record. The competing outcome of interest is ‘other cause’ mortality, deinfed as any death without an ICD-10 code for septicemia, influenza or pneumonia among the listed caused odeath on the death record.
Age- & Sex-Adjusted Mortality Hazard for Race
This report presents the results of age- and sex-adjusted Cox proportional hazard ratios for sespsis, influenza and pneumonia mortality in Blacks compared to Whites. All statistics are computed using the SAS 9.2 SURVEY family of procedures and account for the weighted, complex, multi-stage survey design of the NHIS. Missing observations are treated as missing “not completely at random”
Base Model
This forest plot represents the results of an age-group, sex, and race/ethnicity Cox PH model for sepsis/influenza/pneumonia death and censoring for other causes of death. This gives us our baseline age- and sex- adjusted hazard ratio for Blacks compared to Whites of 1.477.
| variable | Value | Probt |
|---|---|---|
| 17-24 years | NA (NA-NA) | |
| 25-34 years | 2.573 (1.276-5.187) | 0.0084 |
| 35-44 years | 6.109 (3.135-11.905) | <.0001 |
| 45-54 years | 14.766 (7.724-28.225) | <.0001 |
| 55-64 years | 39.815 (21.043-75.333) | <.0001 |
| 65-74 years | 97.635 (52.088-183.009) | <.0001 |
| 75 years and over | 308.108 (163.648-580.089) | <.0001 |
| Non-Hispanic White | NA (NA-NA) | |
| Hispanic | 1.067 (0.918-1.239) | 0.3976 |
| Other | 0.942 (0.72-1.233) | 0.6632 |
| Non-Hispanic Black | 1.477 (1.303-1.673) | <.0001 |
| Female | NA (NA-NA) | |
| Male | 1.44 (1.33-1.559) | <.0001 |
Health Status
Comorbid Medical Conditions
| Label | Value | Probt |
|---|---|---|
| Asthma | 1.47 (1.3-1.67) | <.0001 |
| Hay Fever | 1.48 (1.3-1.67) | <.0001 |
| Severe headache/migrain3(3m)? | 1.48 (1.3-1.68) | <.0001 |
| Angina | 1.49 (1.31-1.68) | <.0001 |
| Cancer | 1.53 (1.35-1.73) | <.0001 |
| Chronic bronchitis | 1.48 (1.31-1.68) | <.0001 |
| Diabetes mellitus | 1.39 (1.22-1.57) | <.0001 |
| Emphysema | 1.51 (1.33-1.71) | <.0001 |
| Heart condition | 1.51 (1.33-1.72) | <.0001 |
| Hypertension | 1.41 (1.24-1.6) | <.0001 |
| Weak or failing kidneys | 1.44 (1.27-1.64) | <.0001 |
| Liver condition | 1.48 (1.3-1.67) | <.0001 |
| Myocardial infarction | 1.5 (1.32-1.7) | <.0001 |
| Neck pain | 1.49 (1.31-1.69) | <.0001 |
| Limb pain | 1.49 (1.31-1.69) | <.0001 |
| Sinusitis(12m) | 1.48 (1.31-1.68) | <.0001 |
| Stroke | 1.46 (1.29-1.65) | <.0001 |
| Stomach or intenstinal ulcer | 1.49 (1.31-1.69) | <.0001 |
General Health Condition
| Label | Value | Probt |
|---|---|---|
| Compared to 1 yr age, health is | 1.46 (1.29-1.65) | <.0001 |
| Days health kept you in bed(12m)? | 1.42 (1.26-1.61) | <.0001 |
| Body-mass Index | 1.46 (1.29-1.65) | <.0001 |
| Any functional limitation | 1.46 (1.29-1.65) | <.0001 |
| Limited in any way | 1.33 (1.17-1.5) | <.0001 |
| Health in general is | 1.17 (1.03-1.32) | 0.0151 |
| Need help with ADLS | 1.35 (1.19-1.54) | <.0001 |
| Need help with IADLS | 1.32 (1.16-1.5) | <.0001 |
| Health prevents working | 1.28 (1.14-1.45) | <.0001 |
| Health problem requires equipment? | 1.34 (1.18-1.51) | <.0001 |
Health Behaviors
| Label | Value | Probt |
|---|---|---|
| Alcohol Use | 1.36 (1.2-1.55) | <.0001 |
| Frequency alcohol(12m)? | 1.42 (1.25-1.61) | <.0001 |
| Chances of AIDS virus | 1.48 (1.3-1.68) | <.0001 |
| Cigarette Use | 1.49 (1.31-1.69) | <.0001 |
| Light or moderate activity | 1.35 (1.19-1.53) | <.0001 |
| Tobacco smoking status | 1.49 (1.31-1.68) | <.0001 |
| Muscle strengthening activity? | 1.46 (1.28-1.65) | <.0001 |
| Vigorous activity | 1.4 (1.23-1.58) | <.0001 |
Healthcare Utilization
| Label | Value | Probt |
|---|---|---|
| Seen health professional(12m)? | 1.47 (1.29-1.67) | <.0001 |
| Seen a general provider(12m)? | 1.48 (1.3-1.68) | <.0001 |
| Visits to ER(12m)? | 1.4 (1.23-1.59) | <.0001 |
| Overnight hospital stays(12m)? | 1.45 (1.28-1.64) | <.0001 |
| Received healthcare > 10 times(12m)? | 1.45 (1.28-1.64) | <.0001 |
| Seen a healthcare professional(2w)? | 1.46 (1.29-1.66) | <.0001 |
| Spoken to healthcare professional(2w)? | 1.49 (1.32-1.69) | <.0001 |
| Overnight in hospital(12m)? | 1.46 (1.29-1.66) | <.0001 |
| Had flu shot(12m)? | 1.51 (1.33-1.72) | <.0001 |
| Ever had a pneumonia shot? | 1.5 (1.32-1.71) | <.0001 |
| A usual place for healtchare? | 1.48 (1.3-1.68) | <.0001 |
Socioeconomic
Material Capital
| Label | Value | Probt |
|---|---|---|
| Not afford medicines(12m)? | 1.44 (1.27-1.64) | <.0001 |
| Healthcare spending(12m)? | 1.45 (1.27-1.65) | <.0001 |
| W/o health insurance(12m)? | 1.48 (1.3-1.68) | <.0001 |
| House ownership arrangement | 1.33 (1.18-1.51) | <.0001 |
| No health insurance | 1.48 (1.31-1.68) | <.0001 |
| Delayed healthcare bc of cost(12m)? | 1.47 (1.29-1.66) | <.0001 |
| Foregone healthcare bc of cost(12m) | 1.45 (1.28-1.64) | <.0001 |
| A telephone number | 1.48 (1.3-1.68) | <.0001 |
| Label | Value | Probt |
|---|---|---|
| Earnings (12m) | 1.41 (1.24-1.6) | <.0001 |
| Family Income(12m) | 1.22 (1.07-1.39) | 0.0026 |
| Family Income(12m) | 1.31 (1.15-1.49) | <.0001 |
| Income-poverty ratio | 1.16 (1.01-1.34) | 0.037 |
Human Capital
| Label | Value | Probt |
|---|---|---|
| Education achieved | 1.31 (1.15-1.48) | <.0001 |
| Language of the interview | 1.46 (1.29-1.65) | <.0001 |
| Born in the US | 1.48 (1.31-1.68) | <.0001 |
Social Capital