The Roles of Health Condition, Health Behaviors and Socioeconomic Factors in Racial Disparities in Sepsis Mortality
Table 4bc:Sex- Adjusted Hazard Ratios forAge at Death Sepsis Mortality
Jordan A. Kempker, MD, MSc
2018-02-16
Introduction
Project Overview
THIS OUTPUT EXAMINES HAZARD OF DEATHS WITH SEPTICEMIA CODES (A40) AND COMPARES TO DEATHS WITHOUT SEPTICEMIA OR INFLUENZA/PNEUMONIA
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
This report presents the results of age- and sex-adjusted Cox proportional hazard ratios for mortality. 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”
Demographic
| Label | response | SepticemiaHR | OtherHR |
|---|---|---|---|
| Age Group | 17-24 years | NA (NA-NA) | NA (NA-NA) |
| Age Group | 25-34 years | NA (NA-NA) | NA (NA-NA) |
| Age Group | 35-44 years | NA (NA-NA) | NA (NA-NA) |
| Age Group | 45-54 years | NA (NA-NA) | NA (NA-NA) |
| Age Group | 55-64 years | NA (NA-NA) | NA (NA-NA) |
| Age Group | 65-74 years | NA (NA-NA) | NA (NA-NA) |
| Age Group | 75 years and over | NA (NA-NA) | NA (NA-NA) |
| Gender | Male | 1.4 (1.3-1.5) | 1.4 (1.4-1.4) |
Health Status
Comorbid Medical Conditions
| Label | response | SepticemiaHR | OtherHR |
|---|---|---|---|
| Angina | Yes | 1.1 (0.9-1.2) | 0.9 (0.9-1) |
| Asthma | Yes | 1.4 (1.2-1.6) | 1.4 (1.3-1.5) |
| Cancer | Yes | 0.8 (0.8-0.9) | 0.9 (0.9-0.9) |
| Chronic bronchitis | Yes | 1.4 (1.2-1.6) | 1.3 (1.2-1.4) |
| Diabetes mellitus | Yes | 1.4 (1.2-1.5) | 1.2 (1.2-1.3) |
| Emphysema | Yes | 1.2 (1.1-1.4) | 1.2 (1.1-1.3) |
| Hay Fever | Yes | 1.3 (1.1-1.5) | 1.2 (1.1-1.3) |
| Heart condition | Yes | 1 (0.9-1) | 0.9 (0.8-0.9) |
| Hypertension | Yes | 1 (1-1.1) | 0.9 (0.9-0.9) |
| Limb pain | Yes | 1.2 (1.1-1.2) | 1.1 (1.1-1.1) |
| Liver condition | Yes | 2.2 (1.7-2.8) | 2 (1.8-2.2) |
| Myocardial infarction | Yes | 0.9 (0.8-1) | 1 (0.9-1) |
| Neck pain | Yes | 1.3 (1.1-1.4) | 1.2 (1.2-1.2) |
| Severe headache/migrain3(3m)? | Yes | 1.8 (1.6-2.1) | 1.7 (1.6-1.8) |
| Sinusitis(12m) | Yes | 1.2 (1.1-1.4) | 1.2 (1.2-1.3) |
| Stomach or intenstinal ulcer | Yes | 1.1 (1-1.2) | 1 (1-1) |
| Stroke | Yes | 0.9 (0.8-1.1) | 0.9 (0.9-1) |
| Weak or failing kidneys | Yes | 1.4 (1.2-1.6) | 1.2 (1.1-1.3) |
General Health Condition
| Label | response | SepticemiaHR | OtherHR |
|---|---|---|---|
| Any functional limitation | Not limited in any way | NA (NA-NA) | NA (NA-NA) |
| Any functional limitation | Limited in any way | 0.9 (0.8-1) | 0.7 (0.7-0.8) |
| Body-mass Index | <18.5 | 1.4 (1.3-1.6) | 1.2 (1.1-1.2) |
| Body-mass Index | 18.5-24.9 | NA (NA-NA) | NA (NA-NA) |
| Body-mass Index | 25-29.9 | 1.1 (1-1.2) | 1.2 (1.1-1.2) |
| Body-mass Index | 30-34.9 | 1.5 (1.4-1.7) | 1.5 (1.4-1.5) |
| Body-mass Index | >/=35 | 2.4 (2.1-2.8) | 2.1 (2-2.3) |
| Compared to 1 yr age, health is | Better | 1.3 (1.1-1.5) | 1.3 (1.2-1.3) |
| Compared to 1 yr age, health is | About the same | NA (NA-NA) | NA (NA-NA) |
| Compared to 1 yr age, health is | Worse | 1.2 (1.1-1.3) | 1.2 (1.1-1.2) |
| Days health kept you in bed(12m)? | None | NA (NA-NA) | NA (NA-NA) |
| Days health kept you in bed(12m)? | 1-7 days | 1.2 (1.1-1.3) | 1.3 (1.2-1.3) |
| Days health kept you in bed(12m)? | >7 days | 1.5 (1.4-1.7) | 1.4 (1.3-1.4) |
| Health in general is | Poor | 1.6 (1.4-1.9) | 1.2 (1.1-1.3) |
| Health in general is | Fair | 1.3 (1.1-1.5) | 1 (0.9-1) |
| Health in general is | Good | 1 (0.9-1.2) | 0.8 (0.8-0.9) |
| Health in general is | Very good | 0.9 (0.8-1.1) | 0.9 (0.8-0.9) |
| Health in general is | Excellent | NA (NA-NA) | NA (NA-NA) |
| Health prevents working | Yes | 1.4 (1.2-1.5) | 1.2 (1.1-1.2) |
| Health problem requires equipment? | Yes | 0.9 (0.8-1) | 0.8 (0.7-0.8) |
| Limited in any way | Not limited in any way | NA (NA-NA) | NA (NA-NA) |
| Limited in any way | Limited in any way | 1 (1-1.1) | 0.9 (0.8-0.9) |
| Need help with ADLS | Yes | 1.3 (1.1-1.4) | 0.9 (0.9-0.9) |
| Need help with IADLS | Yes | 1 (0.9-1.1) | 0.8 (0.8-0.8) |
Health Behaviors
| Label | response | SepticemiaHR | OtherHR |
|---|---|---|---|
| Alcohol Use | Lifetime abstainer [<12 drinks in lifetime] | NA (NA-NA) | NA (NA-NA) |
| Alcohol Use | Former drinker [No drinks in past year] | 1.1 (1-1.2) | 1.2 (1.1-1.2) |
| Alcohol Use | Current drinker [1+ drinks in past year] | 1.1 (1-1.2) | 1.4 (1.3-1.4) |
| Chances of AIDS virus | None | NA (NA-NA) | NA (NA-NA) |
| Chances of AIDS virus | Low | 1.4 (1.2-1.6) | 1.6 (1.5-1.7) |
| Chances of AIDS virus | Medium | 1.8 (1.1-3.2) | 1.9 (1.5-2.4) |
| Chances of AIDS virus | High/Already have AIDS/AIDS virus | 1.8 (0.8-4) | 2.9 (2.1-4) |
| Cigarette Use | None | NA (NA-NA) | NA (NA-NA) |
| Cigarette Use | 1/2 ppd | 1.9 (1.6-2.2) | 2.2 (2.1-2.4) |
| Cigarette Use | 1/2 to 1 ppd | 2.2 (1.9-2.5) | 2.8 (2.6-3) |
| Cigarette Use | > 1 ppd | 3.2 (2.6-3.9) | 3.6 (3.3-4) |
| Frequency alcohol(12m)? | None | NA (NA-NA) | NA (NA-NA) |
| Frequency alcohol(12m)? | 1-2 days/week | 1.2 (1-1.4) | 1.4 (1.3-1.5) |
| Frequency alcohol(12m)? | 3-5 days/week | 1 (0.8-1.2) | 1.3 (1.2-1.4) |
| Frequency alcohol(12m)? | 6-7 days/week | 0.8 (0.7-1) | 1 (1-1.1) |
| Light or moderate activity | None | NA (NA-NA) | NA (NA-NA) |
| Light or moderate activity | 1-3 times/week | 1 (0.9-1.1) | 1.1 (1-1.1) |
| Light or moderate activity | 4-7 times/week | 1 (0.9-1.1) | 1 (1-1.1) |
| Light or moderate activity | >7 times/week | 1 (0.8-1.3) | 1.1 (1-1.3) |
| Muscle strengthening activity? | None | NA (NA-NA) | NA (NA-NA) |
| Muscle strengthening activity? | 1-3 times/week | 1.3 (1-1.5) | 1.4 (1.3-1.5) |
| Muscle strengthening activity? | 4-7 times/week | 1 (0.9-1.3) | 1 (0.9-1) |
| Muscle strengthening activity? | >7 times/week | 0.8 (0.4-1.4) | 0.9 (0.8-1.1) |
| Tobacco smoking status | Never smoker | NA (NA-NA) | NA (NA-NA) |
| Tobacco smoking status | Former smoker | 1.2 (1.1-1.3) | 1.1 (1.1-1.2) |
| Tobacco smoking status | Current some day smoker | 2.3 (1.8-2.9) | 2.6 (2.3-2.9) |
| Tobacco smoking status | Current every day smoker | 2.4 (2.1-2.7) | 2.8 (2.7-3) |
| Vigorous activity | None | NA (NA-NA) | NA (NA-NA) |
| Vigorous activity | 1-3 times/week | 1.3 (1.1-1.5) | 1.7 (1.6-1.8) |
| Vigorous activity | 4-7 times/week | 1.2 (0.9-1.4) | 1.6 (1.5-1.7) |
| Vigorous activity | >7 times/week | 1.8 (1-3.3) | 1.8 (1.4-2.3) |
Healthcare Utilization
| Label | response | SepticemiaHR | OtherHR |
|---|---|---|---|
| A usual place for healtchare? | Yes | 0.7 (0.6-0.8) | 0.6 (0.5-0.6) |
| Ever had a pneumonia shot? | Yes | 0.7 (0.7-0.8) | 0.7 (0.7-0.7) |
| Had flu shot(12m)? | Yes | 0.7 (0.7-0.8) | 0.6 (0.6-0.6) |
| Overnight hospital stays(12m)? | None | NA (NA-NA) | NA (NA-NA) |
| Overnight hospital stays(12m)? | 1 | 1.1 (1-1.2) | 0.9 (0.9-0.9) |
| Overnight hospital stays(12m)? | > 1 | 1.2 (1.1-1.4) | 1.2 (1.1-1.3) |
| Overnight in hospital(12m)? | Yes | 1.1 (1-1.2) | 1 (1-1) |
| Received healthcare > 10 times(12m)? | Yes | 1.3 (1.2-1.4) | 1.1 (1.1-1.2) |
| Seen a general provider(12m)? | Yes | 0.8 (0.7-0.9) | 0.7 (0.7-0.8) |
| Seen a healthcare professional(2w)? | Yes | 1.1 (1-1.2) | 1 (1-1) |
| Seen health professional(12m)? | None | NA (NA-NA) | NA (NA-NA) |
| Seen health professional(12m)? | 1 | 0.7 (0.6-0.9) | 0.8 (0.7-0.8) |
| Seen health professional(12m)? | 2-3 times | 0.7 (0.6-0.9) | 0.7 (0.6-0.7) |
| Seen health professional(12m)? | >3 times | 0.8 (0.7-0.9) | 0.7 (0.6-0.7) |
| Spoken to healthcare professional(2w)? | Yes | 1.2 (1.1-1.3) | 1.1 (1.1-1.2) |
| Visits to ER(12m)? | None | NA (NA-NA) | NA (NA-NA) |
| Visits to ER(12m)? | 1 | 1 (0.9-1.1) | 1 (0.9-1) |
| Visits to ER(12m)? | 2-3 times | 1.2 (1-1.4) | 1.1 (1.1-1.2) |
| Visits to ER(12m)? | >3 times | 1.7 (1.4-2) | 1.6 (1.4-1.7) |
Socioeconomic
Material Capital
| Label | response | SepticemiaHR | OtherHR |
|---|---|---|---|
| A telephone number | No (no phone service) | 1.6 (1.2-2.1) | 2 (1.8-2.3) |
| Delayed healthcare bc of cost(12m)? | Yes | 1.9 (1.6-2.2) | 1.8 (1.7-1.9) |
| Foregone healthcare bc of cost(12m) | Yes | 2.1 (1.8-2.6) | 2 (1.9-2.2) |
| Healthcare spending(12m)? | Zero | NA (NA-NA) | NA (NA-NA) |
| Healthcare spending(12m)? | Less than $500 | 0.8 (0.8-1) | 0.8 (0.8-0.8) |
| Healthcare spending(12m)? | $500-$1,999 | 0.9 (0.8-1) | 0.8 (0.8-0.9) |
| Healthcare spending(12m)? | $2,000-$2,999 | 0.9 (0.7-1.1) | 0.9 (0.8-0.9) |
| Healthcare spending(12m)? | $3,000-$4,999 | 0.8 (0.7-1) | 0.9 (0.8-1) |
| Healthcare spending(12m)? | $5,000 or more | 0.8 (0.6-1) | 1 (0.9-1) |
| House ownership arrangement | Other arrangement | 1 (0.8-1.3) | 1 (0.9-1.1) |
| House ownership arrangement | Rented | 1.2 (1.1-1.3) | 1.2 (1.1-1.3) |
| House ownership arrangement | Owned or being bought | NA (NA-NA) | NA (NA-NA) |
| No health insurance | Not covered | 4.3 (3.4-5.3) | 5.2 (4.6-5.8) |
| Not afford medicines(12m)? | Yes | 2 (1.7-2.4) | 1.9 (1.8-2) |
| W/o health insurance(12m)? | Yes | 3.8 (2.4-5.8) | 5 (4-6.3) |
| Label | response | SepticemiaHR | OtherHR |
|---|---|---|---|
| Earnings (12m) | $0.00 | NA (NA-NA) | NA (NA-NA) |
| Earnings (12m) | $01-$4999 | 0.5 (0.3-0.9) | 0.5 (0.4-0.6) |
| Earnings (12m) | $5000-$9999 | 1 (0.6-1.7) | 0.7 (0.5-0.9) |
| Earnings (12m) | $10000-$14999 | 0.8 (0.4-1.5) | 0.7 (0.5-1) |
| Earnings (12m) | $15000-$19999 | 1 (0.6-1.9) | 1.2 (0.9-1.5) |
| Earnings (12m) | $20000-$24999 | 1.1 (0.6-2) | 1.3 (1-1.7) |
| Earnings (12m) | $25000-$34999 | 1.4 (0.8-2.5) | 1.3 (1-1.7) |
| Earnings (12m) | $35000-$44999 | 2 (1.1-3.6) | 1.5 (1.2-1.9) |
| Earnings (12m) | $45000-$54999 | 1.1 (0.5-2.2) | 1.4 (1.1-1.8) |
| Earnings (12m) | $55000-$64999 | 0.8 (0.3-2) | 1.1 (0.7-1.7) |
| Earnings (12m) | $65000-$74999 | 1.5 (0.5-4.1) | 1.7 (1.3-2.2) |
| Earnings (12m) | $75000 and over | NA (NA-NA) | NA (NA-NA) |
| Family Income(12m) | Less than $20000 (no detail) | 0.7 (0.5-0.8) | 0.6 (0.5-0.6) |
| Family Income(12m) | $20000 or more (no detail) | 0.7 (0.6-0.8) | 0.6 (0.6-0.7) |
| Family Income(12m) | Yes | 1 (0.9-1.1) | 0.8 (0.8-0.9) |
| Family Income(12m) | 0-$4999 | 1 (0.8-1.4) | 0.9 (0.8-1) |
| Family Income(12m) | $5000-$9999 | 0.9 (0.7-1.1) | 0.7 (0.6-0.7) |
| Family Income(12m) | $10000-$14999 | 0.7 (0.6-0.8) | 0.6 (0.5-0.7) |
| Family Income(12m) | $15000-$19999 | 0.7 (0.5-0.8) | 0.6 (0.6-0.7) |
| Family Income(12m) | $20000-$24999 | 0.7 (0.5-0.9) | 0.6 (0.6-0.7) |
| Family Income(12m) | $25000-$34999 | 0.7 (0.6-0.9) | 0.7 (0.7-0.8) |
| Family Income(12m) | $35000-$44999 | 0.8 (0.7-1.1) | 0.8 (0.8-0.9) |
| Family Income(12m) | $45000-$54999 | 0.8 (0.6-1) | 0.9 (0.8-1) |
| Family Income(12m) | $55000-$64999 | 0.9 (0.6-1.3) | 1 (0.9-1.1) |
| Family Income(12m) | $65000-$74999 | 0.9 (0.6-1.3) | 1.1 (0.9-1.2) |
| Family Income(12m) | $75000 and over | NA (NA-NA) | NA (NA-NA) |
| Income-poverty ratio | Under .50 | 1.4 (1.1-1.9) | 1.1 (1-1.3) |
| Income-poverty ratio | .50 to .74 | 1.6 (1.3-2) | 1.2 (1.1-1.3) |
| Income-poverty ratio | .75 to .99 | 1.2 (1-1.4) | 0.8 (0.7-0.8) |
| Income-poverty ratio | 1.00 to 1.24 | 1 (0.8-1.2) | 0.8 (0.7-0.8) |
| Income-poverty ratio | 1.25 to 1.49 | 0.8 (0.7-1) | 0.7 (0.7-0.8) |
| Income-poverty ratio | 1.50 to 1.74 | 0.8 (0.6-0.9) | 0.7 (0.7-0.8) |
| Income-poverty ratio | 1.75 to 1.99 | 0.7 (0.6-0.9) | 0.7 (0.6-0.8) |
| Income-poverty ratio | 2.00 to 2.49 | 0.8 (0.7-1) | 0.7 (0.7-0.8) |
| Income-poverty ratio | 2.50 to 2.99 | 0.9 (0.8-1.2) | 0.8 (0.8-0.9) |
| Income-poverty ratio | 3.00 to 3.49 | 1 (0.8-1.2) | 0.9 (0.8-0.9) |
| Income-poverty ratio | 3.50 to 3.99 | 0.9 (0.7-1.2) | 0.9 (0.8-1) |
| Income-poverty ratio | 4.00 to 4.49 | 1 (0.7-1.3) | 1 (0.9-1.2) |
| Income-poverty ratio | 4.50 to 4.99 | 0.8 (0.6-1.1) | 1 (0.9-1.1) |
| Income-poverty ratio | 5.00 and over | NA (NA-NA) | NA (NA-NA) |
Human Capital
| Label | response | SepticemiaHR | OtherHR |
|---|---|---|---|
| Born in the US | Yes | NA (NA-NA) | NA (NA-NA) |
| Education achieved | Never attended/ kindergarten only | 1 (0.6-2) | 0.9 (0.7-1.1) |
| Education achieved | Grades 1 - 11 | 1 (0.6-1.5) | 0.9 (0.8-1.1) |
| Education achieved | 12th grade, no diploma | 1 (0.6-1.7) | 1.1 (0.9-1.4) |
| Education achieved | HIGH SCHOOL GRADUATE | 1 (0.6-1.6) | 1 (0.9-1.3) |
| Education achieved | GED or equivalent | 1.1 (0.7-1.8) | 1.2 (1-1.5) |
| Education achieved | Some college, no degree | 1.1 (0.7-1.7) | 1.2 (1-1.4) |
| Education achieved | AA degree: technical or vocational | 1 (0.6-1.6) | 1.3 (1-1.5) |
| Education achieved | AA degree: academic program | 0.9 (0.5-1.7) | 1.3 (1-1.6) |
| Education achieved | Bachelor’s degree (BA, AB, BS, BBA) | 1.1 (0.7-1.8) | 1.1 (0.9-1.3) |
| Education achieved | Master’s degree (MA, MS, MEng, MEd, MBA) | 0.9 (0.5-1.4) | 1 (0.9-1.2) |
| Education achieved | Professional degree (MD, DDS, DVM, JD) | 0.9 (0.5-1.6) | 0.9 (0.7-1.1) |
| Education achieved | Doctoral degree (PhD, EdD) | NA (NA-NA) | NA (NA-NA) |
| Language of the interview | English | NA (NA-NA) | NA (NA-NA) |
| Language of the interview | English and Spanish | 1.7 (1.2-2.4) | 1.4 (1.2-1.6) |
| Language of the interview | Spanish | 1.6 (1.2-2.1) | 1.3 (1.1-1.5) |
Social Capital