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      Racial/Ethnic Disparities in Mortality Across the Veterans Health Administration

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          Abstract

          Purpose: Equal-access health care systems such as the Veterans Health Administration (VHA) reduce financial and nonfinancial barriers to care. It is unknown if such systems mitigate racial/ethnic mortality disparities, such as those well documented in the broader U.S. population. We examined racial/ethnic mortality disparities among VHA health care users, and compared racial/ethnic disparities in VHA and U.S. general populations.

          Methods: Linking VHA records for an October 2008 to September 2009 national VHA user cohort, and National Death Index records, we assessed all-cause, cancer, and cardiovascular-related mortality through December 2011. We calculated age-, sex-, and comorbidity-adjusted mortality hazard ratios. We computed sex-stratified, age-standardized mortality risk ratios for VHA and U.S. populations, then compared racial/ethnic disparities between the populations.

          Results: Among VHA users, American Indian/Alaskan Natives (AI/ANs) had higher adjusted all-cause mortality, whereas non-Hispanic Blacks had higher cause-specific mortality versus non-Hispanic Whites. Asians, Hispanics, and Native Hawaiian/Other Pacific Islanders had similar, or lower all-cause and cause-specific mortality versus non-Hispanic Whites. Mortality disparities were evident in non-Hispanic-Black men compared with non-Hispanic White men in both VHA and U.S. populations for all-cause, cardiovascular, and cancer (cause-specific) mortality, but disparities were smaller in VHA. VHA non-Hispanic Black women did not experience the all-cause and cause-specific mortality disparity present for U.S. non-Hispanic Black women. Disparities in all-cause and cancer mortality existed in VHA but not in U.S. population AI/AN men.

          Conclusion: Patterns in racial/ethnic disparities differed between VHA and U.S. populations, with fewer disparities within VHAs equal-access system. Equal-access health care may partially address racial/ethnic mortality disparities, but other nonhealth care factors should also be explored.

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          Most cited references26

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          STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions.

          Racial minorities bear a disproportionate burden of morbidity and mortality. These inequities might be explained by racism, given the fact that racism has restricted the lives of racial minorities and immigrants throughout history. Recent studies have documented that individuals who report experiencing racism have greater rates of illnesses. While this body of research has been invaluable in advancing knowledge on health inequities, it still locates the experiences of racism at the individual level. Yet, the health of social groups is likely most strongly affected by structural, rather than individual, phenomena. The structural forms of racism and their relationship to health inequities remain under-studied. This article reviews several ways of conceptualizing structural racism, with a focus on social segregation, immigration policy, and intergenerational effects. Studies of disparities should more seriously consider the multiple dimensions of structural racism as fundamental causes of health disparities.
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            Overlapping confidence intervals or standard error intervals: What do they mean in terms of statistical significance?

            We investigate the procedure of checking for overlap between confidence intervals or standard error intervals to draw conclusions regarding hypotheses about differences between population parameters. Mathematical expressions and algebraic manipulations are given, and computer simulations are performed to assess the usefulness of confidence and standard error intervals in this manner. We make recommendations for their use in situations in which standard tests of hypotheses do not exist. An example is given that tests this methodology for comparing effective dose levels in independent probit regressions, an application that is also pertinent to derivations of LC50s for insect pathogens and of detectability half-lives for prey proteins or DNA sequences in predator gut analysis.
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              "More than skin deep": stress neurobiology and mental health consequences of racial discrimination.

              Ethnic minority groups across the world face a complex set of adverse social and psychological challenges linked to their minority status, often involving racial discrimination. Racial discrimination is increasingly recognized as an important contributing factor to health disparities among non-dominant ethnic minorities. A growing body of literature has recognized these health disparities and has investigated the relationship between racial discrimination and poor health outcomes. Chronically elevated cortisol levels and a dysregulated hypothalamic-pituitary-adrenal (HPA) axis appear to mediate effects of racial discrimination on allostatic load and disease. Racial discrimination seems to converge on the anterior cingulate cortex (ACC) and may impair the function of the prefrontal cortex (PFC), hence showing substantial similarities to chronic social stress. This review provides a summary of recent literature on hormonal and neural effects of racial discrimination and a synthesis of potential neurobiological pathways by which discrimination affects mental health.
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                Author and article information

                Journal
                Health Equity
                Health Equity
                heq
                Health Equity
                Mary Ann Liebert, Inc., publishers (140 Huguenot Street, 3rd FloorNew Rochelle, NY 10801USA )
                2473-1242
                08 April 2019
                2019
                08 April 2019
                : 3
                : 1
                : 99-108
                Affiliations
                [ 1 ]VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California.
                [ 2 ]Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California.
                [ 3 ]Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California.
                [ 4 ]VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California.
                [ 5 ]Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California.
                [ 6 ]Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California.
                [ 7 ]Division of Cardiology, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California.
                Author notes
                [*] [ * ]Address correspondence to: Michelle S. Wong, PhD, VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Building 206, Los Angeles, CA 90073, michelle.wong6@ 123456va.gov
                Article
                10.1089/heq.2018.0086
                10.1089/heq.2018.0086
                6608703
                31289768
                bb7a0dd1-12a4-4099-a1c9-f56643f9424c
                © Michelle S. Wong et al. 2019; Published by Mary Ann Liebert, Inc.

                This Open Access article is distributed under the terms of the Creative Commons License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Page count
                Figures: 1, Tables: 5, References: 37, Pages: 10
                Categories
                Original Article

                health disparities,mortality,racial/ethnic disparities,veterans

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