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2019 HSR&D/QUERI National Conference Abstract

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4038 — Major Causes of Death Accounting for Premature Mortality Among Racial/Ethnic Minority Veterans in the Veterans Health Administration

Lead/Presenter: Donna Washington,  COIN - Los Angeles
All Authors: Washington DL (VA HSR&D Center for the Study of Health Care Innovation, Implementation & Policy; Health Equity-QUERI Partnered Evaluation Center, Los Angeles, CA), Steers WN (VA HSR&D Center for the Study of Health Care Innovation, Implementation & Policy; Health Equity-QUERI Partnered Evaluation Center, Los Angeles, CA), Ziaeian B (VA HSR&D Center for the Study of Health Care Innovation, Implementation & Policy; Health Equity-QUERI Partnered Evaluation Center, Los Angeles, CA) Wong MS (VA HSR&D Center for the Study of Health Care Innovation, Implementation & Policy; Health Equity-QUERI Partnered Evaluation Center, Los Angeles, CA) Hoggatt KJ (VA HSR&D Center for the Study of Health Care Innovation, Implementation & Policy; Health Equity-QUERI Partnered Evaluation Center, Los Angeles, CA)

Objectives:
Recent evaluation of racial/ethnic variations in all-cause mortality among Veterans using VA healthcare identified disparities for Black and American Indian/Alaska Native (AIAN) Veterans, relative to Whites; decreased mortality for Asians and Hispanics; and similar mortality for Native Hawaiian/Other Pacific Islanders (NHOPIs). Identifying causes of death (CODs) disproportionately contributing to premature mortality can inform actions needed to close racial/ethnic disparities in life expectancy. Our objective was to identify CODs resulting in disproportionate premature mortality in racial/ethnic minority VA users.

Methods:
Linking VA records for all 10/2008-9/2009 VA users with National Death Index records through 12/2016, we assessed cause-specific mortality for 5,032,009 Veterans. We calculated years of potential life lost before age 75 (YPLL), as the difference between 75 and age of death for those who died before age 75, and zero for all others. We used the direct standardization method to compute joint age/sex-standardized mortality rate ratios (SRRs) by race/ethnicity compared to Whites for the overall top twenty CODs. For each racial/ethnic group, we summed YPLL for CODs with SRRs > = 1.2 (and p < 0.05; high disparity CODs), calculated the percentage of total YPLL they accounted for, and contrasted to the same CODs in Whites.

Results:
Nine CODs (A-cerebrovascular disease; B-accidents; C-diabetes; D-nephritis; E-septicemia; F-chronic liver disease/cirrhosis; G-hypertension/hypertensive renal disease; H-assault/homicide; I-HIV disease) had SRRs > = 1.2 for one or more groups: BCFI for AIANs; ACDEGHI for Blacks; CEFGHI for Hispanics; D for NHOPIs; none for Asians. High disparity CODs accounted for 24.2% of YPLL for AIANs (versus 16.7% for Whites), 17.5% for Blacks (versus 10.0%), 18.1% for Hispanics (versus 10.3%), and 1.6% for NHOPIs (versus 1.1%).

Implications:
Diabetes and HIV disease contributed to premature mortality disparities in AIANs, Blacks, and Hispanics. Seven additional high disparity CODs had more heterogeneous effects. Four CODs disproportionately affected AIANs. The "Hispanic paradox" of decreased all-cause mortality masks increased Hispanic premature mortality for 6 CODs.

Impacts:
Several CODs contributing to Veteran racial/ethnic mortality disparities are for conditions that may be prevented or controlled with guideline-adherent healthcare. Further work is needed to identify tailored best practices within VA for achieving equity in control of chronic conditions (e.g., hypertension, diabetes, HIV) and addressing behavioral risk factors.