January 2025
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15 Reads
The Lancet Public Health
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January 2025
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15 Reads
The Lancet Public Health
December 2024
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986 Reads
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4 Citations
The Lancet
Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides a comprehensive assessment of health and risk factor trends at global, regional, national, and subnational levels. This study aims to examine the burden of diseases, injuries, and risk factors in the USA and highlight the disparities in health outcomes across different states. Methods GBD 2021 analysed trends in mortality, morbidity, and disability for 371 diseases and injuries and 88 risk factors in the USA between 1990 and 2021. We used several metrics to report sources of health and health loss related to specific diseases, injuries, and risk factors. GBD 2021 methods accounted for differences in data sources and biases. The analysis of levels and trends for causes and risk factors within the same computational framework enabled comparisons across states, years, age groups, and sex. GBD 2021 estimated years lived with disability (YLDs) and disability-adjusted life-years (DALYs; the sum of years of life lost to premature mortality and YLDs) for 371 diseases and injuries, years of life lost (YLLs) and mortality for 288 causes of death, and life expectancy and healthy life expectancy (HALE). We provided estimates for 88 risk factors in relation to 155 health outcomes for 631 risk–outcome pairs and produced risk-specific estimates of summary exposure value, relative health risk, population attributable fraction, and risk-attributable burden measured in DALYs and deaths. Estimates were produced by sex (male and female), age (25 age groups from birth to ≥95 years), and year (annually between 1990 and 2021). 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws (ie, 500 random samples from the estimate's distribution). Uncertainty was propagated at each step of the estimation process. Findings We found disparities in health outcomes and risk factors across US states. Our analysis of GBD 2021 highlighted the relative decline in life expectancy and HALE compared with other countries, as well as the impact of COVID-19 during the first 2 years of the pandemic. We found a decline in the USA's ranking of life expectancy from 1990 to 2021: in 1990, the USA ranked 35th of 204 countries and territories for males and 19th for females, but dropped to 46th for males and 47th for females in 2021. When comparing life expectancy in the best-performing and worst-performing US states against all 203 other countries and territories (excluding the USA as a whole), Hawaii (the best-ranked state in 1990 and 2021) dropped from sixth-highest life expectancy in the world for males and fourth for females in 1990 to 28th for males and 22nd for females in 2021. The worst-ranked state in 2021 ranked 107th for males (Mississippi) and 99th for females (West Virginia). 14 US states lost life expectancy over the study period, with West Virginia experiencing the greatest loss (2·7 years between 1990 and 2021). HALE ranking declines were even greater; in 1990, the USA was ranked 42nd for males and 32nd for females but dropped to 69th for males and 76th for females in 2021. When comparing HALE in the best-performing and worst-performing US states against all 203 other countries and territories, Hawaii ranked 14th highest HALE for males and fifth for females in 1990, dropping to 39th for males and 34th for females in 2021. In 2021, West Virginia—the lowest-ranked state that year—ranked 141st for males and 137th for females. Nationally, age-standardised mortality rates declined between 1990 and 2021 for many leading causes of death, most notably for ischaemic heart disease (56·1% [95% UI 55·1–57·2] decline), lung cancer (41·9% [39·7–44·6]), and breast cancer (40·9% [38·7–43·7]). Over the same period, age-standardised mortality rates increased for other causes, particularly drug use disorders (878·0% [770·1–1015·5]), chronic kidney disease (158·3% [149·6–167·9]), and falls (89·7% [79·8–95·8]). We found substantial variation in mortality rates between states, with Hawaii having the lowest age-standardised mortality rate (433·2 per 100 000 [380·6–493·4]) in 2021 and Mississippi having the highest (867·5 per 100 000 [772·6–975·7]). Hawaii had the lowest age-standardised mortality rates throughout the study period, whereas Washington, DC, experienced the most improvement (a 40·7% decline [33·2–47·3]). Only six countries had age-standardised rates of YLDs higher than the USA in 2021: Afghanistan, Lesotho, Liberia, Mozambique, South Africa, and the Central African Republic, largely because the impact of musculoskeletal disorders, mental disorders, and substance use disorders on age-standardised disability rates in the USA is so large. At the state level, eight US states had higher age-standardised YLD rates than any country in the world: West Virginia, Kentucky, Oklahoma, Pennsylvania, New Mexico, Ohio, Tennessee, and Arizona. Low back pain was the leading cause of YLDs in the USA in 1990 and 2021, although the age-standardised rate declined by 7·9% (1·8–13·0) from 1990. Depressive disorders (56·0% increase [48·2–64·3]) and drug use disorders (287·6% [247·9–329·8]) were the second-leading and third-leading causes of age-standardised YLDs in 2021. For females, mental health disorders had the highest age-standardised YLD rate, with an increase of 59·8% (50·6–68·5) between 1990 and 2021. Hawaii had the lowest age-standardised rates of YLDs for all sexes combined (12 085·3 per 100 000 [9090·8–15 557·1]), whereas West Virginia had the highest (14 832·9 per 100 000 [11 226·9–18 882·5]). At the national level, the leading GBD Level 2 risk factors for death for all sexes combined in 2021 were high systolic blood pressure, high fasting plasma glucose, and tobacco use. From 1990 to 2021, the age-standardised mortality rates attributable to high systolic blood pressure decreased by 47·8% (43·4–52·5) and for tobacco use by 5·1% (48·3%–54·1%), but rates increased for high fasting plasma glucose by 9·3% (0·4–18·7). The burden attributable to risk factors varied by age and sex. For example, for ages 15–49 years, the leading risk factors for death were drug use, high alcohol use, and dietary risks. By comparison, for ages 50–69 years, tobacco was the leading risk factor for death, followed by dietary risks and high BMI. Interpretation GBD 2021 provides valuable information for policy makers, health-care professionals, and researchers in the USA at the national and state levels to prioritise interventions, allocate resources effectively, and assess the effects of health policies and programmes. By addressing socioeconomic determinants, risk behaviours, environmental influences, and health disparities among minority populations, the USA can work towards improving health outcomes so that people can live longer and healthier lives.
December 2024
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24 Reads
This appendix provides supplementary tables and figures for the paper titled “The burden of diseases, injuries, and risk factors by state in the USA, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021.”
November 2024
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3 Reads
Circulation
Background: Despite profound disparities in stroke mortality, there is limited research on geographic variation across and within US racial and ethnic populations. Research Question/Hypothesis: Do geographic trends in stroke mortality vary across and within racial and ethnic populations living in the US? We hypothesized that changes in county-level stroke mortality would vary across and within racial and ethnic groups. Methods: We applied validated small-area estimation methods to US National Vital Statistics System death certificates to estimate stroke mortality rates by county (N=3110) and race and ethnicity (American Indian or Alaska Native [AIAN], Asian, Black, Hispanic or Latino [Latino], and White) from 2000-19. Mortality estimates were corrected for race and ethnicity misclassification on death certificates and age-standardized to the 2010 Census. Results: In 2019, age-standardized county-level stroke mortality rates per 100,000 ranged from 10.9 to 170.6 among AIAN, 11.8 to 96.9 among Asian, 17.4 to 179.7 among Black, 6.5 to 114.3 among Latino, and 14.5 to 139.7 among White populations. Despite stroke mortality declining nationally among all racial and ethnic populations, there were counties where mortality increased (AIAN: 15/474; Asian: 46/667; Black: 11/1488; Latino: 154/1478; White: 46/3051), Fig . Among these counties, median absolute increases were 3.5 (IQR 1.9-5.3; max: 26.8) among AIAN, 4.1 (1.1-5.4; max: 12.2) among Asian, 7.1 (1.0-10.2; max: 52.5) among Black, 2.4 (1.3-4.6; max: 18.3) among Latino, and 5.6 (1.9-12.3; max: 47.5) among White populations. Increased stroke mortality largely occurred in the Carolinas, Florida, and Georgia (72.4% of counties with increases) for all racial and ethnic groups except AIAN, which were mostly in Oklahoma (n=9). Geographic and temporal trends also varied across stroke type. Conclusions: Stroke mortality increased in over 200 counties nationally, with differential effects by race and ethnicity. Most increases occurred in the lower South Atlantic states. These findings underscore the importance of understanding drivers of stroke mortality disparities, as well as creating prevention and treatment strategies that target populations and places at high risk.
November 2024
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12 Reads
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8 Citations
The Lancet
Background Nearly two decades ago, the Eight Americas study offered a novel lens for examining health inequities in the USA by partitioning the US population into eight groups based on geography, race, urbanicity, income per capita, and homicide rate. That study found gaps of 12·8 years for females and 15·4 years for males in life expectancy in 2001 across these eight groups. In this study, we aimed to update and expand the original Eight Americas study, examining trends in life expectancy from 2000 to 2021 for ten Americas (analogues to the original eight, plus two additional groups comprising the US Latino population), by year, sex, and age group. Methods In this systematic analysis, we defined ten mutually exclusive and collectively exhaustive Americas comprising the entire US population, starting with all combinations of county and race and ethnicity, and assigning each to one of the ten Americas based on race and ethnicity and a variable combination of geographical location, metropolitan status, income, and Black–White residential segregation. We adjusted deaths from the National Vital Statistics System to account for misreporting of race and ethnicity on death certificates. We then tabulated deaths from the National Vital Statistics System and population estimates from the US Census Bureau and the National Center for Health Statistics from Jan 1, 2000, to Dec 31, 2021, by America, year, sex, and age, and calculated age-specific mortality rates in each of these strata. Finally, we constructed abridged life tables for each America, year, and sex, and extracted life expectancy at birth, partial life expectancy within five age groups (0–4, 5–24, 25–44, 45–64, and 65–84 years), and remaining life expectancy at age 85 years. Findings We defined the ten Americas as: America 1—Asian individuals; America 2—Latino individuals in other counties; America 3—White (majority), Asian, and American Indian or Alaska Native (AIAN) individuals in other counties; America 4—White individuals in non-metropolitan and low-income Northlands; America 5—Latino individuals in the Southwest; America 6—Black individuals in other counties; America 7—Black individuals in highly segregated metropolitan areas; America 8—White individuals in low-income Appalachia and Lower Mississippi Valley; America 9—Black individuals in the non-metropolitan and low-income South; and America 10—AIAN individuals in the West. Large disparities in life expectancy between the Americas were apparent throughout the study period but grew more substantial over time, particularly during the first 2 years of the COVID-19 pandemic. In 2000, life expectancy ranged 12·6 years (95% uncertainty interval 12·2–13·1), from 70·5 years (70·3–70·7) for America 9 to 83·1 years (82·7–83·5) for America 1. The gap between Americas with the lowest and highest life expectancies increased to 13·9 years (12·6–15·2) in 2010, 15·8 years (14·4–17·1) in 2019, 18·9 years (17·7–20·2) in 2020, and 20·4 years (19·0–21·8) in 2021. The trends over time in life expectancy varied by America, leading to changes in the ordering of the Americas over this time period. America 10 was the only America to experience substantial declines in life expectancy from 2000 to 2019, and experienced the largest declines from 2019 to 2021. The three Black Americas (Americas 6, 7, and 9) all experienced relatively large increases in life expectancy before 2020, and thus all three had higher life expectancy than America 10 by 2006, despite starting at a lower level in 2000. By 2010, the increase in America 6 was sufficient to also overtake America 8, which had a relatively flat trend from 2000 to 2019. America 5 had relatively similar life expectancy to Americas 3 and 4 in 2000, but a faster rate of increase in life expectancy from 2000 to 2019, and thus higher life expectancy in 2019; however, America 5 experienced a much larger decline in 2020, reversing this advantage. In some cases, these trends varied substantially by sex and age group. There were also large differences in income and educational attainment among the ten Americas, but the patterns in these variables differed from each other and from the patterns in life expectancy in some notable ways. For example, America 3 had the highest income in most years, and the highest proportion of high-school graduates in all years, but was ranked fourth or fifth in life expectancy before 2020. Interpretation Our analysis confirms the continued existence of different Americas within the USA. One's life expectancy varies dramatically depending on where one lives, the economic conditions in that location, and one's racial and ethnic identity. This gulf was large at the beginning of the century, only grew larger over the first two decades, and was dramatically exacerbated by the COVID-19 pandemic. These results underscore the vital need to reduce the massive inequity in longevity in the USA, as well as the benefits of detailed analyses of the interacting drivers of health disparities to fully understand the nature of the problem. Such analyses make targeted action possible—local planning and national prioritisation and resource allocation—to address the root causes of poor health for those most disadvantaged so that all Americans can live long, healthy lives, regardless of where they live and their race, ethnicity, or income. Funding State of Washington, Bloomberg Philanthropies, Bill & Melinda Gates Foundation.
November 2024
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39 Reads
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5 Citations
The Lancet
August 2024
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52 Reads
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2 Citations
The Lancet Public Health
July 2024
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7 Reads
We consider statistical inference problems under uncertain equality constraints, and provide asymptotically valid uncertainty estimates for inferred parameters. The proposed approach leverages the implicit function theorem and primal-dual optimality conditions for a particular problem class. The motivating application is multi-dimensional raking, where observations are adjusted to match marginals; for example, adjusting estimated deaths across race, county, and cause in order to match state all-race all-cause totals. We review raking from a convex optimization perspective, providing explicit primal-dual formulations, algorithms, and optimality conditions for a wide array of raking applications, which are then leveraged to obtain the uncertainty estimates. Empirical results show that the approach obtains, at the cost of a single solve, nearly the same uncertainty estimates as computationally intensive Monte Carlo techniques that pass thousands of observed and of marginal draws through the entire raking process.
July 2024
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47 Reads
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2 Citations
The Lancet Public Health
May 2024
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12 Reads
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8 Citations
Obstetric Anesthesia Digest
( JAMA . 2023;330(1):52–61. doi: 10.1001/jama.2023.9043) Although the US spends more per person on health care, the maternal mortality rate (MMR) has continued to increase in the past 2 decades, while other high-income countries have been able to decrease maternal mortality. The Global Burden of Disease has studied MMRs and has estimated about 4 deaths per 100,000 live births to 44 deaths per 100,000 live births in high-income countries in 2019. Further, in the non-Hispanic Black population and non-Hispanic White population, MMRs are 2 to 4 times higher. There is a paucity of data regarding state-level trends of maternal mortality in many states. This study provided estimates of MMRs by state to support the development of maternal mortality surveillance.
... [54][55][56][57] In this Article, we have not specifically examined health disparities by race and ethnicity. However, in our other publications, 16,17,[58][59][60] we have shown significant variations in life expectancy and mortality at the county level by race and ethnicity. For instance, one of our studies 17 revealed that life expectancy for Native American and Alaska Native populations remained unchanged from 2000 to 2019, whereas it improved for other race and ethnicity groups. ...
November 2024
The Lancet
... Liver disease is a common cause of mortality in adults in the United States, resulting in over 50,000 deaths annually [1]. Liver transplantation can dramatically improve survival and quality of life for a wide range of otherwise fatal chronic hepatic diseases [2]. ...
July 2024
The Lancet Public Health
... In the Islamic Republic of Iran, a middle-income country with a population of approximately 84 million (49% female), the maternal mortality ratio was 22 deaths per 100,000 live births in 2020 which is not sufficiently low compared with some developed countries [3]. It is important to note that the majority of these deaths could have been prevented by identifying high-risk pregnant women and enhancing their quality of care before, during, and after pregnancy [2,4]. Accordingly, the Ministry of Health and Medical Education (MOHME) emphasized that risks during pregnancy must be avoided or reduced by effectively monitoring the pregnancy and ensuring timely diagnoses due to the aging population crisis in Iran. ...
May 2024
Obstetric Anesthesia Digest
... The stark contrast between central sub-Saharan Africa and other regions, where the disease burden is comparatively minimal, highlights the uneven nature of malaria's global footprint. In fact, the majority of countries outside of this specific African belt have achieved the elimination of indigenous malaria transmission, with any annual malaria cases primarily consisting of imported infections [61,62]. ...
April 2024
The Lancet
... As such, governments will need to adapt to changing family structures and aging populations. The distribution of live births is shifting, with a larger proportion occurring in the lowest-income countries, particularly in parts of Africa (Bhattacharjee et al., 2024). Moreover, while the decline in fertility indicates a decrease in the average number of children per woman, it does not necessarily mean that the average number of children among mothers is significantly lower. ...
March 2024
The Lancet
... Over the coming decades the population will see a significant increase in the number of people over the age of 65, who will require health services to meet their needs. Ireland, like many high-income countries are experiencing a reduction in fertility rates, which has the potential to affect birth rates and maternity services in the future (Bhattacharjee et al. 2024). With such a change in demographics there is a need to develop strategies that proactively respond to and manage the healthcare needs of the Irish population in the 21st century. ...
May 2024
The Lancet
... Hepatocellular carcinoma (HCC) is recognized as a major public health problem worldwide and is particularly prevalent among individuals with chronic liver disease [1,2].The most common risk factors for HCC include chronic hepatitis B and C infections, alcohol use, and non-alcoholic fatty liver disease (NAFLD). The incidence of HCC is higher in Asian and African regions where hepatitis B and C are endemic but has also been increasing in Western countries in recent years, which is associated with an increase in NAFLD and alcohol consumption [3][4][5][6]. ...
March 2024
The Lancet Public Health
... 2,3 Disparities in maternal mortality across countries are well-known, 2-4 although measurement remains challenging, with even less known about disparities in maternal health outcomes for subgroups (i.e., subnational geographic areas and demographic groups) within countries, as most estimates are country-level. 2,4 Some studies have described disparities in maternal mortality in specific settings, such as the United States, Canada, and Zambia, [5][6][7][8] and disparities in intermediate variables such as utilization of maternal healthcare services have also been documented in sub-Saharan Africa. 9,10 However, at a global level, systematic estimates of within-country disparities in maternal mortality are lacking. ...
January 2024
Obstetrical and Gynecological Survey
... Early diagnosis and timely treatment are heavily dependent on access to healthcare services. In Brazil, medical specialists and specialized care are predominantly concentrated in the central urban areas of cities with higher socioeconomic development [16,17,19,36,58,63]. Within this context, it is crucial to highlight that the Black population primarily resides in regions with lower socioeconomic development, characterized by significant disparities in healthcare accessibility across all levels of care. ...
August 2023
The Lancet Regional Health - Americas
... Our third result that poor neighborhoods with a higher concentration of Hispanic/Latino and Asian populations tend to have lower mortality risk than those with a White majority, aligns with prior research using individual or countylevel data that show lower mortality rates among Hispanic and Asian populations when compared to White populations [17,78]. In the case of Hispanic communities, the "Hispanic density-effect" is a social support hypothesis that has been proposed as a potential explanation for this phenomenon, in which stronger family ties among Hispanics help them build a sense of community, fostering better health outcomes [79]. ...
August 2023
The Lancet