Widening mortality disparities by educational attainment among native-born Americans adults over 3 decades of follow up: the mystery deepens

Abstract Background Educational attainment is an indicator of socioeconomic status and is inversely associated with cardiovascular risk factors and risk for incident coronary artery disease (CAD). Whether the level of educational attainment (EL) in patients with CAD influences outcomes remains understudied. Purpose To ascertain the relationship between EL and adverse outcomes in patients with CAD. We hypothesize that EL will be inversely associated with adverse outcomes in this high-risk patient population. Methods Subjects undergoing cardiac catheterization for known or suspected CAD were recruited in a cardiovascular biobank and had their highest level of educational attainment assessed using predefined options of elementary/middle school, high school, college, or graduate education. The primary outcome of interest was all-cause mortality and secondary outcomes included a composite of cardiovascular deaths and nonfatal myocardial infarction (MI) events, and nonfatal MI events during follow-up. Cox proportional hazards regression models were used to analyze the association between EL and adverse outcomes after adjustment for demographic characteristics, cardiovascular risk factors, cardiovascular medication use, and estimated zip code-based annual family income. Results Among the 6,318 subjects (mean age 64 years, 63% male, 23% black) enrolled, 998 (16%) had received graduate or a higher qualification, 2,689 (43%) had received a college education, 2,403 (38%) had received a high school education, and 228 (3%) had received elementary/middle school education. During a median follow-up of 3 years,there were 1,110 deaths from all causes, 851 cardiovascular deaths/nonfatal MI, and 286 nonfatal MI events. After adjusting for covariates and compared to patients with graduate education or higher, those with lower EL (elementary/middle school, high school, or college education) had a higher risk of all-cause mortality [hazard ratio 1.66, (95% CI 1.08, 2.54), 1.58 (95% CI 1.22, 2.04), and 1.45 (95% CI 1.13, 1.57), respectively]. Similar findings were observed for secondary outcomes. EL dichotomized at graduate education was associated with all-cause mortality (hazard ratio 1.48, 95% CI 1.16, 1.88), but this relationship was significantly modified by sex (p-interaction 0.023) and the association was attenuated among male patients (hazard ratio 1.23, 95% CI 0.94, 1.61) but not female patients (hazard ratio 2.70, 95% CI 1.53, 4.77). Conclusions Lower educational attainment is an independent predictor of adverse outcomes in patients with CAD. The causal link between low education level and increased CV risk needs further investigation. Acknowledgement/Funding Dr. Quyyumi is supported by NIH grants 5P01HL101398-02, 1P20HL113451-01, 1R56HL126558-01, 1RF1AG051633-01, R01 NS064162-01, R01 HL89650-01, HL095479-0

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Relation of fertility to educational attainment in a Kalamazoo Public School population: A follow‐up study

Eugenics Quarterly ◽

10.1080/19485565.1966.9987684 ◽

1966 ◽

Vol 13 (4) ◽

pp. 306-315 ◽

Cited By ~ 24

Author(s):

Carl Jay Bajema

Keyword(s):

Public School ◽

Educational Attainment ◽

Follow Up Study ◽

School Population

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Early emotional and behavioral difficulties and adult educational attainment:18-year follow-up of the TEMPO study

European Journal of Public Health ◽

10.1093/eurpub/cky213.890 ◽

2018 ◽

Vol 28 (suppl_4) ◽

Author(s):

M Melchior ◽

M Mary-Krause

Keyword(s):

Educational Attainment ◽

Behavioral Difficulties

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Why are patients lost to follow-up in a gynecologic oncology clinic?

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.e17571 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. e17571-e17571 ◽

Cited By ~ 1

Author(s):

V. C. Garcia ◽

A. M. Manalo ◽

J. B. Toral ◽

M. L. Siasu

Keyword(s):

Educational Attainment ◽

Marital Status ◽

Gynecologic Oncology ◽

Gynecologic Cancer ◽

Cancer Type ◽

Monthly Income ◽

Family Commitment ◽

Number Of Patients ◽

Lost To Follow Up

e17571 Background: The aim of this study is to investigate why patients are lost to follow-up in a gynecologic oncology clinic. Methods: Patients who had been lost to follow up previously, and eventually followed up between April and August 2007 were given a consent form and questionnaire to answer. An approximately equal number of patients who were not lost to follow-up were given the same questionnaire as controls. The first part of the questionnaire included the age, marital status, location, diagnosis/type of gynecologic cancer, type of intervention, educational attainment, occupation and monthly income. The second part asked directly the reason why they were lost to follow-up. Data were recorded in a computerized database via Microsoft Excel. Descriptive statistics were presented in mean, median, standard deviation, minimum, maximum and frequencies. Differences between patients who failed to follow-up (LF) and their controls (NLF) with respect to demographics, disease and treatment characteristics were assessed by an x2 test or independent t test, depending on the variable. SPSS version 15 was used to perform all analyses. A p < 0.05 was considered significant. Results: There were 50 patients who were not lost and 52 patients who were lost to follow-up. The demographic characteristics between these two groups; i.e., age, marital status, location, diagnosis/type of gynecologic cancer, type of intervention, educational attainment, occupation, and monthly income of patients were all not statistically significant. The most common reason why patients were lost to follow-up was they had no money. Other reasons included: symptoms became better or problems resolved, the follow up was at an inconvenient time and I had family commitment. Conclusions: Patients expressed that the main reason for not following-up was the lack of funds. The majority in these respondents lived below the minimum salary wages. No significant financial relationships to disclose.

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Early emotional and behavioral difficulties and adult educational attainment: an 18-year follow-up of the TEMPO study

European Child & Adolescent Psychiatry ◽

10.1007/s00787-016-0858-x ◽

2016 ◽

Vol 25 (10) ◽

pp. 1141-1143 ◽

Cited By ~ 8

Author(s):

Ariella Zbar ◽

Pamela J. Surkan ◽

Eric Fombonne ◽

Maria Melchior

Keyword(s):

Educational Attainment ◽

Behavioral Difficulties

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Neighborhood and Family Influences on Educational Attainment: Results from the Ontario Child Health Study Follow-Up 2001

Child Development ◽

10.1111/j.1467-8624.2007.00991.x ◽

2007 ◽

Vol 78 (1) ◽

pp. 168-189 ◽

Cited By ~ 69

Author(s):

Michael H. Boyle ◽

Katholiki Georgiades ◽

Yvonne Racine ◽

Cameron Mustard

Keyword(s):

Child Health ◽

Educational Attainment ◽

Health Study ◽

Family Influences

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Epigenome-wide association studies of three social determinants of health and implications for lung functions among survivors of childhood cancer

10.1101/2020.10.30.20223313 ◽

2020 ◽

Author(s):

Nan Song ◽

Jin-ah Sim ◽

Qian Dong ◽

Yinan Zheng ◽

Lifang Hou ◽

...

Keyword(s):

Educational Attainment ◽

Childhood Cancer ◽

Social Determinants Of Health ◽

Median Time ◽

Social Determinants ◽

Association Studies ◽

Personal Income ◽

Mediation Effect ◽

Survivors Of Childhood Cancer

AbstractBackgroundEmerging evidence suggests that social determinants of health (SDOH) may influence health and wellness through an epigenetic mechanism in the general population. However, the social epigenomic approach has not yet been applied to survivors of childhood cancer, a vulnerable population with elevated risk for chronic health conditions (CHCs).MethodsStudy participants were drawn from the St Jude Lifetime Cohort, a hospital-based retrospective cohort with prospective follow up. DNA methylation (DNAm) profiling was generated based on blood derived DNA collected during follow-up visit. SDOH included educational attainment, personal income, and area deprivation index (ADI) based on baseline or follow-up questionnaires and geocoding. CHCs were clinically assessed with severity grade.ResultsWe included 258 childhood cancer survivors of African ancestry (AA) (median time from diagnosis=25.2 years, interquartile range [IQR]=19.9-32.1 years) and 1,618 survivors of European ancestry (EA) (median time from diagnosis=27.3, IQR=21.1-33.7 years). Through epigenome-wide association studies, we identified 130 SDOH-CpG associations including educational attainment (N=88), personal income (N=23), and ADI (N=19) at epigenome-wide significance level (P<9×10−8). There were 13 CpGs, commonly associated with all three SDOH factors, with attenuated remaining effect sizes (36.8-48.3%) after additionally adjusting body mass index and smoking, mapped to smoking-related genes including GPR55, CLDND1, CPOX, GPR15, AHRR, PRRC2B, and ELMSAN1. Among 130 SDOH-related CpGs, three independent CpGs (cg04180924, cg1120500, and cg27470486) had a significant combined mediation effect for educational attainment (%mediation=48.9%), and a single mediator cg08064403 was found with significant mediation effect for personal income (25.9%) and ADI (24.1%) on pulmonary diffusion deficit, which showed higher incidence in AA than in EA survivors implying racial disparity which is possibly due to more disadvantageous SDOH factors in AA than in EA.ConclusionsWe demonstrated striking DNAm signatures associated with multiple SDOH factors (educational attainment, personal income, and ADI) and many epigenome-wide significant CpG sites resembling the effect of smoking exposure. We also identified an exemplified racial health disparity in pulmonary diffusion deficit between AA and EA survivors and illuminated DNAm as potential mechanistic mediators for SDOH factors using a social epigenomic approach.

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