Disparities in Opioid Overdose Death Trends by Race/Ethnicity, 2018–2019, From the HEALing Communities Study

Objectives. To examine trends in opioid overdose deaths by race/ethnicity from 2018 to 2019 across 67 HEALing Communities Study (HCS) communities in Kentucky, New York, Massachusetts, and Ohio. Methods. We used state death certificate records to calculate opioid overdose death rates per 100 000 adult residents of the 67 HCS communities for 2018 and 2019. We used Poisson regression to calculate the ratio of 2019 to 2018 rates. We compared changes by race/ethnicity by calculating a ratio of rate ratios (RRR) for each racial/ethnic group compared with non-Hispanic White individuals. Results. Opioid overdose death rates were 38.3 and 39.5 per 100 000 for 2018 and 2019, respectively, without a significant change from 2018 to 2019 (rate ratio = 1.03; 95% confidence interval [CI] = 0.98, 1.08). We estimated a 40% increase in opioid overdose death rate for non-Hispanic Black individuals (RRR = 1.40; 95% CI = 1.22, 1.62) relative to non-Hispanic White individuals but no change among other race/ethnicities. Conclusions. Overall opioid overdose death rates have leveled off but have increased among non-Hispanic Black individuals. Public Health Implications. An antiracist public health approach is needed to address the crisis of opioid-related harms. (Am J Public Health. Published online ahead of print September 9, 2021:e1–e4. https://doi.org/10.2105/AJPH.2021.306431 )

Etiology and Outcomes of Hepatocellular Carcinoma in an Ethnically Diverse Population: The Multiethnic Cohort

Backgrounds: HCC incidence varies by race/ethnicity. We characterized racial differences in underlying etiology, presentation, and survival in the linkage of Multiethnic Cohort Study with SEER and Medicare claims. Methods: HCC characteristics, treatment, and underlying etiology in participants were obtained. Deaths were ascertained using state death certificates and the National Death Index. Risk factors were collected via questionnaires. Cox models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for death. Results: Among 359 cases, the average age at diagnosis was 75.1. The most common etiology was hepatitis C (HCV) (33%), followed by nonalcoholic fatty liver disease (NAFLD) (31%), and different by ethnicity (p < 0.0001). African Americans (AA) (59.5%) and Latinos (40.6%) were more likely to be diagnosed with HCV-related HCC. In Japanese Americans (33.1%), Native Hawaiians (39.1%), and whites (34.8%), NAFLD was the most common etiology. Receipt of treatment varied across ethnic groups (p = 0.0005); AA had the highest proportion of no treatment (50.0%), followed by Latinos (45.3%), vs. whites (15.2%). HCC (72.2%) was the most common cause of death. In a multivariate analysis, AA (HR = 1.87; 95% CI: 1.06–3.28) had significantly higher mortality compared to whites. Conclusions: We found significant ethnic differences in HCC underlying etiology, receipt of treatment, and outcome. The findings are important for reducing disparities.

Territorial wars and absolute outcomes

Why do some wars end with an absolute outcome, with state death or regime change? I argue that we are more likely to see absolute outcomes when we have territorial disputes with the potential for credible commitment problems and asymmetric disputants. In the absence of credible commitment problems, disputes are less likely to recur, and states are unlikely to seek to absorb the opponent state or remove its government. Among more symmetric disputants, states cannot impose an absolute outcome, and we are more likely to see recurrent disputes in the face of credible commitment problems. Only in very asymmetric dyads are we likely to have both the required willingness and opportunity to impose absolute outcomes to attempt to solve a credible commitment problem over territorial conflict.

Temporal trends in heart failure mortality in an integrated healthcare delivery system, California, and the US, 2001–2017

Background In recent years, decreases in mortality rates attributable to cardiovascular diseases have slowed but mortality attributable to heart failure (HF) has increased. Methods Between 2001–2017, trends in age-adjusted mortality with HF as an underlying cause for Kaiser Permanente Southern California (KPSC) members were derived through linkage with state death files and compared with trends among California residents and the US. Average annual percent change (AAPC) and 95% confidence intervals (CI) were calculated using Joinpoint regression. Analyses were repeated examining HF as a contributing cause of death. Results In KPSC, the age-adjusted HF mortality rates were comparable to California but lower than the US, increasing from 23.9 per 100,000 person-years (PY) in 2001 to 44.7 per 100,000 PY in 2017, representing an AAPC of 1.3% (95% CI 0.0%, 2.6%). HF mortality also increased in California from 33.9 to 46.5 per 100,000 PY (AAPC 1.5%, 95% CI 0.3%, 2.7%), while remaining unchanged in the US at 57.9 per 100,000 PY in 2001 and 2017 (AAPC 0.0%, 95% CI − 0.5%, 0.5%). Trends among KPSC members ≥ 65 years old were similar to the overall population, while trends among members 45–64 years old were flat between 2001–2017. Small changes in mortality with HF as a contributing cause were observed in KPSC members between 2001 and 2017, which differed from California and the US. Conclusion Lower rates of HF mortality were observed in KPSC compared to the US. Given the aging of the US population and increasing prevalence of HF, it will be important to examine individual and care-related factors driving susceptibility to HF mortality.

Validating the Matching of Patients in the Linkage of a Large Hospital System's EHR with State and National Death Databases

Background Though electronic health record (EHR) data have been linked to national and state death registries, such linkages have rarely been validated for an entire hospital system's EHR. Objectives The aim of the study is to validate West Virginia University Medicine's (WVU Medicine) linkage of its EHR to three external death registries: the Social Security Death Masterfile (SSDMF), the national death index (NDI), the West Virginia Department of Health and Human Resources (DHHR). Methods Probabilistic matching was used to link patients to NDI and deterministic matching for the SSDMF and DHHR vital statistics records (WVDMF). In subanalysis, we used deaths recorded in Epic (n = 30,217) to further validate a subset of deaths captured by the SSDMF, NDI, and WVDMF. Results Of the deaths captured by the SSDMF, 59.8 and 68.5% were captured by NDI and WVDMF, respectively; for deaths captured by NDI this co-capture rate was 80 and 78%, respectively, for the SSDMF and WVDMF. Kappa statistics were strongest for NDI and WVDMF (61.2%) and NDI and SSDMF (60.6%) and weakest for SSDMF and WVDMF (27.9%). Of deaths recorded in Epic, 84.3, 85.5, and 84.4% were captured by SSDMF, NDI, and WVDMF, respectively. Less than 2% of patients' deaths recorded in Epic were not found in any of the death registries. Finally, approximately 0.2% of “decedents” in any death registry re-emerged in Epic at least 6 months after their death date, a very small percentage and thus further validating the linkages. Conclusion NDI had greatest validity in capturing deaths in our EHR. As a similar, though slightly less capture and agreement rate in identifying deaths is observed for SSDMF and state vital statistics records, these registries may be reasonable alternatives to NDI for research and quality assurance studies utilizing entire EHRs from large hospital systems. Investigators should also be aware that there will be a very tiny fraction of “dead” patients re-emerging in the EHR.

Abstract 16350: Predicted versus Observed 10-year Cardiovascular Event Rates in a Rural Population-Based Health Program: The Heart of New Ulm Project

Introduction: Assessment of 10-year ASCVD risk via the Pooled Cohorts Equation (PCE) is a standard component of the clinician-patient risk discussion to aid treatment decisions for the primary prevention of ASCVD. However, calibration of the PCE to modern populations remains a concern. Methods: We studied a sample of individuals participating in the Heart of New Ulm (HONU) Project, a population-based health program aimed at reducing ASCVD risk in a rural, agricultural community of New Ulm, Minnesota. HONU collected baseline survey data on 5,221 individuals in 2009. For this analysis, we included participants who were aged 40-79 years, free of ASCVD at baseline and had adequate data to calculate 10-year ASCVD risk. New Ulm is served by a single healthcare system, allowing surveillance via electronic health records (EHR). EHR data and state death records were used to determine rates of non-fatal myocardial infarction and stroke, and ASCVD death from 2010-2019. ASCVD event rates were compared to estimated 10-year risks calculated using the PCE, and stratified by sex and clinically relevant risk categories. Results: The sample (n=2,819, mean age 56.1 ± 9.9 years, 59.6% female) had a low prevalence of tobacco use (8.1% current smokers), diabetes (6.5%) and higher prevalence of hypertension (44.4%) and hyperlipidemia (56.6%). The median estimated 10-year ASCVD risk for the entire sample was 5.7% (interquartile range 2.3 -13.5%) with an observed 10-year ASCVD event rate of 3.4%. ASCVD rates were lower than predicted across all risk categories in both men and women, especially in those with a 10-year risk ≥7.5% (Table). Conclusion: In a rural sample exposed to ASCVD risk reduction efforts, observed rates of ASCVD were substantially lower compared to estimated ASCVD risk. The uncertainty of current risk models and the potential for significantly lower than predicted ASCVD event rates in certain populations should be included in the clinician-patient risk discussion.

702. Characteristics of Infective Endocarditis (IE) and Predictors of 90-day Mortality Among People Who Do and Do Not Inject Drugs with IE in Seattle, Washington

Background People who inject drugs (PWID) are at high risk for IE and account for a growing proportion of IE cases in the United States. We describe key characteristics of IE and predictors of 90-day mortality among people who do and do not inject drug at two large academic medical centers. Methods We used a string-searching and pattern-matching algorithm within all discharge (DC) summaries to query the electronic medical record (EMR) for cases of IE among adults ≥18 years of age at two academic medical centers in Seattle, Washington from December 1, 2013 to July 31, 2019. All cases were chart reviewed by a member of the study team to confirm a clinical diagnosis of IE and verify housing and PWID status, the latter defined as any injection drug use in the 3 months prior to admission. Microbiology and valve involvement were extracted from DC summaries and chart-reviewed where needed. Deaths were obtained from Washington state death index, which links to our EMR. Descriptive statistics were used to compare PWID and non-PWID with IE, and Kaplan-Meier log rank tests and Cox proportional hazard models were used to assess for predictors of 90-day mortality. Results We identified 387 patients with IE, 44% (n=166) of whom were PWID. When compared to non-PWID, PWID were younger (median age 33 vs. 55 years, p&lt; 0.001) and more likely to be female (48% vs. 31%, p=0.001), homeless (41% vs. 9%, p&lt; 0.001), have coagulase-positive Staphylococcal IE (69% vs. 32%, p&lt; 0.001), and have right sided IE (66% vs. 26%, p&lt; 0.001). Seventeen percent (n=64) of patients died within 90 days of admission, including 14% (n=23) of PWID and 19% (n=41) of non-PWID, with no difference in 90-day mortality between these groups (log-rank p=0.3). In univariate analyses, having left sided IE was the only predictor of 90-day mortality (HR 4.79, 95% CI 2.18 – 10.5). Conclusion Despite PWID being significantly younger and having a much higher frequency of right sided IE, they had similar 90-day mortality to non-PWID in this contemporary, urban cohort of hospitalized IE patients. Table 1. Demographic Characteristics of People Who Do and Do Not Inject Drugs with Infective Endocarditis at Two Seattle Hospitals, 2014 – 2019 Disclosures All Authors: No reported disclosures

Public Opinion and Death Penalty Policy Under Direct Democracy Institutions: A Longitudinal Analysis of the American States

Capital punishment remains legal in most U.S. states even though only a small number of them regularly impose it. I attribute the persistence of death penalty statutes to the existence of direct democracy institutions in about half the states. Applying a longitudinal research design that leverages annual estimates of state death penalty opinion, I show that these institutions strengthen the connection between public opinion and capital punishment’s legality, indicating that they foster policy responsiveness. By extension, because citizens have generally favored capital punishment, I find that direct democracy states are more likely to have the death penalty. I also demonstrate that direct democracy increases the likelihood that policy will be congruent with majority opinion, especially in states where opinion leans strongly in one direction. The representation-enhancing effect of direct democracy, however, does not extend to the punishment’s application, as measured by states’ issuance of death sentences.

Thirty Years of Innocence

Systematic reporting of data about wrongful conviction cases in the United States typically begins with 1989, the year of the country’s first post-conviction, DNA-based exonerations. Year-end 2018 thus concludes a full thirty years of information and marks a propitious time to take stock. In this article, we provide an overview of known exonerations, innocence advocacy, and wrongful conviction-related policy reforms in the U.S. during these three decades. First, we provide a brief history of wrongful convictions in the U.S. before turning to the modern era of innocence. We describe the key sources of data pertaining to wrongful convictions and exonerations. Then, using case data from the National Registry of Exonerations, we offer a detailed analysis of national and state-by-state trends in exonerations, including annual totals, DNA- and non-DNA-exonerations, and capital case exonerations. Our examination includes factors corresponding to sources of error, state death-penalty status, and regional differences. We then discuss innocence advocacy organizations, with a particular focus on Centurion Ministries and members of the Innocence Network. This is followed by an examination of state-by-state trends in innocence-related policy reforms on key issues as identified by the Innocence Project. The final section of the article discusses the many important matters we do not yet know about wrongful convictions and poses thoughts, questions, and ideas for continued scholarship focusing on miscarriages of justice. The Appendix provides state-by-state summaries of select information relating to wrongful convictions and innocence reforms.

Abstract 270: Temporal Trends in Heart Failure Mortality in an Integrated Healthcare Delivery System, California and the US, 2001-2017

Background: In recent years declines in the rate of mortality attributable to cardiovascular diseases have slowed and mortality attributable to heart failure (HF) has increased. Objective: To examine secular trends in mortality with HF as the underlying cause in Kaiser Permanente Southern California (KPSC), California, and the US among adults 45 years of age and older from 2001 and 2017. Methods: KPSC mortality rates with HF as an underlying cause from 2001 to 2017 were derived through linkage with California State death files and were compared with rates in California and the US. Rates were age-standardized to the 2000 US Census population. Trends were examined overall and among men and women, separately, using best-fit Joinpoint regression models. Average annual percent change (AAPC) and 95% confidence intervals (CI) were calculated for the overall study period, and within earlier (2001-2011) and later (2011-2017) time periods. Results: Between 2001-2017, age-adjusted mortality rates with HF as the underlying cause were lower comparing KPSC to California and the US. In KPSC, rates increased from 23.9 to 44.7 per 100,000 person-years (PY) in KPSC, representing an AAPC of 1.3% (95% CI 0.0%, 2.6%). (Table) During the same time period, HF mortality rates in California also increased from 33.9 to 46.5 per 100,000 PY (AAPC 1.5%, 95% CI 0.3%, 2.7%), while remaining unchanged in the US at 57.9 per 100,000 PY in 2001 and 2017 (AAPC 0.0%, 95% CI -0.5%, 0.5%). AAPCs were not statistically different comparing KPSC to both California and the US (all p > 0.05). Between 2001-2011, rates of HF mortality increased in KPSC (AAPC 1.3%, 95% CI 0.0, 2.6), non-significantly increased in California (AAPC 0.2%, 95% CI -0.8%, 1.2%) and decreased in the US (AAPC -2.1%, 95% CI -2.7%, -1.5%). Between 2011-2017, rates of HF mortality increased in KPSC (AAPC 1.3%, 95% CI 0.0%, 2.6%), California (AAPC 3.7%, 95% CI 1.0%, 6.5%), and the US (AAPC 3.6%, 95% CI 2.4%, 4.8%) except among KPSC women (AAPC 0.3% [95% CI -1.6%, 2.2%]). Conclusion: Despite increases in HF mortality after 2011, rates of HF mortality were lower among KPSC compared to California and the US. Given the mortality burden of HF at older age, there is a need to improve HF prevention, treatment and management efforts earlier in life.