Epidemiology • Volume 26, Number 4, July 2015
Letters
TABLE.
Simulation Results for θ = ln(0.7) Uncertain Qj (Quality Effects Model in MetaXL)
Random Effects Model
Median γ
MSE
Var
Bias Sq
CI Width
Coverage
MSE
Var
Bias Sq
CI Width
Coverage
0.000 0.686 1.124 1.475 1.793 2.098 2.359 2.754 2.991 3.171
0.043 0.116 0.163 0.220 0.251 0.297 0.332 0.367 0.397 0.436
0.043 0.113 0.157 0.210 0.238 0.281 0.315 0.349 0.377 0.415
0.000 0.004 0.006 0.011 0.013 0.016 0.017 0.017 0.020 0.022
0.691 1.666 2.098 2.419 2.726 2.982 3.196 3.443 3.623 3.806
0.964 0.968 0.971 0.972 0.974 0.973 0.970 0.973 0.972 0.970
0.028 0.183 0.318 0.461 0.585 0.736 0.865 1.018 1.167 1.324
0.026 0.177 0.313 0.455 0.578 0.730 0.859 1.013 1.162 1.319
0.002 0.006 0.005 0.006 0.007 0.006 0.007 0.005 0.005 0.005
0.517 1.317 1.621 1.846 2.037 2.207 2.347 2.507 2.623 2.736
0.957 0.864 0.846 0.830 0.820 0.804 0.793 0.788 0.776 0.762
2
No Qj Input (IVhet Model in MetaXL)
Random Qj Input
Median γ2
MSE
Var
Bias Sq
CI Width
Coverage
MSE
Var
Bias Sq
CI Width
Coverage
0.000 0.686 1.124 1.475 1.793 2.098 2.359 2.754 2.991 3.171
0.026 0.202 0.277 0.353 0.400 0.462 0.504 0.549 0.597 0.628
0.025 0.181 0.245 0.308 0.350 0.402 0.441 0.486 0.523 0.553
0.002 0.021 0.033 0.045 0.051 0.060 0.063 0.063 0.074 0.074
0.533 1.725 2.202 2.556 2.894 3.157 3.406 3.649 3.844 4.041
0.959 0.939 0.952 0.957 0.962 0.960 0.964 0.966 0.967 0.966
0.044 0.232 0.351 0.475 0.579 0.715 0.800 0.935 1.051 1.134
0.044 0.226 0.341 0.462 0.564 0.699 0.779 0.916 1.025 1.110
0.001 0.007 0.010 0.013 0.015 0.016 0.021 0.019 0.025 0.024
0.691 1.669 2.069 2.373 2.634 2.868 3.077 3.295 3.454 3.617
0.965 0.914 0.910 0.906 0.904 0.896 0.892 0.889 0.887 0.882
Each row represents one run of 10,000 iterations. There is an overall better performance in terms of the MSE of the quality effects estimator with or without (IVhet) quality rank input. The variance was smaller whereas bias was larger (compared with the random effects estimator) but the decrease in variance (due to weighting) was greater than the increase in bias (due to weighting) and thus the MSE remains smaller. Confidence interval coverage for the interval based on the quality effects methods were better than that of the random effects method which had an inappropriate drop off in coverage. γ2 indicates between studies variance by method of moments; coverage, coverage probability; Qj, quality rank; Sq, squared; Var; variance.
REFERENCES 1. Brockwell SE, Gordon IR. A comparison of statistical methods for meta-analysis. Stat Med. 2001;20:825–840. 2. Noma H. Confidence intervals for a randomeffects meta-analysis based on Bartlett-type corrections. Stat Med. 2011;30:3304–3312. 3. Poole C, Greenland S. Random-effects metaanalyses are not always conservative. Am J Epidemiol. 1999;150:469–475. 4. Overton RC. A comparison of fixed-effects and mixed (random-effects) models for metaanalysis tests of moderator variable effects. Psychological Methods 1998;3:354–379. 5. Doi SA, Thalib L. A quality-effects model for meta-analysis. Epidemiology. 2008;19: 94–100. 6. Doi SA, Thalib L. An alternative quality adjustor for the quality effects model for metaanalysis. Epidemiology. 2009;20:314. 7. Burton A, Altman DG, Royston P, Holder RL. The design of simulation studies in medical statistics. Stat Med. 2006;25:4279–4292. 8. Shuster JJ. Empirical vs natural weighting in random effects meta-analysis. Stat Med. 2010;29: 1259–1265.
e44 | www.epidem.com
Mental Health Impact of the Deepwater Horizon Oil Spill Among Wives of Clean-up Workers To the Editor: he Deepwater Horizon drilling rig exploded in April 2010, resulting in widespread environmental, economic, and population health damage. Previous oil spills have resulted in emotional consequences in local populations that rely on affected areas for their economic and nutritional livelihoods.1–4 Less is known about the mental health effects among specific subpopulations, particu-
T
larly women who may have been both directly and indirectly exposed to the oil and dispersants through their husbands who worked on clean-up efforts. The objective of this study is to describe the impact of the Deepwater Horizon Oil Spill on the mental health of female part-
Supported by the National Institute of Environmental Health Sciences (Grant R21ES00061). Supplemental digital content is avail able through direct URL citations in the HTML and PDF versions of this article (www.epidem.com). This content is not peer-reviewed or copy-edited; it is the sole responsibility of the authors. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1044-3983/15/2604-0e44 DOI: 10.1097/EDE.0000000000000303
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Epidemiology • Volume 26, Number 4, July 2015 Letters
ners of men who participated in oil spill clean-up efforts in southern Louisiana. We enrolled 252 female partners of male participants in the National Institute of Environmental Health Sciences Gulf Long-term Follow-up Study.5 Participants resided in coastal Louisiana parishes and responded to a telephone survey between November 2011 and June 2013. The Louisiana State University Health Sciences Center Institutional Review Board reviewed and approved the study and granted a waiver of documentation of informed consent. Participants provided verbal informed consent. Details on the methods and results can be found in the eAppendix (http://links. lww.com/EDE/A909). Participants were predominantly white (71%), had a high school education (84%), earned less than $50,000/year before the spill (58%), and had a mean age of 47 years (SD 12.9). Almost half the women or another household member worked in the commercial fishing industry. The prevalence of depression in the sample was 31%, 33% reported increases in domestic fights, 31%–32% reported memory loss post-spill, and 39%–43% reported an inability to concentrate postspill. An index representing total exposure to the spill, including both direct physical exposure to the oil/dispersants as well as indirect economic impact from the consequences of the oil spill, was constructed from 12 questionnaire items (mean 4.2 ± 2.39, out of a possible range of 0–12) and further subdivided into physical exposure (mean score 1.6 ± 1.19, out of a possible range of 0–6) and economic exposure indices (mean score 2.4 ± 1.50, out of a possible range of 0–6). Table presents adjusted models for the relation between each mental health outcome and total exposure to the spill (Model 1) and physical and economic exposure to the spill (Model 2). For every unit increase in total exposure, the odds of depressive symptomatology increased by 14% (odds ratio [OR]: 1.1, 95% confidence interval [CI] = 1.0, 1.3); the number of partner fights increased by 35% (OR: 1.4, 95% CI = 1.2, 1.5); memory loss in the past month and immediately post-spill
increased by 23% (OR: 1.2, 95% CI = 1.1, 1.4) and 32% (OR: 1.3, 95% CI = 1.2, 1.5), respectively; and inability to concentrate, in the past month and immediately postspill, increased by 20% (OR: 1.2, 95% CI = 1.17, 1.4) and 27% (OR: 1.3, 95% CI = 1.1, 1.4), respectively. After adjustment for economic exposure, for every unit increase in physical exposure, the odds of depression increased by 47% (OR: 1.5, 95% CI = 1.1, 1.9), and the odds of more partner fights increased by 38% (OR: 1.4, 95% CI = 1.1, 1.8). Similarly, for every unit increase in physical exposure, the odds of experiencing memory loss in the past month and post-spill increased by 38% (OR: 1.4, 95% CI = 1.1, 1.8) and 45% (OR: 1.5, 95% CI = 1.1, 1.9), respectively, whereas the odds of experiencing an inability to concentrate in the past month and post-spill increased by 39% (OR: 1.4, 95% CI = 1.1, 1.8) and 57% (OR: 1.6, 95% CI = 1.20, 2.04), respectively. After adjustment for physical exposure, economic exposure was only associated with an increase in the number of partner fights (OR: 1.4, 95% CI = 1.1, 1.7) and memory loss post-spill (OR: 1.3, 95% CI = 1.0, 1.6).
These results suggest that exposure to the Deepwater Horizon Oil Spill was associated with depression, increase in domestic partner fights, memory loss, and an inability to concentrate among female partners of oil spill clean-up workers. When exposure is divided into its separate physical and economic components, depression, memory loss in the past month, and inability to concentrate are associated with physical but not economic exposure, whereas domestic partner fights and memory loss post-oil spill remain associated with both types of exposure.
ACKNOWLEDGMENTS The authors wish to thank the study participants as well as the staff of the GuLF STUDY for their assistance with subject recruitment and use of their partner data. Ariane L. Rung Epidemiology Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA [email protected]
Evrim Oral Biostatistics Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA
TABLE. Adjusted Odds Ratios and 95% Confidence Intervals for Total Exposure to the Deepwater Horizon Oil Spill and Each Mental Health Outcome (Model 1) and for Physical and Economic Impact Exposure to the Oil Spill and Each Mental Health Outcome (Model 2) Model 1
Depressiona Increase in number of fights with partnera Memory loss past montha Memory loss post-oil spilla,c Inability to concentrate past montha Inability to concentrate post-oil spillb,c
Model 2
Total Exposure
Physical Exposure
Economic Impact Exposure
N
OR (95% CI)
OR (95% CI)
OR (95% CI)
245 242 245 241 244 240
1.1 (1.0, 1.3) 1.4 (1.2, 1.5) 1.2 (1.1, 1.4) 1.3 (1.2, 1.5) 1.2 (1.1, 1.4) 1.3 (1.1, 1.4)
1.5 (1.1, 1.9) 1.4 (1.1, 1.8) 1.4 (1.1, 1.8) 1.5 (1.1, 1.9) 1.4 (1.1, 1.8) 1.6 (1.2, 2.1)
1.0 (0.8, 1.2) 1.4 (1.1, 1.7) 1.2 (1.0, 1.5) 1.3 (1.1, 1.6) 1.1 (0.9, 1.4) 1.2 (0.9, 1.4)
a
Model adjusted for race (African American, multi/other, and white). Model adjusted for race (African American, multi/other, and white) and alcohol consumption status (never, former, current drinker). c Post-oil spill refers to the 8-month window immediately after the Deepwater Horizon drilling rig explosion that occurred on April 20, 2010. b
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.epidem.com | e45
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Epidemiology • Volume 26, Number 4, July 2015
Letters
Elizabeth Fontham Epidemiology Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA
Daniel J. Harrington Environmental and Occupational Health Sciences Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA
Edward J. Trapido Edward S. Peters Epidemiology Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA
REFERENCES 1. Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry. 2002;65:207–239. 2. Lyons RA, Temple JM, Evans D, Fone DL, Palmer SR. Acute health effects of the Sea Empress oil spill. J Epidemiol Community Health. 1999;53:306–310. 3. Carrasco JM, Pérez-Gómez B, García-Mendizábal MJ, et al. Health-related quality of life and mental health in the medium-term aftermath of the Prestige oil spill in Galiza (Spain): a cross-sectional study. BMC Public Health. 2007;7:245. 4. Sabucedo JM, Arce C, Senra C, Seoane G, Vázquez I. Symptomatic profile and health-related quality of life of persons affected by the Prestige catastrophe. Disasters. 2010;34:809–820. 5. National Institute of Environmental Health Sciences. Protocol and Background Documents of the GuLF STUDY. Available at: http://www. niehs.nih.gov/research/atniehs/labs/epi/studies/ gulfstudy/publications/. Accessed October 21, 2014.
Recent National Trends in Acute Myocardial Infarction Hospitalizations in Medicare Shrinking Declines and Growing Disparities To the Editor: tudies reporting steep declines in acute myocardial infarction (AMI) hospitalization rates through 2007 have
S
e46 | www.epidem.com
found lesser declines among blacks.1–4 Although subsequent studies have reported continuing—albeit less steep— declines overall through 2011,5 racial differences in declines have not been closely examined. Therefore, we looked at trends in AMI hospitalization rates among elderly Medicare beneficiaries over the 10-year period 2002 to 2011, focusing specifically on whether the post-2007 declines are also more modest for blacks than for whites, potentially reflecting a growing gap in care. Using the Centers for Medicare and Medicaid Services 100% sample Medicare Provider Analysis and Review files linked to Medicare Denominator files, we compared trends in hospitalizations with a principal discharge diagnosis of AMI (410.xx, excluding 410.x2) for black and white Medicare beneficiaries ages 65 and older, with fee-for-service coverage between January 2002 and December 2011. We calculated annual AMI hospitalization rates per 100,000 beneficiaryyears, adjusted to the age–sex distribution of the 2007 Medicare population. We examined time trends using multivariable Poisson regression, reporting annual changes in AMI hospitalization rates as incidence rate ratios (IRRs) with 99% confidence intervals (CIs; eAppendix; http://links.lww.com/EDE/A908). Over 10 years, AMI hospitalization rates declined 36.6% among whites (from 1,057 per 100,000 beneficiary-years in 2002 to just 670 in 2011), with average declines of 5.1% per year (IRR: 0.949; 99% CI = 0.948, 0.950). Declines were
Research supported by P01AG031098 from the National Institute of Aging, UL1TR000161 from the National Center for Research Resources, and 5U01HL05268-04 from the National Heart, Lung, and Blood Institute. The authors report no conflicts of interest. Supplemental digital content is avail able through direct URL citations in the HTML and PDF versions of this article (www.epidem.com). This content is not peer-reviewed or copy-edited; it is the sole responsibility of the authors. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1044-3983/15/2604-0e46 DOI: 10.1097/EDE.0000000000000298
more modest among blacks, with AMI hospitalization rates dropping 26.4% (from 966 per 100,000 in 2002 to 711 per 100,000 in 2011); the average annual decline for blacks, 3.4% (IRR: 0.966; 99% CI = 0.964, 0.968), was only 2/3 that for whites. Rates of decline slowed for both blacks and whites in the latter part of the study period, to 4.1% per year for whites (IRR: 0.959; 99% CI = 0.958, 0.961), but only 2.7% (IRR: 0.973; 99% CI = 0.967, 0.979) for blacks between 2007 and 2011. Strikingly, although AMI hospitalization rates were initially 9% lower among blacks than whites in 2002 (blacks: 966 per 100,000 beneficiaryyears vs. whites: 1,057), the rates crossed over around 2007, and were 6% higher for blacks by 2011 (blacks: 711 vs. whites: 670; see Figure and eAppendix; http://links.lww.com/EDE/A908). Our finding that declines in AMI hospitalization rates among blacks continue to lag those in whites raises important questions for policy and clinical practice. It is unlikely that blacks in 2002 were more heart-healthy than their white peers; therefore, the lower AMI hospitalization rates for blacks at that time may have been due to problems with symptom recognition, mistrust of the healthcare system, or inequities in access.6–8 If such barriers have been reduced, with blacks increasingly likely to be hospitalized when they have an AMI, our results may—paradoxically—reflect improvements in their quality of care. Nonetheless, our findings suggest that blacks continue to have more difficulty accessing care and have benefitted less from the national cardiovascular health initiatives that have been so effective for whites. To the extent that primary and secondary prevention efforts are more successfully disseminated among whites, quality improvement initiatives could be contributing to increased health disparities in AMI prevalence. In conclusion, over the 10-year period 2002–2011, the benefits of reductions in AMI hospitalizations through aggressive cardiovascular risk factor management may be slowing overall, with even smaller declines for blacks resulting in a crossover;
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Letters
TABLE.
Simulation Results for θ = ln(0.7) Uncertain Qj (Quality Effects Model in MetaXL)
Random Effects Model
Median γ
MSE
Var
Bias Sq
CI Width
Coverage
MSE
Var
Bias Sq
CI Width
Coverage
0.000 0.686 1.124 1.475 1.793 2.098 2.359 2.754 2.991 3.171
0.043 0.116 0.163 0.220 0.251 0.297 0.332 0.367 0.397 0.436
0.043 0.113 0.157 0.210 0.238 0.281 0.315 0.349 0.377 0.415
0.000 0.004 0.006 0.011 0.013 0.016 0.017 0.017 0.020 0.022
0.691 1.666 2.098 2.419 2.726 2.982 3.196 3.443 3.623 3.806
0.964 0.968 0.971 0.972 0.974 0.973 0.970 0.973 0.972 0.970
0.028 0.183 0.318 0.461 0.585 0.736 0.865 1.018 1.167 1.324
0.026 0.177 0.313 0.455 0.578 0.730 0.859 1.013 1.162 1.319
0.002 0.006 0.005 0.006 0.007 0.006 0.007 0.005 0.005 0.005
0.517 1.317 1.621 1.846 2.037 2.207 2.347 2.507 2.623 2.736
0.957 0.864 0.846 0.830 0.820 0.804 0.793 0.788 0.776 0.762
2
No Qj Input (IVhet Model in MetaXL)
Random Qj Input
Median γ2
MSE
Var
Bias Sq
CI Width
Coverage
MSE
Var
Bias Sq
CI Width
Coverage
0.000 0.686 1.124 1.475 1.793 2.098 2.359 2.754 2.991 3.171
0.026 0.202 0.277 0.353 0.400 0.462 0.504 0.549 0.597 0.628
0.025 0.181 0.245 0.308 0.350 0.402 0.441 0.486 0.523 0.553
0.002 0.021 0.033 0.045 0.051 0.060 0.063 0.063 0.074 0.074
0.533 1.725 2.202 2.556 2.894 3.157 3.406 3.649 3.844 4.041
0.959 0.939 0.952 0.957 0.962 0.960 0.964 0.966 0.967 0.966
0.044 0.232 0.351 0.475 0.579 0.715 0.800 0.935 1.051 1.134
0.044 0.226 0.341 0.462 0.564 0.699 0.779 0.916 1.025 1.110
0.001 0.007 0.010 0.013 0.015 0.016 0.021 0.019 0.025 0.024
0.691 1.669 2.069 2.373 2.634 2.868 3.077 3.295 3.454 3.617
0.965 0.914 0.910 0.906 0.904 0.896 0.892 0.889 0.887 0.882
Each row represents one run of 10,000 iterations. There is an overall better performance in terms of the MSE of the quality effects estimator with or without (IVhet) quality rank input. The variance was smaller whereas bias was larger (compared with the random effects estimator) but the decrease in variance (due to weighting) was greater than the increase in bias (due to weighting) and thus the MSE remains smaller. Confidence interval coverage for the interval based on the quality effects methods were better than that of the random effects method which had an inappropriate drop off in coverage. γ2 indicates between studies variance by method of moments; coverage, coverage probability; Qj, quality rank; Sq, squared; Var; variance.
REFERENCES 1. Brockwell SE, Gordon IR. A comparison of statistical methods for meta-analysis. Stat Med. 2001;20:825–840. 2. Noma H. Confidence intervals for a randomeffects meta-analysis based on Bartlett-type corrections. Stat Med. 2011;30:3304–3312. 3. Poole C, Greenland S. Random-effects metaanalyses are not always conservative. Am J Epidemiol. 1999;150:469–475. 4. Overton RC. A comparison of fixed-effects and mixed (random-effects) models for metaanalysis tests of moderator variable effects. Psychological Methods 1998;3:354–379. 5. Doi SA, Thalib L. A quality-effects model for meta-analysis. Epidemiology. 2008;19: 94–100. 6. Doi SA, Thalib L. An alternative quality adjustor for the quality effects model for metaanalysis. Epidemiology. 2009;20:314. 7. Burton A, Altman DG, Royston P, Holder RL. The design of simulation studies in medical statistics. Stat Med. 2006;25:4279–4292. 8. Shuster JJ. Empirical vs natural weighting in random effects meta-analysis. Stat Med. 2010;29: 1259–1265.
e44 | www.epidem.com
Mental Health Impact of the Deepwater Horizon Oil Spill Among Wives of Clean-up Workers To the Editor: he Deepwater Horizon drilling rig exploded in April 2010, resulting in widespread environmental, economic, and population health damage. Previous oil spills have resulted in emotional consequences in local populations that rely on affected areas for their economic and nutritional livelihoods.1–4 Less is known about the mental health effects among specific subpopulations, particu-
T
larly women who may have been both directly and indirectly exposed to the oil and dispersants through their husbands who worked on clean-up efforts. The objective of this study is to describe the impact of the Deepwater Horizon Oil Spill on the mental health of female part-
Supported by the National Institute of Environmental Health Sciences (Grant R21ES00061). Supplemental digital content is avail able through direct URL citations in the HTML and PDF versions of this article (www.epidem.com). This content is not peer-reviewed or copy-edited; it is the sole responsibility of the authors. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1044-3983/15/2604-0e44 DOI: 10.1097/EDE.0000000000000303
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Epidemiology • Volume 26, Number 4, July 2015 Letters
ners of men who participated in oil spill clean-up efforts in southern Louisiana. We enrolled 252 female partners of male participants in the National Institute of Environmental Health Sciences Gulf Long-term Follow-up Study.5 Participants resided in coastal Louisiana parishes and responded to a telephone survey between November 2011 and June 2013. The Louisiana State University Health Sciences Center Institutional Review Board reviewed and approved the study and granted a waiver of documentation of informed consent. Participants provided verbal informed consent. Details on the methods and results can be found in the eAppendix (http://links. lww.com/EDE/A909). Participants were predominantly white (71%), had a high school education (84%), earned less than $50,000/year before the spill (58%), and had a mean age of 47 years (SD 12.9). Almost half the women or another household member worked in the commercial fishing industry. The prevalence of depression in the sample was 31%, 33% reported increases in domestic fights, 31%–32% reported memory loss post-spill, and 39%–43% reported an inability to concentrate postspill. An index representing total exposure to the spill, including both direct physical exposure to the oil/dispersants as well as indirect economic impact from the consequences of the oil spill, was constructed from 12 questionnaire items (mean 4.2 ± 2.39, out of a possible range of 0–12) and further subdivided into physical exposure (mean score 1.6 ± 1.19, out of a possible range of 0–6) and economic exposure indices (mean score 2.4 ± 1.50, out of a possible range of 0–6). Table presents adjusted models for the relation between each mental health outcome and total exposure to the spill (Model 1) and physical and economic exposure to the spill (Model 2). For every unit increase in total exposure, the odds of depressive symptomatology increased by 14% (odds ratio [OR]: 1.1, 95% confidence interval [CI] = 1.0, 1.3); the number of partner fights increased by 35% (OR: 1.4, 95% CI = 1.2, 1.5); memory loss in the past month and immediately post-spill
increased by 23% (OR: 1.2, 95% CI = 1.1, 1.4) and 32% (OR: 1.3, 95% CI = 1.2, 1.5), respectively; and inability to concentrate, in the past month and immediately postspill, increased by 20% (OR: 1.2, 95% CI = 1.17, 1.4) and 27% (OR: 1.3, 95% CI = 1.1, 1.4), respectively. After adjustment for economic exposure, for every unit increase in physical exposure, the odds of depression increased by 47% (OR: 1.5, 95% CI = 1.1, 1.9), and the odds of more partner fights increased by 38% (OR: 1.4, 95% CI = 1.1, 1.8). Similarly, for every unit increase in physical exposure, the odds of experiencing memory loss in the past month and post-spill increased by 38% (OR: 1.4, 95% CI = 1.1, 1.8) and 45% (OR: 1.5, 95% CI = 1.1, 1.9), respectively, whereas the odds of experiencing an inability to concentrate in the past month and post-spill increased by 39% (OR: 1.4, 95% CI = 1.1, 1.8) and 57% (OR: 1.6, 95% CI = 1.20, 2.04), respectively. After adjustment for physical exposure, economic exposure was only associated with an increase in the number of partner fights (OR: 1.4, 95% CI = 1.1, 1.7) and memory loss post-spill (OR: 1.3, 95% CI = 1.0, 1.6).
These results suggest that exposure to the Deepwater Horizon Oil Spill was associated with depression, increase in domestic partner fights, memory loss, and an inability to concentrate among female partners of oil spill clean-up workers. When exposure is divided into its separate physical and economic components, depression, memory loss in the past month, and inability to concentrate are associated with physical but not economic exposure, whereas domestic partner fights and memory loss post-oil spill remain associated with both types of exposure.
ACKNOWLEDGMENTS The authors wish to thank the study participants as well as the staff of the GuLF STUDY for their assistance with subject recruitment and use of their partner data. Ariane L. Rung Epidemiology Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA [email protected]
Evrim Oral Biostatistics Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA
TABLE. Adjusted Odds Ratios and 95% Confidence Intervals for Total Exposure to the Deepwater Horizon Oil Spill and Each Mental Health Outcome (Model 1) and for Physical and Economic Impact Exposure to the Oil Spill and Each Mental Health Outcome (Model 2) Model 1
Depressiona Increase in number of fights with partnera Memory loss past montha Memory loss post-oil spilla,c Inability to concentrate past montha Inability to concentrate post-oil spillb,c
Model 2
Total Exposure
Physical Exposure
Economic Impact Exposure
N
OR (95% CI)
OR (95% CI)
OR (95% CI)
245 242 245 241 244 240
1.1 (1.0, 1.3) 1.4 (1.2, 1.5) 1.2 (1.1, 1.4) 1.3 (1.2, 1.5) 1.2 (1.1, 1.4) 1.3 (1.1, 1.4)
1.5 (1.1, 1.9) 1.4 (1.1, 1.8) 1.4 (1.1, 1.8) 1.5 (1.1, 1.9) 1.4 (1.1, 1.8) 1.6 (1.2, 2.1)
1.0 (0.8, 1.2) 1.4 (1.1, 1.7) 1.2 (1.0, 1.5) 1.3 (1.1, 1.6) 1.1 (0.9, 1.4) 1.2 (0.9, 1.4)
a
Model adjusted for race (African American, multi/other, and white). Model adjusted for race (African American, multi/other, and white) and alcohol consumption status (never, former, current drinker). c Post-oil spill refers to the 8-month window immediately after the Deepwater Horizon drilling rig explosion that occurred on April 20, 2010. b
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.epidem.com | e45
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Epidemiology • Volume 26, Number 4, July 2015
Letters
Elizabeth Fontham Epidemiology Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA
Daniel J. Harrington Environmental and Occupational Health Sciences Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA
Edward J. Trapido Edward S. Peters Epidemiology Program Louisiana State University Health Sciences Center School of Public Health New Orleans, LA
REFERENCES 1. Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry. 2002;65:207–239. 2. Lyons RA, Temple JM, Evans D, Fone DL, Palmer SR. Acute health effects of the Sea Empress oil spill. J Epidemiol Community Health. 1999;53:306–310. 3. Carrasco JM, Pérez-Gómez B, García-Mendizábal MJ, et al. Health-related quality of life and mental health in the medium-term aftermath of the Prestige oil spill in Galiza (Spain): a cross-sectional study. BMC Public Health. 2007;7:245. 4. Sabucedo JM, Arce C, Senra C, Seoane G, Vázquez I. Symptomatic profile and health-related quality of life of persons affected by the Prestige catastrophe. Disasters. 2010;34:809–820. 5. National Institute of Environmental Health Sciences. Protocol and Background Documents of the GuLF STUDY. Available at: http://www. niehs.nih.gov/research/atniehs/labs/epi/studies/ gulfstudy/publications/. Accessed October 21, 2014.
Recent National Trends in Acute Myocardial Infarction Hospitalizations in Medicare Shrinking Declines and Growing Disparities To the Editor: tudies reporting steep declines in acute myocardial infarction (AMI) hospitalization rates through 2007 have
S
e46 | www.epidem.com
found lesser declines among blacks.1–4 Although subsequent studies have reported continuing—albeit less steep— declines overall through 2011,5 racial differences in declines have not been closely examined. Therefore, we looked at trends in AMI hospitalization rates among elderly Medicare beneficiaries over the 10-year period 2002 to 2011, focusing specifically on whether the post-2007 declines are also more modest for blacks than for whites, potentially reflecting a growing gap in care. Using the Centers for Medicare and Medicaid Services 100% sample Medicare Provider Analysis and Review files linked to Medicare Denominator files, we compared trends in hospitalizations with a principal discharge diagnosis of AMI (410.xx, excluding 410.x2) for black and white Medicare beneficiaries ages 65 and older, with fee-for-service coverage between January 2002 and December 2011. We calculated annual AMI hospitalization rates per 100,000 beneficiaryyears, adjusted to the age–sex distribution of the 2007 Medicare population. We examined time trends using multivariable Poisson regression, reporting annual changes in AMI hospitalization rates as incidence rate ratios (IRRs) with 99% confidence intervals (CIs; eAppendix; http://links.lww.com/EDE/A908). Over 10 years, AMI hospitalization rates declined 36.6% among whites (from 1,057 per 100,000 beneficiary-years in 2002 to just 670 in 2011), with average declines of 5.1% per year (IRR: 0.949; 99% CI = 0.948, 0.950). Declines were
Research supported by P01AG031098 from the National Institute of Aging, UL1TR000161 from the National Center for Research Resources, and 5U01HL05268-04 from the National Heart, Lung, and Blood Institute. The authors report no conflicts of interest. Supplemental digital content is avail able through direct URL citations in the HTML and PDF versions of this article (www.epidem.com). This content is not peer-reviewed or copy-edited; it is the sole responsibility of the authors. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1044-3983/15/2604-0e46 DOI: 10.1097/EDE.0000000000000298
more modest among blacks, with AMI hospitalization rates dropping 26.4% (from 966 per 100,000 in 2002 to 711 per 100,000 in 2011); the average annual decline for blacks, 3.4% (IRR: 0.966; 99% CI = 0.964, 0.968), was only 2/3 that for whites. Rates of decline slowed for both blacks and whites in the latter part of the study period, to 4.1% per year for whites (IRR: 0.959; 99% CI = 0.958, 0.961), but only 2.7% (IRR: 0.973; 99% CI = 0.967, 0.979) for blacks between 2007 and 2011. Strikingly, although AMI hospitalization rates were initially 9% lower among blacks than whites in 2002 (blacks: 966 per 100,000 beneficiaryyears vs. whites: 1,057), the rates crossed over around 2007, and were 6% higher for blacks by 2011 (blacks: 711 vs. whites: 670; see Figure and eAppendix; http://links.lww.com/EDE/A908). Our finding that declines in AMI hospitalization rates among blacks continue to lag those in whites raises important questions for policy and clinical practice. It is unlikely that blacks in 2002 were more heart-healthy than their white peers; therefore, the lower AMI hospitalization rates for blacks at that time may have been due to problems with symptom recognition, mistrust of the healthcare system, or inequities in access.6–8 If such barriers have been reduced, with blacks increasingly likely to be hospitalized when they have an AMI, our results may—paradoxically—reflect improvements in their quality of care. Nonetheless, our findings suggest that blacks continue to have more difficulty accessing care and have benefitted less from the national cardiovascular health initiatives that have been so effective for whites. To the extent that primary and secondary prevention efforts are more successfully disseminated among whites, quality improvement initiatives could be contributing to increased health disparities in AMI prevalence. In conclusion, over the 10-year period 2002–2011, the benefits of reductions in AMI hospitalizations through aggressive cardiovascular risk factor management may be slowing overall, with even smaller declines for blacks resulting in a crossover;
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
