Skip to main content
SpringerLink
Log in

Comparison of Racial and Ethnic Mortality Disparities among Post-9/11 Veterans with and without Traumatic Brain Injury to the Total U.S. Adult Population

  • Published:
Journal of Racial and Ethnic Health Disparities Aims and scope Submit manuscript

Abstract

Introduction

The extent of racial/ethnic disparities and whether they are attenuated in the Veteran population compared to the total US population is not well understood. We aimed to assess racial/ethnic mortality disparities from all-cause, cardiovascular (CVD) and cancer among post-9/11 military Veterans with and without exposure to TBI, compared to the total US population.

Methods

This cohort study included 2,502,101 US military Veterans (18,932,083 person-years) who served after 09/11/2001 with 3 or more years of care in the Military Health System (MHS); or had 3 or more years of care in the MHS and 2 or more years of care in the Veterans Health Administration. Mortality follow-up occurred from 01/01/2002 to 12/31/2020. Mortality rate ratios (MRR) from negative binomial regression models were reported for racial/ethnic groups compared to White non-Hispanic Veterans for all-cause, CVD and cancer mortality. Veteran MRR were compared to the total US population.

Results

Mortality rates for Black Non-Hispanic Veterans were higher for all-cause (MRR = 1.21;95%CI: 1.13–1.29; p < 0.001), CVD (MRR = 1.78;95%CI: 1.62–1.96; p < 0.001) and cancer (MRR = 1.17;95%CI: 1.10–1.25; p < 0.001) than in White Non-Hispanic Veterans. Among Veterans with TBI, only Black Non-Hispanics had higher mortality than White Non-Hispanics and only for CVD (MRR = 1.32;95%CI: 1.12–1.54; p < 0.001), while CVD mortality was higher among Veterans without TBI (MRR = 1.77;95%CI: 1.63–1.93;p < 0.001). MRR for Black Non-Hispanics in the total US population, were consistently higher than those in the Veteran population for all-cause (MRR = 1.52;95%CI: 1.46–1.58; p < 0.001), CVD (MRR = 2.03;95%CI: 1.95–2.13; p < 0.001) and cancer (MRR = 1.26;95%CI: 1.22–1.30; p < 0.001).

Conclusion

This Veteran cohort experienced less racial/ethnic disparity in mortality than the total US population, especially among Veterans with TBI.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data Availability

The authors do not control access to the data, therefore we cannot offer to share data. The data are owned by the VA and DoD and require permisions to access. We would however be willing to advise others on how to go through the process of acquiring these permissions.

References

  1. Xu J, Murphy S, Kochanek K, Arias E. Mortality in the United States, 2021. NCHS data brief, no 456. Hyattsville, MD: National Center for Health Statistics; 2022. https://doi.org/10.15620/cdc:122516.

  2. Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press; 2003. https://doi.org/10.17226/12875.

  3. Sidney S, Quesenberry CP Jr, Jaffe MG, Sorel M, Nguyen-Huynh MN, Kushi LH, et al. Recent Trends in Cardiovascular Mortality in the United States and Public Health Goals. JAMA Cardiol. 2016;1(5):594–9. https://doi.org/10.1001/jamacardio.2016.1326.

    Article  PubMed  Google Scholar 

  4. Tajeu GS, Safford MM, Howard G, Howard VJ, Chen L, Long DL, et al. Black-White Differences in Cardiovascular Disease Mortality: A Prospective US Study, 2003–2017. Am J Public Health. 2020;110(5):696–703. https://doi.org/10.2105/ajph.2019.305543.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA: Cancer J Clin. 2023;73(1):17–48. https://doi.org/10.3322/caac.21763.

    Article  PubMed  Google Scholar 

  6. Williams CD, Alpert N, Redding TSt, Bullard AJ, Flores RM, Kelley MJ, et al. Racial differences in treatment and survival among veterans and non-veterans with stage I NSCLC: An evaluation of Veterans Affairs and SEER-Medicare populations. Cancer Epidemiol Biomarkers Prev. 2020;29(1):112–8. https://doi.org/10.1158/1055-9965.Epi-19-0245.

    Article  PubMed  Google Scholar 

  7. Navuluri N, Morrison S, Green CL, Woolson SL, Riley IL, Cox CE, et al. Racial disparities in lung cancer screening among veterans, 2013 to 2021. JAMA Netw Open. 2023;6(6):e2318795-e. https://doi.org/10.1001/jamanetworkopen.2023.18795.

    Article  Google Scholar 

  8. Wong MS, Hoggatt KJ, Steers WN, Frayne SM, Huynh AK, Yano EM, et al. Racial/ethnic disparities in mortality across the Veterans Health Administration. Health Equity. 2019;3(1):99–108. https://doi.org/10.1089/heq.2018.0086.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Walker LE, Poltavskiy E, Janak JC, Beyer CA, Stewart IJ, Howard JT. US military service and racial/ethnic differences in cardiovascular disease: An analysis of the 2011–2016 Behavioral Risk Factor Surveillance System. Ethn Dis. 2019;29(3):451–62. https://doi.org/10.18865/ed.29.3.451.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Howard J, Sosnov J, Janak J, Gundlapalli A, Pettey W, Walker L, et al. Associations of initial injury severity and posttraumatic stress disorder diagnoses with long-term hypertension risk after combat injury. Hypertension. 2018;71(5):824–32.

    Article  CAS  PubMed  Google Scholar 

  11. Miller K, Driscoll D, Smith LM, Ramaswamy S. The role of inflammation in late-life post-traumatic stress disorder. Mil Med. 2017;182(11–12):e1815–8. https://doi.org/10.7205/milmed-d-17-00073.

    Article  PubMed  Google Scholar 

  12. Boos CJ, Schofield S, Cullinan P, Dyball D, Fear NT, Bull AMJ, et al. Association between combat-related traumatic injury and cardiovascular risk. Heart. 2022;108(5):367–74. https://doi.org/10.1136/heartjnl-2021-320296.

    Article  PubMed  Google Scholar 

  13. Walker LE, Poltavskiy E, Howard JT, Janak JC, Watrous J, Alcover K, et al. Suicide attempts and mental health diagnoses in combat-injured service members: A retrospective cohort study. Suicide Life-Threat Behav. 2023;53(2):227–40. https://doi.org/10.1111/sltb.12938.

    Article  PubMed  Google Scholar 

  14. Walker LE, Watrous J, Poltavskiy E, Howard JT, Janak JC, Pettey WBP, et al. Longitudinal mental health outcomes of combat-injured service members. Brain Behav. 2021;11(5):e02088. https://doi.org/10.1002/brb3.2088.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Alcover KC, Poltavskiy EA, Howard JT, Watrous JR, Janak JC, Walker LE, et al. Post-combat-injury opioid prescription and alcohol use disorder in the military. Am J Prev Med. 2022;63(6):904–14. https://doi.org/10.1016/j.amepre.2022.07.010.

    Article  PubMed  Google Scholar 

  16. Beyer CA, Poltavskiy E, Walker LE, Pettey W, Suo Y, Redd A, et al. Persistent opioid use after combat injury and subsequent long-term risk of abuse: a retrospective cohort study. Ann Surg. 2021;274(6):e957–e965. https://doi.org/10.1097/SLA.0000000000003658.

  17. Howard J, Stewart I, Kolaja C, Sosnov J, Rull R, Torres I, et al. Hypertension in military veterans is associated with combat exposure and combat injury. J Hypertens. 2020;38:1293–301. https://doi.org/10.1097/HJH.0000000000002364.

    Article  CAS  PubMed  Google Scholar 

  18. Stewart IJ, Poltavskiy E, Howard JT, Janak JC, Pettey W, Zarzabal LA, et al. The enduring health consequences of combat trauma: a legacy of chronic disease. J Gen Intern Med. 2021;36(3):713–21. https://doi.org/10.1007/s11606-020-06195-1.

    Article  PubMed  Google Scholar 

  19. Stewart IJ, Sosnov JA, Howard JT, Orman JA, Fang R, Morrow BD, et al. Retrospective analysis of long-term outcomes after combat injury. Circulation. 2015;132(22):2126–33. https://doi.org/10.1161/CIRCULATIONAHA.115.016950.

    Article  PubMed  Google Scholar 

  20. Boos CJ, Haling U, Schofield S, Cullinan P, Bull AMJ, Fear NT, et al. Relationship between combat-related traumatic injury and its severity to predicted cardiovascular disease risk: ADVANCE cohort study. BMC Cardiovasc Disord. 2023;23(1):581. https://doi.org/10.1186/s12872-023-03605-0.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Stewart IJ, Amuan ME, Wang C-P, Kennedy E, Kenney K, Werner JK, et al. Association between traumatic brain injury and subsequent cardiovascular disease among post-9/11–era Veterans. JAMA Neurol. 2022;79(11):1122–9. https://doi.org/10.1001/jamaneurol.2022.2682.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Stewart IJ, Howard JT, Poltavskiy E, Dore M, Amuan ME, Ocier K, et al. Traumatic brain injury and subsequent risk of brain cancer in US veterans of the Iraq and Afghanistan Wars. JAMA Netw Open. 2024;7(2):e2354588-e. https://doi.org/10.1001/jamanetworkopen.2023.54588.

    Article  Google Scholar 

  23. Howard JT, Stewart IJ, Amuan M, Janak JC, Pugh MJ. Association of traumatic brain injury with mortality among military veterans serving after September 11, 2001. JAMA Netw Open. 2022;5(2):e2148150-e. https://doi.org/10.1001/jamanetworkopen.2021.48150.

    Article  Google Scholar 

  24. Muncan B. Cardiovascular disease in racial/ethnic minority populations: illness burden and overview of community-based interventions. Public Health Rev. 2018;39:32. https://doi.org/10.1186/s40985-018-0109-4.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Thotamgari SR, Sheth AR, Grewal US. Racial disparities in cardiovascular disease among patients with cancer in the United States: The elephant in the room. EClinicalMedicine. 2022;44:101297. https://doi.org/10.1016/j.eclinm.2022.101297.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Cohen R, Cha A. Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2022. Natl Cent Health Stat Natl Cent Health Stat. 2023. https://doi.org/10.15620/cdc:127055.

    Article  Google Scholar 

  27. Evans CT, St Andre JR, Pape TL, Steiner ML, Stroupe KT, Hogan TP, et al. An evaluation of the Veterans Affairs traumatic brain injury screening process among Operation Enduring Freedom and/or Operation Iraqi Freedom veterans. Pm R. 2013;5(3):210–20. https://doi.org/10.1016/j.pmrj.2012.12.004. (quiz 20).

    Article  PubMed  Google Scholar 

  28. Management of Concussion/mTBI Working Group. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. J Rehabil Res Dev. 2009;46(6):CP1–68.

  29. Byers AL, Li Y, Barnes DE, Boscardin WJ, Peltz CB, Yaffe K. TBI and risk of death in military veterans over 14 years: Injury severity, timing, and cause of death. J Psychiatr Res. 2022;156:200–5. https://doi.org/10.1016/j.jpsychires.2022.09.035.

    Article  PubMed  Google Scholar 

  30. Beydoun MA, Beydoun HA, Mode N, Dore GA, Canas JA, Eid SM, et al. Racial disparities in adult all-cause and cause-specific mortality among us adults: mediating and moderating factors. BMC Public Health. 2016;16(1):1113. https://doi.org/10.1186/s12889-016-3744-z.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Harper S, Rushani D, Kaufman JS. Trends in the Black-White Life Expectancy Gap, 2003–2008. JAMA. 2012;307(21):2257–9. https://doi.org/10.1001/jama.2012.5059.

    Article  CAS  PubMed  Google Scholar 

  32. Curtin SC, Arias E. Mortality trends by race and ethnicity among adults aged 25 and over: United States, 2000-2017. NCHS Data Brief. 2019;(342):1–8.

  33. Post WS, Watson KE, Hansen S, Folsom AR, Szklo M, Shea S, et al. Racial and ethnic differences in all-cause and cardiovascular disease mortality: The MESA study. Circulation. 2022;146(3):229–39. https://doi.org/10.1161/CIRCULATIONAHA.122.059174.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Norris KC, Mensah GA, Boulware LE, Lu JL, Ma JZ, Streja E, et al. Age, race and cardiovascular outcomes in African American veterans. Ethn Dis. 2016;26(3):305–14. https://doi.org/10.18865/ed.26.3.305.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Peterson K, Anderson J, Boundy E, Ferguson L, McCleery E, Waldrip K. Mortality disparities in racial/ethnic minority groups in the Veterans Health Administration: An evidence review and map. Am J Public Health. 2018;108(3):e1–11. https://doi.org/10.2105/ajph.2017.304246.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Egede LE, Dismuke C, Echols C. Racial/Ethnic disparities in mortality risk among US veterans with traumatic brain injury. Am J Public Health. 2012;102 Suppl 2(Suppl 2):S266-71. https://doi.org/10.2105/ajph.2011.300176.

    Article  PubMed  Google Scholar 

  37. Dismuke CE, Gebregziabher M, Egede LE. Racial/ethnic disparities in VA services utilization as a partial pathway to mortality differentials among veterans diagnosed with TBI. Glob J Health Sci. 2015;8(2):260–72. https://doi.org/10.5539/gjhs.v8n2p260.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

This work was supported by U.S. Department of Defense (W81XWH1920067 and W81XWH-13-2-0095) and U.S Department of Veterans Affairs Rehabilitation Research and Development Service (I01 RX003443-01).

Funding

This work was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense, through the Psychological Health/Traumatic Brain Injury Research Program Long-Term Impact of Military-Relevant Brain Injury Consortium (LIMBIC) Award/W81XWH-18-PH/TBIRP-LIMBIC under Awards No. W81XWH1920067 and W81XWH-13–2-0095, and by the U.S. Department of Veterans Affairs Award No. I01 RX003443. The U.S. Army Medical Research Acquisition Activity, 839 Chandler Street, Fort Detrick MD 21702–5014 is the awarding and administering acquisition office. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense.

Author information

Authors and Affiliations

  1. Department of Public Health, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249, USA

    Jeffrey T. Howard

  2. Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA

    Ian J. Stewart & Lauren E. Walker

  3. Military Cardiovascular Outcomes Research Program, Bethesda, MD, USA

    Ian J. Stewart

  4. The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA

    Lauren E. Walker

  5. University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, Utah, USA

    Megan Amuan & Mary Jo Pugh

  6. United States Department of Veterans Affairs, 550 Foothill Dr, Salt Lake City, Utah, USA

    Megan Amuan & Mary Jo Pugh

  7. Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, USA

    Kara Rayha

  8. Bexar Data, LLC, San Antonio, TX, USA

    Jud C. Janak

Authors
  1. Jeffrey T. Howard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ian J. Stewart
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lauren E. Walker
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Megan Amuan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kara Rayha
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jud C. Janak
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Mary Jo Pugh
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Dr. Howard had full access to the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Howard, Stewart, Janak, Pugh.

Acquisition, analysis, or interpretation of data: Stewart, Amuan, Pugh.

Drafting of the manuscript: Howard, Walker, Stewart, Janak, Rayha.

Critical revision of the manuscript for important intellectual content: Howard, Walker, Stewart, Amuan, Rayha, Janak, Pugh.

Statistical analysis: Howard, Amuan.

Obtained funding: Pugh (PI), Stewart (co-PI), Howard (co-I), Amuan (co-I).

Administrative, technical, or material support: Stewart, Pugh.

Study supervision: Stewart, Pugh.

Corresponding author

Correspondence to Jeffrey T. Howard.

Ethics declarations

Ethics Approval

This study was reviewed and approved by the University of Utah Institutional Review Board (3/16/2020/IRB_00127108).

Conflict of Interest

The authors have no financial or non-financial conflicts.

Role of the Funder/Sponsor

The funder had no role in data acquisition, analysis, or manuscript development.

Disclaimer

The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University, the Department of Defense, the Department of Veteran’s Affairs or the Henry M. Jackson Foundation.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Howard, J.T., Stewart, I.J., Walker, L.E. et al. Comparison of Racial and Ethnic Mortality Disparities among Post-9/11 Veterans with and without Traumatic Brain Injury to the Total U.S. Adult Population. J. Racial and Ethnic Health Disparities (2024). https://doi.org/10.1007/s40615-024-02004-1

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s40615-024-02004-1

Keywords

Search

Navigation