Low educational attainment is associated with higher all-cause and cardiovascular mortality in the United States adult population

Najah Khan, Department of Internal Medicine, Houston Methodist Hospital, Houston, TX), USA.
Zulqarnain Javed, Center for Cardiovascular Computational Health and Precision Medicine (C3-PH) , Houston Methodist, Houston, TX), USA.
Isaac Acquah, Houston Methodist Academic Institute, Houston Methodist, Houston, TX), USA.
Kobina Hagan, Houston Methodist Academic Institute, Houston Methodist, Houston, TX), USA.
Madiha Khan, Department of Internal Medicine, Houston Methodist Hospital, Houston, TX), USA.
Javier Valero-Elizondo, Houston Methodist Academic Institute, Houston Methodist, Houston, TX), USA.
Ryan Chang, Washington University in St. Louis, St. Louis, MO), USA.
Umair Javed, National University of Medical Sciences, Rawalpindi, Pakistan.
Mohamad B. Taha, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin St Suite 1801, Houston, TX, 77030, USA.
Michael J. Blaha, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD), USA.
Salim S. Virani, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX), USA.
Garima Sharma, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD), USA.
Ron Blankstein, Cardiovascular Imaging Program, Department of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA), USA.
Martha Gulati, Department of Preventive Cardiology, Harbor-UCLA Medical Center, Los Angeles, CA, USA.
Elias Mossialos, Department of Health Policy, London School of Economics and Political Science, London, UK.
Adnan A. Hyder, Center On Commercial Determinants of Health, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA.
Miguel Cainzos Achirica, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD), USA.
Khurram Nasir, Center for Cardiovascular Computational Health and Precision Medicine (C3-PH) , Houston Methodist, Houston, TX), USA. knasir@houstonmethodist.org.

Document Type

Journal Article

Publication Date

5-16-2023

Journal

BMC public health

Volume

23

Issue

1

DOI

10.1186/s12889-023-15621-y

Keywords

All-cause mortality; Cardiovascular disease; Educational attainment; Health disparities

Abstract

INTRODUCTION: Educational attainment is an important social determinant of health (SDOH) for cardiovascular disease (CVD). However, the association between educational attainment and all-cause and CVD mortality has not been longitudinally evaluated on a population-level in the US, especially in individuals with atherosclerotic cardiovascular disease (ASCVD). In this nationally representative study, we assessed the association between educational attainment and the risk of all-cause and cardiovascular (CVD) mortality in the general adult population and in adults with ASCVD in the US. METHODS: We used data from the 2006-2014 National Death Index-linked National Health Interview Survey for adults ≥ 18 years. We generated age-adjusted mortality rates (AAMR) by levels of educational attainment (< high school (HS), HS/General Education Development (GED), some college, and ≥ College) in the overall population and in adults with ASCVD. Cox proportional hazards models were used to examine the multivariable-adjusted associations between educational attainment and all-cause and CVD mortality. RESULTS: The sample comprised 210,853 participants (mean age 46.3), representing ~ 189 million adults annually, of which 8% had ASCVD. Overall, 14.7%, 27%, 20.3%, and 38% of the population had educational attainment < HS, HS/GED, Some College, and ≥ College, respectively. During a median follow-up of 4.5 years, all-cause age-adjusted mortality rates were 400.6 vs. 208.6 and 1446.7 vs. 984.0 for the total and ASCVD populations for < HS vs ≥ College education, respectively. CVD age adjusted mortality rates were 82.1 vs. 38.7 and 456.4 vs 279.5 for the total and ASCVD populations for < HS vs ≥ College education, respectively. In models adjusting for demographics and SDOH, < HS (reference =  ≥ College) was associated with 40-50% increased risk of mortality in the total population and 20-40% increased risk of mortality in the ASCVD population, for both all-cause and CVD mortality. Further adjustment for traditional risk factors attenuated the associations but remained statistically significant for < HS in the overall population. Similar trends were seen across sociodemographic subgroups including age, sex, race/ethnicity, income, and insurance status. CONCLUSIONS: Lower educational attainment is independently associated with increased risk of all-cause and CVD mortality in both the total and ASCVD populations, with the highest risk observed for individuals with < HS education. Future efforts to understand persistent disparities in CVD and all-cause mortality should pay close attention to the role of education, and include educational attainment as an independent predictor in mortality risk prediction algorithms.

Department

Global Health

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