The Association Between Neighborhood Environment and Mortality: Results from a National Study of Veterans.
BACKGROUND
As the largest integrated US health system, the Veterans Health Administration (VHA) provides unique national data to expand knowledge about the association between neighborhood socioeconomic status (NSES) and health. Although living in areas of lower NSES has been associated with higher mortality, previous studies have been limited to higher-income, less diverse populations than those who receive VHA care.


OBJECTIVE
To describe the association between NSES and all-cause mortality in a national sample of veterans enrolled in VHA primary care.


METHODS
One-year observational cohort of veterans who were alive on December 31, 2011. Data on individual veterans (vital status, and clinical and demographic characteristics) were abstracted from the VHA Corporate Data Warehouse. Census tract information was obtained from the US Census Bureau American Community Survey. Logistic regression was used to model the association between NSES deciles and all-cause mortality during 2012, adjusting for individual-level income and demographics, and accounting for spatial autocorrelation.


METHODS
Veterans who had vital status, demographic, and NSES data, and who were both assigned a primary care physician and alive on December 31, 2011 (n = 4,814,631).


METHODS
Census tracts were used as proxies for neighborhoods. A summary score based on census tract data characterized NSES. Veteran addresses were geocoded and linked to census tract NSES scores. Census tracts were divided into NSES deciles.


RESULTS
In adjusted analysis, veterans living in the lowest-decile NSES tract were 10 % (OR 1.10, 95 % CI 1.07, 1.14) more likely to die than those living in the highest-decile NSES tract.


CONCLUSIONS
Lower neighborhood SES is associated with all-cause mortality among veterans after adjusting for individual-level socioeconomic characteristics. NSES should be considered in risk adjustment models for veteran mortality, and may need to be incorporated into strategies aimed at improving veteran health.
VA Puget Sound Healthcare System, Health Services Research and Development Seattle-Denver COIN, Seattle, WA, USA. Karin.Nelson@va.gov.|VA Puget Sound Healthcare System, General Internal Medicine Service, Seattle, WA, USA. Karin.Nelson@va.gov.|School of Medicine, Department of Medicine, University of Washington, Seattle, WA, USA. Karin.Nelson@va.gov.|School of Public Health, Department of Health Services, University of Washington, Seattle, WA, USA. Karin.Nelson@va.gov.
Karin
K
Nelson
VHA Office of Analytics and Business Intelligence, Seattle, WA, USA.
Greg
G
Schwartz
School of Public Health, Department of Health Services, University of Washington, Seattle, WA, USA.
Susan
S
Hernandez
VA Puget Sound Healthcare System, Health Services Research and Development Seattle-Denver COIN, Seattle, WA, USA.|School of Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.
Joseph
J
Simonetti
VHA Office of Analytics and Business Intelligence, Seattle, WA, USA.
Idamay
I
Curtis
VA Puget Sound Healthcare System, General Internal Medicine Service, Seattle, WA, USA.|School of Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.|School of Public Health, Department of Health Services, University of Washington, Seattle, WA, USA.|VHA Office of Analytics and Business Intelligence, Seattle, WA, USA.
Stephan D
SD
Fihn
D000293:Adolescent; D000328:Adult; D000368:Aged; D004777:Environment; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D011204:Poverty Areas; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012307:Risk Factors; D012423:Rural Health / Q000706:statistics & numerical data; D012923:Social Class; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D014504:Urban Health / Q000706:statistics & numerical data; D014728:Veterans / Q000706:statistics & numerical data; D058014:Veterans Health / Q000706:statistics & numerical data*; D055815:Young Adult
clinical epidemiology; public health; risk adjustment; socioeconomic factors; veteran