Educational attainment and cardiovascular disease in the United States: A quasi-experimental instrumental variables analysis
Educational attainment and cardiovascular disease in the United States: A quasi-experimental instrumental variables analysis
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DOI：
10.1371/journal.pmed.1002834
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发表时间：
2019-06-01
期刊：
影响因子：
15.8
通讯作者：
Rehkopf, David H.
中科院分区：
文献类型：
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作者：
Hamad, Rita;Nguyen, Thu T.;Rehkopf, David H.
背景关于是否应该将教育或社会经济地位(SES)作为心血管疾病(CVD)预测算法和临床风险调整模型的输入，一直存在争论。对教育的干预是否会影响心血管疾病，也不清楚，部分原因是关于教育是心血管疾病的决定因素，还是仅仅由于混淆或反向因果关系而相互关联，存在争议。我们利用自然实验来评估受教育程度对心血管疾病及相关风险因素的人口水平的影响。方法和发现我们利用了美国州级义务教育法律(CSL)的变化，这是一个自然实验，与儿童需要上学的最低年限的地理和时间差异有关。我们使用1992-2012年健康和退休研究浪潮(HRS；N=30,853)的队列数据和1971-2012年国家健康和营养检查调查(NHANES；N=44,732)浪潮的一系列横断面数据，将关于儿童时期教育程度(N=约540万)的人口普查数据与成年后的结果联系起来。我们检查了自我报告的CVD结果和相关的危险因素，以及相关的血清生物标志物。使用工具变量(IV)分析，我们发现教育程度的提高与减少吸烟(HRS beta-0.036，95%CI：-0.06，-0.02，p<；0.01；NHANES beta-0.032，95%CI：-0.05，-0.02，p<；0.01)，抑郁(HRS beta-0.049，95%CI：-0.07，-0.03，p<；0.01)相关。甘油三酯(NHANESβ-0.039，95%CI：-0.06，-0.01，P<；0.01)和心脏病(HRSβ-0.025，95%CI：-0.04，-0.002，p=0.01)，以及高密度脂蛋白胆固醇(HRS beta-1.50，95%CI：0.34，2.49，P<；0.01；体重指数(HRSβ0.20，95%CI：0.002，0.40，p=0.05；NHANES beta 0.13，95%CI：0.01，0.32，p=0.05)和总胆固醇(HRS beta 2.73，95%CI：0.09，4.97，p=0.03)。虽然大多数发现在两个数据集上都得到了交叉验证，但它们对包括国家固定效应的情况并不稳健。局限性包括残留的混淆，在某些分析中使用自我报告的结果，以及可能对最近的队列的概括性有限。结论这项研究对教育程度与心血管疾病的关联提供了严格的人群水平估计。这些发现可能会指导今后实施干预措施，以解决心血管疾病的社会决定因素，并加强将教育程度纳入心血管疾病预测算法和初级预防指南的论点。
BackgroundThere is ongoing debate about whether education or socioeconomic status (SES) should be inputs into cardiovascular disease (CVD) prediction algorithms and clinical risk adjustment models. It is also unclear whether intervening on education will affect CVD, in part because there is controversy regarding whether education is a determinant of CVD or merely correlated due to confounding or reverse causation. We took advantage of a natural experiment to estimate the population-level effects of educational attainment on CVD and related risk factors.Methods and findingsWe took advantage of variation in United States state-level compulsory schooling laws (CSLs), a natural experiment that was associated with geographic and temporal differences in the minimum number of years that children were required to attend school. We linked census data on educational attainment (N = approximately 5.4 million) during childhood with outcomes in adulthood, using cohort data from the 1992-2012 waves of the Health and Retirement Study (HRS; N = 30,853) and serial cross-sectional data from 1971-2012 waves of the National Health and Nutrition Examination Survey (NHANES; N = 44,732). We examined self-reported CVD outcomes and related risk factors, as well as relevant serum biomarkers. Using instrumental variables (IV) analysis, we found that increased educational attainment was associated with reduced smoking (HRS beta -0.036, 95%CI: -0.06, -0.02, p < 0.01; NHANES beta -0.032, 95%CI: -0.05, -0.02, p < 0.01), depression (HRS beta -0.049, 95%CI: -0.07, -0.03, p < 0.01), triglycerides (NHANES beta -0.039, 95%CI: -0.06, -0.01, p < 0.01), and heart disease (HRS beta -0.025, 95%CI: -0.04, -0.002, p = 0.01), and improvements in high-density lipoprotein (HDL) cholesterol (HRS beta 1.50, 95%CI: 0.34, 2.49, p < 0.01; NHANES beta 0.86, 95%CI: 0.32, 1.48, p < 0.01), but increased BMI (HRS beta 0.20, 95%CI: 0.002, 0.40, p = 0.05; NHANES beta 0.13, 95%CI: 0.01, 0.32, p = 0.05) and total cholesterol (HRS beta 2.73, 95%CI: 0.09, 4.97, p = 0.03). While most findings were cross-validated across both data sets, they were not robust to the inclusion of state fixed effects. Limitations included residual confounding, use of self-reported outcomes for some analyses, and possibly limited generalizability to more recent cohorts.ConclusionsThis study provides rigorous population-level estimates of the association of educational attainment with CVD. These findings may guide future implementation of interventions to address the social determinants of CVD and strengthen the argument for including educational attainment in prediction algorithms and primary prevention guidelines for CVD.