Variation in bariatric surgery utilization by state from 2010 to 2019: analysis of the PearlDiver Mariner database

BackgroundBariatric surgery is the most effective treatment for severe obesity and its associated complications, but it remains underutilized. The degree to which bariatric surgery utilization varies by state is unclear.ObjectivesThe aim of this study was to quantify variation in bariatric surgery utilization across U.S. states.SettingUnited States.MethodsPatients who underwent sleeve gastrectomy or gastric bypass and patients with body mass index (BMI) >40 or BMI >35 with comorbidities between 2010 and 2019 were identified with Current Procedural Terminology, International Classification of Diseases-9 and -10 codes using the PearlDiver Mariner insurance claims database. Patients living in Puerto Rico and other U.S. territories were excluded.ResultsA total of 99,173 bariatric surgery patients were identified out of 1,789,457 patients eligible for bariatric surgery between 2010 and 2019 (5.5%). Bariatric surgery patients were more likely to be female (78.8% versus 65.6%) and have commercial insurance (81.4% versus 69.6%) compared with eligible patients who did not undergo bariatric surgery. Bariatric surgery utilization varied widely between states, from 10.4% in New Jersey to 2.1% in Vermont. The Northeast region had the highest rates at 7.95%, and the Midwest had the lowest at 4.47%. The proportion of bariatric surgeries that were sleeve gastrectomies also varied from <30% in Alaska, North Dakota, and Rhode Island to >80% in New Jersey, Nevada, and Mississippi.ConclusionThere is significant variation in bariatric surgery utilization between states, with almost a 5-fold difference between the states with the highest and lowest utilization.     

Geographic variation in the surgical management of lumbar spondylolisthesis: characterizing practice patterns and outcomes

Background Context

The role of arthrodesis in the surgical management of lumbar spondylolisthesis remains controversial. We hypothesized that practice patterns and outcomes for this patient population may vary widely.

Trends in the incidence of treated end-stage renal disease secondary to diabetic nephropathy: 1975-1984

A study of the incidence of treated end-stage renal disease (ESRD) secondary to diabetic nephropathy (DN) in Missouri from 1975 to 1984 documented a relative risk of treated ESRD due to DN 3.7 times higher for blacks than whites. Between 1980 and 1984, the incidence rate for treated ESRD due to DN increased by 150% for white patients and 315% for black patients. Blacks over age 50 have incidence rates of treated ESRD due to DN 4.9 times their white counterparts. Black females have the highest rate of all race/sex groups with DN. The escalating high risk of older blacks for treated ESRD due to DN mandates the development of effective community based identification and referral efforts.     

End-stage renal disease in US minority groups.

Medicare's End-Stage Renal Disease (ESRD) Program makes renal replacement services accessible for the majority of Americans with renal failure. National data from Medicare demonstrate complex and variable patterns of use of renal replacement services among US racial and ethnic groups. The black population has consistently suffered from a greater than 3.5-fold higher rate of treated ESRD than has the white population. The rates of hypertensive, diabetic, and glomerulopathic ESRD are all substantially greater in blacks than in whites, and hypertension has accounted for a far greater proportion of ESRD in blacks than any other diagnosis. There is a paucity of national data on the occurrence of ESRD in Hispanic Americans. However, data from Texas strongly suggest that the incidence rate of treated ESRD is much higher in Mexican Americans than in non-Hispanic whites. Higher rates are apparent for each of the three most important causes of ESRD: hypertension, diabetes, and glomerulonephritis. Native Americans experience ESRD at a rate intermediate between those of whites and blacks, but their rate of diabetic ESRD is higher than in either blacks or whites. However, considerable diversity exists among Native American tribal groups. Significant barriers to the acquisition of preventive care have been identified, especially for blacks. While these barriers to preventive care are accompanied by a significantly impaired health status of the black American population, a specific causal relationship between impaired access to care for blacks and their predisposition to ESRD has not been established.     

Racial differences in the incidence of hypertensive end-stage renal disease (ESRD) are not entirely explained by differences in the prevalence of hypertension

Blacks experience a disproportionate risk of end-stage renal disease (ESRD) compared with whites. The increased prevalence of hypertension in blacks has been suggested as an explanation for this increased risk. We were able to examine this possibility using hypertensive ESRD incidence rates in a population with well-characterized prevalence of hypertension and rate of its control. After adjusting rates of hypertensive ESRD for age, sex, and differences in the prevalence of hypertension by race, we found black:white (B:W) relative risk still to be increased. Prevalence estimates for moderate-severe hypertension and differences in the control of hypertension between the two race groups are of insufficient magnitude to explain the increase in adjusted relative risk. This observation provides further support for the possibility that there are racial differences in the susceptibility to renal damage from elevated BP, which may explain increased risk for hypertensive ESRD in blacks, or that hypertension is being erroneously diagnosed as the cause of ESRD in blacks when another cause is present.     

Neighborhood poverty and racial differences in ESRD incidence

Poverty is associated with increased risk of ESRD, but its contribution to observed racial differences in disease incidence is not well-defined. To explore the contribution of neighborhood poverty to racial disparity in ESRD incidence, we analyzed a combination of US Census and ESRD Network 6 data comprising 34,767 patients that initiated dialysis in Georgia, North Carolina, or South Carolina between January 1998 and December 2002. Census tracts were used as the geographic units of analysis, and the proportion of the census tract population living below the poverty level was our measure of neighborhood poverty. Incident ESRD rates were modeled using two-level Poisson regression, where race, age and gender were individual covariates (level 1), and census tract poverty was a neighborhood covariate (level 2). Neighborhood poverty was strongly associated with higher ESRD incidence for both blacks and whites. Increasing poverty was associated with a greater disparity in ESRD rates between blacks and whites, with the former at greater risk. This raises the possibility that blacks may suffer more from lower socioeconomic conditions than whites. The disparity persisted across all poverty levels. The reasons for increasingly higher ESRD incidence among US blacks as neighborhood poverty increases remain to be explained.     

End-stage renal disease in the Asian-Pacific region

Information on end-stage renal disease (ESRD) is important in assisting health care providers in planning renal replacement therapy. A questionnaire was sent to various countries in the Asian Pacific region and 10 countries responded. Data from Australia and New Zealand was obtained from their registry report. The questionnaire requested information on incidence, prevalence, transplantation rate, demographic data, causes of ESRD, causes of death, and mortality rates for the years 1998 to 2000. All the countries surveyed had national registries and there was a greater than 90% response rate in 7 of 12 countries. The incidence and prevalence rates of ESRD were linked to funding of dialysis, with higher reported rates in countries where dialysis was totally or heavily subsidized by the government. There was an increase in both incidence and prevalence rates between 1998 and 2000, with the mean annual percentage increase of 1.2% to 14.1% for incidence and 4.2% to 17.3% for prevalence. Diabetic nephropathy was the most common cause of ESRD in 9 of the 12 countries surveyed and 6 of the 12 countries had greater than 35% of their dialysis patients age 60 years and older. Peritoneal dialysis (PD) use varied between 3.9% to 81% of the dialysis population and reflected the health care policies of the individual countries. The transplantation rate was influenced by socioeconomic, religious, and cultural attitudes and varied between 3.1 per million population (pmp) to 32 pmp with the percentage of cadaveric transplants ranging between 0% of 85% of total transplants. Cardiovascular mortality remained the most common cause of death in the ESRD patients. Collaboration between the various national registries in the form of specific international studies may yield useful information of ESRD patients in the Asian-Pacific region.     

Spinal cord injury in Mississippi. Findings and evaluation, 1992-1994

STUDY DESIGN: The Mississippi spinal cord injury surveillance system is both active and passive, designed to capture all cases of spinal cord injury through mandated reporting by multiple sources. Each case is confirmed by medical record review. OBJECTIVES: To describe the development of a state-wide spinal cord injury surveillance system, discuss findings from the system, and evaluate sensitivity. SUMMARY OF BACKGROUND DATA: In the United States, the annual incidence rate of spinal cord injury requiring hospital admission has been estimated at 32-50 per million. With prehospital fatalities included, the estimated incidence rate ranges from 43 to 55 per million population annually. METHODS: In the current study all cases identified during the first 2 years of operation of the spinal cord injury (SCI) system were included. To evaluate the sensitivity of the system, International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes from each hospital's discharge database were used. RESULTS: The incidence rate among patients in hospitals and prehospital fatal cases was 77 per million. The rate for patients in hospitals was 59 per million. The incidence rate of spinal cord injury among males was 4.4 times higher than among females. Rates of spinal cord injury were highest among persons 20-24 years of age. Rates were similar for whites and blacks. The most frequent causes of spinal cord injury were motor vehicle collisions, violence, and falls. Additional cases were identified during the evaluation, resulting in a 94% sensitivity. CONCLUSIONS: Mississippi's spinal cord injury incidence rates are substantially higher than rates reported for other states except Alaska. The surveillance system was found to be very complete. Prevention efforts should focus on increasing safety belt usage, increasing alcohol awareness, and reducing violence.     

Unintentional falls mortality among elderly in the United States: Time for action

Fall injury is a leading cause of death and disability among older adults. The objective of this study is to identify the groups among the ≥65 population by age, gender, race, ethnicity and state of residence which are most vulnerable to unintentional fall mortality and report the trends in falls mortality in the United States. Using mortality data from the Centers for Disease Control and Prevention, the age specific and age-adjusted fall mortality rates were calculated by gender, age, race, ethnicity and state of residence for a five year period (2003-2007). Annual percentage changes in rates were calculated and linear regression using natural logged rates were used for time-trend analysis. There were 79,386 fall fatalities (rate: 40.77 per 100,000 population) reported. The annual mortality rate varied from a low of 36.76 in 2003 to a high of 44.89 in 2007 with a 22.14% increase (p=0.002 for time-related trend) during 2003-2007. The rates among whites were higher compared to blacks (43.04 vs. 18.83; p=0.01). While comparing falls mortality rate for race by gender, white males had the highest mortality rate followed by white females. The rate was as low as 20.19 for Alabama and as high as 97.63 for New Mexico. The relative attribution of falls mortality among all unintentional injury mortality increased with age (23.19% for 65-69 years and 53.53% for 85+ years), and the proportion of falls mortality was significantly higher among females than males (46.9% vs. 40.7%: p<0.001) and among whites than blacks (45.3% vs. 24.7%: p<0.001). The burden of fall related mortality is very high and the rate is on the rise; however, the burden and trend varied by gender, age, race and ethnicity and also by state of residence. Strategies will be more effective in reducing fall-related mortality when high risk population groups are targeted.     

Changing patterns of end-stage renal disease due to hypertension

We analyzed the records of all residents of Jefferson County, Alabama, accepted for renal replacement therapy between 1982 and 1987 and compared them with those accepted between 1974 and 1978 to determine any changes in the distribution and frequency of end-stage renal disease (ESRD) due to hypertension (H-ESRD). H-ESRD increased from 6.4 to 9.6 per 100,000 in blacks and from 0.36 to 0.62 per 100,000 in whites. Smoothed age- and race-specific yearly H-ESRD rates decreased in blacks under age 50. Peak incidence of H-ESRD shifted from age 40 to 49 in 1974 through 1978 to age 50 to 59 in 1982 through 1987 (P less than 0.0001). Blacks were referred for care with significantly higher blood pressure levels and serum creatinine concentrations than whites, and had more severe retinal vascular disease. Factors significantly associated with a shorter time from referral to renal replacement therapy were black race, female gender, blood urea nitrogen and serum creatinine concentrations, carbohydrate intolerance, and the use of alpha-agonist and/or angiotensin-converting enzyme (ACE) inhibitor. We conclude that racial distribution and risk for H-ESRD have not changed. Peak rates of H-ESRD have been delayed nearly a decade, suggesting a possible effect of better awareness and treatment of hypertension.     

Racial and ethnic differences in trends of end-stage renal disease: United States, 1995 to 2005

End-stage renal disease (ESRD) disproportionately affects racial/ethnic minority populations in the United States, whereas the prevalence of ESRD risk factors such as diabetes continues to increase. Using data from the US Renal Data System, we examined trends in ESRD incidence, including ESRD caused by diabetes or hypertension. We determined the total number of persons in the United States by race/ethnicity who began treatment during 1995 to 2005 for ESRD and for ESRD with diabetes or hypertension as the primary diagnosis. Incidence rates were calculated by using census data and age-adjusted based on the 2000 US standard population. Joinpoint regression was used to analyze trends. Overall, during 1995 to 2005, the age-adjusted ESRD incidence increased from 260.7 per million to 350.9 per million, but the rate of increase slowed from 1998 to 2005. In the 2000s, compared with the 1990s, the age-adjusted ESRD incidence has continued to increase but at a slower rate among whites and blacks and has decreased significantly among Native Americans, Asians, and Hispanics. The disparity gap in ESRD incidence between minority populations and whites narrowed during 1995 to 2005. Continued interventions to reduce the prevalence of ESRD risk factors are needed to decrease ESRD incidence.     

Differences between blacks and whites in the incidence of end-stage renal disease and associated risk factors

In the United States, the age-and-gender-adjusted incident rate of end-stage renal disease (ESRD) for blacks has been 4 times higher than that for whites. We analyzed patient information and medical services contained in the Medicare 5% random sample database. White (n = 977,436) and black (n = 77,800) Medicare enrollees who were at least 65 years old on January 1, 1997, were followed from 1999 to 2001. Hierarchical Cox regression models were used to estimate the relative risk of ESRD for blacks (with reference to whites) after adjustment for age and gender, socioeconomic status, special health conditions (anemia, chronic obstructive pulmonary disease, cardiovascular disease), primary causal diseases of ESRD (eg, diabetes, hypertension), diabetes care and preventive care (eg, hemoglobin A1c or lipid testing), and physician visits for primary or specialty care. The relative risk of ESRD for blacks (with reference to whites) was 3.52 (95% confidence interval [CI], 3.25-3.80) after adjustment for age and gender; 2.90 (95% CI, 2.67-3.15) after adjustment for socioeconomic status and special health conditions; and 2.11 (95% CI, 1.94-2.30) after further adjustment for primary causal diseases of ESRD, diabetes care and preventive care, and physician visits. We conclude that a higher prevalence of primary causal diseases of ESRD and lower access to diabetes care, preventive care, and primary physician visits in blacks compared with whites partially accounts for the racial difference in the incidence of ESRD in the elderly Medicare population. Public health policy should focus on improving access to care, which may lower the burden of ESRD in minority and other at-risk populations.     

State-level adjusted ESRD incident rates: use of observed vs model-predicted category-specific rates

Because of differences in case-mix across states, state-level case-mix-adjusted end-stage renal disease (ESRD) incident rates are reported in each United States Renal Data System Annual Data Report to make the across-state comparisons valid. The adjusted rates were estimated by the direct adjustment method, a widely used method for adjusted event rate calculation, based on observed category-specific ESRD incident rates in each state (called the observation-based method). However, when some adjusting categories in a state are small, the adjusted rate and the standard error for this state as estimated by this method may be inaccurate. This report proposes a model-based method that can overcome the disadvantages of the observation-based method and can be extended to continuous adjusting variables. National ESRD incident data and national population data from 1990 to 1999 were used. State-level adjusted ESRD incident rates were estimated by both the observation- and the model-based methods. For the model-based method, a Poisson regression model was used to estimate category-specific ESRD incident rates. For large-population states, both observation- and model-based methods produced similar estimates for adjusted ESRD incident rates. For small-population states, however, the observation-based method produced year-to-year estimates of adjusted ESRD incident rates that varied considerably and also had very large standard errors. In contrast, the model-based method produced stable estimates. The model-based method can overcome the disadvantages of the observation-based method for estimating state-level adjusted ESRD incident rates, especially for small states.     

Trials and tribulations of multicenter studies

Multicenter studies in Pediatric Nephrology have been acknowledged in recent years as an important mechanism for studying renal disease in children. The purpose of this review is to describe some of the experiences of the Southwest Pediatric Nephrology Study Group (SPNSG) in order to assist others in developing their own multicenter studies. The importance of protocol development, including adequate attention to study design, data management, and data analysis, is emphasized. Mechanisms for facilitating the frequency and productivity of study group meetings that are so essential for the success of multicenter studies, are described in some detail. The need and some of the methods for achieving ongoing collaboration within a climate of critical peer review are also discussed. Controversial issues such as authorship and the question of institutional credit for involvement in multicenter studies are discussed in brief. Finally, some of the features of the SPNSG that have permitted us to meintain a relatively high rate of productivity are described. The two most important of these, ongoing commitment to the group and willingness to collaborate across differences of opinion, are stressed throughout the review.SPNSG centers Baylor College of Medicine, Houston, Tex.; Baylor University Medical Center, Dallas, Tex.; Cook-Fort Worth Children's Medical Center, Fort Worth, Tex., Louisiana State University, New Orleans, La.; Texas A and M University, Temple, Tex.; Tulane University Medical Center, New Orleans, La.; University of Alabama at Birmingham, Birmingham, Ala.; University of Arkansas, Little Rock, Ark.; University of Colorado, Denver, Colo.; Oklahoma University Health Science Center, Oklahoma City, Okla.; University of Tennessee, Memphis, Tenn.; University of Texas Health Science Center, San Antonio, Tex.; University of Texas Medical Branch, Galveston, Tex.; University of Texas Medical School, Houston, Tex.; University of Texas Southwestern Medical Center, Dallas, Tex.; University of Utah, Salt$Lake City, Utah     

Racial differences in the incidence of end-stage renal disease in types I and II diabetes mellitus

An increased risk of end-stage renal disease (ESRD) among blacks has been previously shown for most causes of chronic renal failure, including diabetes. Most previous studies have not considered the higher prevalence of diabetes in the black population and have not analyzed relative risk by type of diabetes. We found that the incidence of ESRD among blacks with diabetes was 3.6 times the rate in whites with diabetes. The relative risk for blacks increases progressively with age, reaching a maximum of 6.9 in persons over the age of 65. The incidence of ESRD due to diabetes is higher in the population with type I diabetes (492 per 100,000) than in the population with type II diabetes (71 per 100,000). Blacks have a higher incidence of ESRD in both type I diabetes (odds ratio, 2.96; 95% confidence interval, 1.8 to 4.9) and type II diabetes (odds ratio, 4.9; 95% confidence interval, 3.6 to 6.5). The incidence of ESRD in patients with diabetes varies with age, race, and type of diabetes.     

Racial differences in the progression from chronic renal insufficiency to end-stage renal disease in the United States

Black Americans experience a disproportionate burden of ESRD compared with whites. Whether this is caused by the increased prevalence of chronic renal insufficiency (CRI) among blacks or by their increased progression from CRI to ESRD was investigated. A birth cohort analysis was performed using data from the Third National Health and Nutrition Examination Survey and the United States Renal Data System. It was assumed that those who developed ESRD in 1996 aged 25 to 79 yr came from the source population with CRI aged 20 to 74 yr that was sampled in the Third National Health and Nutrition Examination Survey (midpoint 1991). GFR was estimated using the Modification of Diet in Renal Disease study equation. The prevalence of CRI (GFR 15 to 59 ml/min per 1.73 m(2)) was not different among black compared with white adults (2060 versus 2520 per 100,000; P = 0.14). For each 100 blacks with CRI in 1991, five new cases of ESRD developed in 1996, whereas only one case of ESRD developed per 100 whites with CRI (risk ratio, 4.8; 95% confidence interval, 2.9 to 8.4). The increased risk for blacks compared with whites was only modestly affected by adjustment for age, gender, and diabetes. Blacks with CRI had higher systolic (147 versus 136 mmHg; P = 0.001) and diastolic (82 versus 77 mmHg; P = 0.02) BP and greater albuminuria (422 versus 158 micro g urine albumin/mg urine creatinine; P = 0.01). The higher incidence of ESRD among blacks is not due to a greater prevalence of CRI among blacks. The key to understanding black-white differences in ESRD incidence lies in understanding the extreme differences in their progression from CRI to ESRD.     

Interstate Variation in the Burden of Fragility Fractures

Demographic differences may produce interstate variation in the burden of osteoporosis. We estimated the burden of fragility fractures by race/ethnicity, age, sex, and service site across five diverse and populous states. State inpatient databases for 2000 were used to describe hospital fracture admissions, and a Markov decision model was used to estimate annual fracture incidence and cost for populations ≥50 yr of age for 2005–2025 in Arizona (AZ), California (CA), Florida (FL), Massachusetts (MA), and New York (NY). In 2000, mean hospital charges for incident fractures varied 1.7‐fold across states. For hip fracture, mean charges ranged from $16,700 (MA) to $29,500 (CA), length of stay from 5.3 (AZ) to 8.9 days (NY), and discharge rate to long‐term care from 43% (NY) to 71% (CA). In 2005, projected fracture incidence rates ranged from 199 (CA) to 266 (MA) per 10,000. Total cost ranged from $270 million (AZ) to $1,434 million (CA). Men accounted for 26–30% of costs. Across states, hip fractures constituted on average 77% of costs; “other” fractures (e.g., leg, arm), 10%; pelvic, 6%; vertebral, 5%; and wrist, 2%. By 2025, Hispanics are projected to represent 20% of fractures in AZ and CA and Asian/Other populations to represent 27% of fractures in NY. In conclusion, state initiatives to prevent fractures should include nonwhite populations and men, as well as white women, and should address fractures at all skeletal sites. Interstate variation in service utilization merits further evaluation to determine efficient and effective disease management strategies.     

Relationships of race and ethnicity to progression of kidney dysfunction and clinical outcomes in patients with chronic kidney failure

In the United States, the incidence of end-stage renal disease (ESRD) is much higher for blacks, Native Americans, and Asians than for whites. The incidence of kidney disease is also higher for populations of Hispanic ethnicity. ESRD attributed to diabetes (ESRD-DM), hypertension (ESRD-HT), and glomerulonephritis (ESRD-GN), in this order of frequency, are the major categories of ESRD in the United States for all race/ethnic groups. By using the incidence rates of ESRD, during the period from 1997 through 2000, and with whites as reference, the highest rate ratio (RR) was observed for ESRD-HT in blacks (RR = 5.96), ESRD-DM in Native Americans (RR = 5.11), and ESRD-GN in Asians (RR=2.20). The data suggest that the excess of ESRD observed for racial/ethnic minorities may be reduced by interventions aimed at prevention/control of hypertension and diabetes. The data suggest that before developing ESRD, patients with chronic renal failure from minority groups have to face more barriers to receive high-quality health care. This may explain why they see nephrologists later and are less likely to receive renal transplantation at initiation of renal replacement therapy (RRT). Improvements in quality of care after initiating RRT may explain the lower mortality and higher scores in heath-related quality of life observed for patients from racial/ethnic minorities.     

The conundrum of increased burden of end-stage renal disease in Asians

BACKGROUND: Few cohort studies have examined the risk of end-stage renal disease (ESRD) among Asians compared with whites and blacks. METHODS: To compare the incidence of ESRD in Asians, whites, and blacks in Northern California, we examined sociodemographic and clinical data on 299,168 adults who underwent a screening health checkup at Kaiser Permanente between 1964 and 1985. Incident cases of ESRD were ascertained by matching patient identifiers with the nationally comprehensive United States Renal Data System ESRD registry. RESULTS: Overall, 1346 cases of ESRD occurred during 7,837,310 person-years of follow-up. The age-adjusted rate of ESRD (per 100,000 person-years) was 14.0 [95% confidence interval (CI) 10.5-18.5] among Asians, 7.9 (95% CI 6.5-9.5) among whites, and 43.4 (95% CI 36.6-51.4)] among blacks. Controlling for age, gender, educational attainment, diabetes, prior myocardial infarction, serum creatinine, systolic and diastolic blood pressure, proteinuria, hematuria, cigarette smoking, serum total cholesterol, and body mass index increased the risk of ESRD in Asians relative to whites from 1.69 to 2.08 (95% CI 1.61-2.67). By contrast, adjustment for the same covariates decreased the risk of ESRD in blacks relative to whites from 5.30 to 3.28 (95% CI 2.91-3.69). CONCLUSION: Factors contributing to the excess ESRD risk in Asians relative to whites extend beyond usually considered sociodemographic and comorbidity disparities. Strategies aimed at examining novel risk factors for kidney disease and efforts to increase awareness of kidney disease among Asians may reduce ESRD incidence in this high-risk group.     

Head and neck cancer in a young age group: High incidence in black patients

From the Tumor Registries of the East Orange, New Jersey, Veterans Administration Medical Center, and the College of Medicine and Dentistry of New Jersey/New Jersey Medical School, 1,066 cases of head and neck cancer were reviewed. Blacks comprised 32% of the population reviewed. Charts of 70 patients, 45 years old or younger, were examined. Seventy percent of this group was black. At diagnosis, the proportion of patients 45 years old or younger was 14% for blacks and 2.9% for whites, a significant difference (P < 0.001). Seventy-six percent of lesions in black patients and 86% in white patients were situated above the hypopharynx. Sixty-one percent of all patients 45 years old or younger had Stage III or IV lesions when first diagnosed, regardless of race. Black-to-white survival rates were 23 to 40% after 2 years, and 5 to 13% for those at risk after 5 years. Prognosis is poor for younger patients, in general, and worse for young black patients than for whites.