Culturally adaptive storytelling intervention versus didactic intervention to improve hypertension control in Vietnam- 12 month follow up results: A cluster randomized controlled feasibility trial

INTRODUCTION

Vietnam is experiencing an epidemiologic transition with an increased prevalence of non-communicable diseases. The country needs novel, large-scale, and sustainable interventions to improve hypertension control. We report the 12 month follow-up results of a cluster randomized feasibility trial in Hung Yen province, Vietnam, which evaluated the feasibility and acceptability of two community-based interventions to improve hypertension control: a "storytelling" and a didactic intervention.

METHODS

The storytelling intervention included stories in the patients' own words about coping with hypertension and didactic content about the importance of healthy lifestyle behaviors in controlling elevated blood pressure levels. The didactic intervention included only didactic content, which were general recommendations for managing several important risk factors for hypertension and other non-communicable diseases. The storytelling intervention was delivered by two DVDs three months apart; the didactic intervention included only one DVD. The trial was conducted in patients with poorly controlled hypertension from 4 communes (communities), which were equally randomized to the two interventions.

RESULTS

The mean age of the 160 patients was 66 years and 54% were men. Between baseline enrollment and the 12 month follow-up, mean systolic blood pressure declined by 10.8 mmHg (95% CI: 6.5-14.9) in the storytelling group and by 5.8 mmHg (95% CI: 1.6-10.0) in the didactic content group. The storytelling group also experienced more improvement in several health behaviors, including increased levels of physical activity and reduced consumption of salt and alcohol.

CONCLUSIONS

We observed considerable long-term beneficial effects of both interventions, especially of our storytelling intervention, among patients with inadequately controlled hypertension. A large scale randomized trial should more systematically compare the short and long-term effectiveness of the two interventions in controlling hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02483780.

Are we "missing the big picture" in transitions of care? Perspectives of healthcare providers managing patients with unplanned hospitalization

BACKGROUND

Healthcare providers play a critical role in the care transitions. Therefore, efforts to improve this process should be informed by their perspectives.

AIM

The study objective was to explore the factors that negatively/positively influence care transitions following an unplanned hospitalization from the perspective of healthcare providers.

METHODS

A qualitative study using semi-structured interviews conducted between February and September of 2016 at a single academic medical center. We enrolled fifteen healthcare providers from multiple disciplines involved in the management of patients experiencing an unplanned hospitalization. Respondents shared their experiences with care transitions and identified factors within and outside of the discharging health facility that impede or facilitate this process. Transcribed interviews were analyzed using emerging themes from the interviews.

RESULTS

We identified six themes and associated subthemes from the interviews on factors that influence care transitions. Three themes focused on factors within the discharging healthcare facility: untailored and overloaded patient discharge information, timing of the post-discharge care conversation, provider-to-patient and provider-to-provider miscommunication. The other three themes were related to external factors including caregiver involvement, having a safe and stable housing environment, and access to healthcare and community resources. Providers discussed how these factors positively/negatively influence the hospital-to-home transition.

CONCLUSIONS

Our study identifies factors within and outside the discharging healthcare facility that influence care transitions, ultimately affect patient-centered outcomes and provider satisfaction with delivered care. Strategies aimed at improving the quality of care transitions should address these barriers and actively engage healthcare providers who are pivotal in care transitions.

Racial differences in weathering and its associations with psychosocial stress: The CARDIA study

Biological age (BA) is a construct that captures accelerated biological aging attributable to "wear and tear" from various exposures; we measured BA and weathering, defined as the difference between BA and chronological age, and their associations with race and psychosocial factors in a middle-aged bi-racial cohort. We used data from the Coronary Artery Risk in Young Adults study (CARDIA), conducted in 4 U.S. cities from 1985-2016 to examine weathering for adults aged 48-60 years. We estimated BA via the Klemera and Doubal method using selected biomarkers. We assessed overall and race-specific associations between weathering and psychosocial measures. For the 2694 participants included, Blacks had a BA (SD) that was 2.6 (11.8) years older than their chronological age while the average BA among Whites was 3.5 (10.0) years younger than their chronological age (Blacks weathered 6.1 years faster than Whites). Belonging to more social groups was associated with less weathering in Blacks but not Whites, and after multivariable adjustment, lower SES and more depressive symptoms were associated with more weathering among Blacks than among Whites. We confirmed racial differences in weathering, and newly documented that similar psychosocial factors may take a greater toll on the biological health of Blacks than Whites.

Online health information seeking by adults hospitalized for acute coronary syndromes: Who looks for information, and who discusses it with healthcare providers?

OBJECTIVE

To describe characteristics associated with online health information-seeking and discussing resulting information with healthcare providers among adults with acute coronary syndromes (ACS).

METHODS

Consecutive patients hospitalized with ACS in 6 hospitals in Massachusetts and Georgia who reported Internet use in the past 4 weeks (online patients) were asked about online health information-seeking and whether they discussed information with healthcare providers. Participants reported demographic and psychosocial characteristics; clinical characteristics were abstracted from medical records. Logistic regression models estimated associations with information-seeking and provider communication.

RESULTS

Online patients (N = 1142) were on average aged 58.8 (SD: 10.6) years, 30.3% female, and 82.8% non-Hispanic white; 56.7% reported online health information-seeking. Patients with higher education and difficulty accessing medical care were more likely to report information-seeking; patients hospitalized with myocardial infarction, and those with impaired health numeracy and limited social networks were less likely. Among information-seekers, 33.9% discussed information with healthcare providers. More education and more frequent online information-seeking were associated with provider discussions.

CONCLUSION

Over half of online patients with ACS seek health information online, but only 1 in 3 of these discuss information with healthcare providers.

PRACTICE IMPLICATIONS

Clinician awareness of patient information-seeking may enhance communication including referral to evidence-based online resources.

Cardiovascular Risk Factors, Depression, and Alcohol Consumption During Joblessness and During Recessions Among Young Adults in CARDIA

Research has shown that recessions are associated with lower cardiovascular mortality, but unemployed individuals have a higher risk of cardiovascular disease (CVD) or death. We used data from 8 consecutive examinations (1985-2011) of the Coronary Artery Risk Development in Young Adults (CARDIA) cohort, modeled in fixed-effect panel regressions, to investigate simultaneously the associations of CVD risk factors with the employment status of individuals and the macroeconomic conditions prevalent in the state where the individual lives. We found that unemployed individuals had lower levels of blood pressure, high-density lipoprotein cholesterol, and physical activity, and they had significantly higher depression scores, but they were similar to their counterparts in smoking status, alcohol consumption, low-density lipoprotein cholesterol levels, body mass index, and waist circumference. A 1-percentage-point higher unemployment rate at the state level was associated with lower systolic (-0.41 mm Hg, 95% CI: -0.65, -0.17) and diastolic (-0.19, 95% CI: -0.39, 0.01) blood pressure, higher physical activity levels, higher depressive symptom scores, lower waist circumference, and less smoking. We conclude that levels of CVD risk factors tend to improve during recessions, but mental health tends to deteriorate. Unemployed individuals are significantly more depressed, and they likely have lower levels of physical activity and high-density lipoprotein cholesterol.

Association of religiosity and spirituality with quality of life in patients with cardiovascular disease: a systematic review

PURPOSE

This review systematically identified and critically appraised the available literature that has examined the association between religiosity and/or spirituality (R/S) and quality of life (QOL) in patients with cardiovascular disease (CVD).

METHODS

We searched several electronic online databases (PubMed, SCOPUS, PsycINFO, and CINAHL) from database inception until October 2017. Included articles were peer-reviewed, published in English, and quantitatively examined the association between R/S and QOL. We assessed the methodological quality of each included study.

RESULTS

The 15 articles included were published between 2002 and 2017. Most studies were conducted in the US and enrolled patients with heart failure. Sixteen dimensions of R/S were assessed with a variety of instruments. QOL domains examined were global, health-related, and disease-specific QOL. Ten studies reported a significant positive association between R/S and QOL, with higher spiritual well-being, intrinsic religiousness, and frequency of church attendance positively related with mental and emotional well-being. Approximately half of the included studies reported negative or null associations.

CONCLUSIONS

Our findings suggest that higher levels of R/S may be related to better QOL among patients with CVD, with varying associations depending on the R/S dimension and QOL domain assessed. Future longitudinal studies in large patient samples with different CVDs and designs are needed to better understand how R/S may influence QOL. More uniformity in assessing R/S would enhance the comparability of results across studies. Understanding the influence of R/S on QOL would promote a holistic approach in managing patients with CVD.

Hyperglycemia and risk of ventricular tachycardia among patients hospitalized with acute myocardial infarction

Background

Little is known about the association of hyperglycemia with the development of ventricular tachycardia (VT) in patients hospitalized with acute myocardial infarction (AMI) which we examined in the present study. The objectives of this community-wide observational study were to examine the relation between elevated serum glucose levels at the time of hospital admission for AMI and occurrence of VT, and time of occurrence of VT, during the patient’s acute hospitalization.

Methods

We used data from a population-based study of patients hospitalized with AMI at all central Massachusetts medical centers between 2001 and 2011. Hyperglycemia was defined as a serum glucose level ≥ 140 mg/dl at the time of hospital admission. The development of VT was identified from physicians notes and electrocardiographic findings by our trained team of data abstractors.

Results

The average age of the study population was 70 years, 58.0% were men, and 92.7% were non-Hispanic whites. The mean and median serum glucose levels at the time of hospital admission were 171.4 mg/dl and 143.0, respectively. Hyperglycemia was present in 51.9% of patients at the time of hospital admission; VT occurred in 652 patients (15.8%), and two-thirds of these episodes occurred during the first 48 h after hospital admission (early VT). After multivariable adjustment, patients with hyperglycemia were at increased risk for developing VT (adjusted OR = 1.48, 95% CI = 1.23–1.78). The presence of hyperglycemia was significantly associated with early (multivariable adjusted OR = 1.39, 95% CI = 1.11–1.73) but not with late VT. Similar associations were observed in patients with and without diabetes and in patients with and without ST-segment elevation AMI.

Conclusions

Efforts should be made to closely monitor and treat patients who develop hyperglycemia, especially early after hospital admission, to reduce their risk of VT.

The current State of the acute care surgery workforce: A boots on the ground perspective

BACKGROUND

Acute care surgery (ACS) was proposed to address a general surgery workforce crisis; however, the ACS workforce composition is unknown. A national survey was conducted to determine the differences in the emergency general surgery (EGS) workforce between ACS and non-ACS hospitals.

METHODS

The American Hospital Association (AHA) Annual Survey of Hospitals database was queried to identify acute care general hospitals. A hybrid mail/electronic survey was sent to 2811 acute care hospitals that met the inclusion criteria of hospitals that care for adult patients (≥18 years old) with an emergency room (ER), ≥ 1 operating room (OR), and 24-h ER access. Hospitals were queried on whether they utilized an ACS model. The workforce composition among ACS and non-ACS hospitals was evaluated using X² tests, t tests, and Wilcoxon rank-sum tests.

RESULTS

Survey response was 60% (N = 1690). ACS hospitals had a higher proportion of emergency surgeons who were female (20% vs. 14%, p < 0.0001), newly-trained (17% vs 10%, p < 0.0001), critical care trained (78% vs. 31%, p < 0.0001), and who had an additional degree (35% vs. 13%, p < 0.0001). More ACS hospitals had 24/7 in-house OR nursing staff (72% vs. 15%, p < 0.0001) and ancillary staff.

CONCLUSIONS

ACS and non-ACS hospitals differ in their surgical workforce. It is clear that ACS hospitals have more human capital, which suggests that ACS hospitals may require more dedicated resources compared to non-ACS hospitals.

Barriers to Healthcare Access and Long-Term Survival After an Acute Coronary Syndrome

BACKGROUND

Barriers to healthcare are common in the USA and may result in worse outcomes among hospital survivors of an acute coronary syndrome (ACS).

OBJECTIVE

To examine the relationship between barriers to healthcare and 2-year mortality after hospital discharge for an ACS.

DESIGN

Longitudinal study.

SETTING

Survivors of an ACS hospitalization were recruited from 6 medical centers in central Massachusetts and Georgia in 2011-2013.

PATIENTS

Study participants with a confirmed ACS reported whether they had a financial-related healthcare barrier, no usual source of care, or a transportation-related healthcare barrier around the time of hospital admission.

INTERVENTIONS

None.

MEASUREMENTS

Cox regression analyses calculated adjusted hazard ratios (aHRs) for 2-year all-cause mortality for the three healthcare barriers while controlling for several demographic, clinical, and psychosocial characteristics.

RESULTS

The mean age of study participants (n = 2008) was 62 years, 33% were women, and 77% were non-Hispanic white. One third of patients reported a financial barrier, 17% lacked a usual source of care, and 12% had a transportation barrier. Five percent (n = 100) died within 2 years after hospital discharge. Compared to patients without these barriers, those lacking a usual source of care and with barriers to transportation experienced significantly higher mortality (aHRs 1.40, 95% CI 1.30 to 1.51 and 1.46, 95% CI 1.13 to 1.89, respectively). Financial barriers were not associated with all-cause mortality (aHR 0.79, 95% CI 0.60 to 1.06).

LIMITATIONS

Observational study with other unmeasured potentially confounding prognostic factors.

CONCLUSIONS

Absence of an established usual source of care and inconsistent transportation availability were associated with a higher risk for dying after an ACS. Patients with these barriers to follow-up care may benefit from more intensive follow-up and support.

Variations in the Delivery of Emergency General Surgery Care in the Era of Acute Care Surgery

BACKGROUND

Acute care surgery (ACS) was proposed to improve emergency general surgery (EGS) care; however, the extent of ACS model adoption in the United States is unknown. A national survey was conducted to ascertain factors associated with variations in EGS models of care, with particular focus on ACS use.

METHODS

A hybrid mail/electronic survey was sent in 2015 to 2,811 acute care hospitals with an emergency room and an operating room. If a respondent indicated that the approach to EGS was a dedicated clinical team whose scope encompasses EGS (± trauma, ± elective general surgery, ± burns), the hospital was considered an ACS hospital.

RESULTS

Survey response was 60.1% (n = 1,690); 272 (16.1%) of these hospitals reported having used an ACS model of care for EGS patients. Teaching status and general hospital practices (for example, interventional radiology available within one hour) were associated with ACS use. In bivariate analyses, ACS use was associated with many EGS-specific practices (40.1% of ACS hospitals freed their surgeons of daytime clinical responsibilities after operating overnight vs. 4.7% of general surgeon on call (GSOC) hospitals; p < 0.0001).

CONCLUSION

There are wide variations in EGS practices in the United States, with use of an ACS model of care being relatively low despite reported benefits of ACS models of care on EGS access, quality, and costs. Hospital factors associated with using ACS models are overall size and higher level of existing resources. These findings could be applied to the development of centers of excellence for EGS care.

Change in Cognitive Function in the Month After Hospitalization for Acute Coronary Syndromes: Findings From TRACE-CORE (Transition, Risks, and Actions in Coronary Events-Center for Outcomes Research and Education)

BACKGROUND

Cognitive function is often impaired during hospitalization, but whether this impairment resolves or persists after discharge is unknown.

METHODS AND RESULTS

We enrolled (April 2011-May 2013) and interviewed during hospitalization and 1-month post-discharge 1521 nondemented acute coronary syndrome survivors enrolled in TRACE (Transitions, Risks and Actions in Coronary Events). Cognitive function was assessed using the Telephone Interview of Cognitive Status (range: 0-41) at both time points. Patients reported demographic and psychosocial characteristics and medical records were abstracted. Using the Telephone Interview of Cognitive Status cut point of ≤28, we defined 4 groups of cognitive change based on cognitive status during hospitalization and 1 month later: consistently impaired, transiently impaired, newly impaired, and consistently nonimpaired. Characteristics associated with cognitive change categories were examined using multinomial logistic regression. Participants were 67% male, 84% non-Hispanic white, with mean age±SD 62±11 years; 16% (n=237) were cognitively impaired during hospitalization, and 11% (n=174) were impaired 1 month after discharge. Overall, 80% were consistently nonimpaired, 9% transiently impaired, 7% consistently impaired, and 4% newly impaired. Lower education level, minority status, low health literacy and numeracy, and higher severity of disease were independently associated with cognitive impairment during and after hospitalization. Male sex was associated with increased risk of cognitive impairment after hospital discharge.

CONCLUSIONS

Cognitive function changes during the transition from hospital to home after acute coronary syndrome are less favorable for men and those with psychosocial vulnerability. Assessing cognitive status both in hospital and post-discharge is important for detecting patients who could benefit from tailored transitional care including early follow-up and booster discharge instructions.

Racial Disparities in Cardiovascular Health Behaviors: The Coronary Artery Risk Development in Young Adults Study

INTRODUCTION

There are known racial differences in cardiovascular health behaviors, including smoking, physical activity, and diet quality. A better understanding of these differences may help identify intervention targets for reducing cardiovascular disease disparities. This study examined whether socioeconomic, psychosocial, and neighborhood environmental factors, in isolation or together, mediate racial differences in health behaviors.

METHODS

Participants were 3,081 men and women from the Coronary Artery Risk Development in Young Adults study who were enrolled in 1985-1986 (Year 0) and completed a follow-up examination in 2015-2016 (Year 30). A health behavior score was created at Years 0, 7, 20, and 30 using smoking, physical activity, and diet assessed that year. The race difference in health behavior score was estimated using linear regression in serial cross-sectional analyses. Mediation analyses computed the proportion of the race and health behavior score association attributable to socioeconomic, psychosocial, and neighborhood factors.

RESULTS

Data analysis conducted in 2016-2017 found that blacks had significantly lower health behavior scores than whites across 30 years of follow-up. Individual socioeconomic factors mediated 48.9%-70.1% of the association between race and health behavior score, psychosocial factors 20.3%-30.0%, and neighborhood factors 22.1%-41.4% (p<0.01 for all).

CONCLUSIONS

Racial differences in health behavior scores appear to be mediated predominately by correspondingly large differences in socioeconomic factors. This study highlights the profound impact of socioeconomic factors, which are mostly not under an individual's control, on health behaviors. Policy action targeting socioeconomic factors may help reduce disparities in health behaviors.

Who’s in charge? Results from a qualitative study of caregiver perspectives on the care transition process

Background: Care transitions are a topic of increasing interest as researchers and clinicians focus their effects on patient outcomes. Engaging caregivers, who play important roles in care transitions, may yield valuable insight into how care transition processes can be improved. Methods: We conducted semi-structured interviews, focusing on caregivers’ experiences with and perceptions of care transitions, with 11 eligible caregivers whose loved ones had recently experienced an unplanned admission to a single academic medical center. Our research team analyzed the transcripts to identify key themes.Results: Caregivers detailed multiple factors affecting care transitions, including both in-hospital and external elements. Identifying the medical provider in charge of care emerged as a common difficulty. Other areas of interest included receiving discharge information, length of stay, health insurance status, the presence of social support, access to transportation and educational level, among others. Caregivers’ views on the quality of various in-hospital aspects of their own care transition experiences varied.Conclusions: Caregivers re-affirmed the complexity of the care transition process by identifying myriad factors that influence their quality. Taking steps to address these factors may help hospitals to empower and engage caregivers, as well as to improve care transitions overall and better manage the health of their patients.

Priorities for Cardiovascular Outcomes Research: A Report of the National Heart, Lung, and Blood Institute's Centers for Cardiovascular Outcomes Research Working Group

The Centers for Cardiovascular Outcomes Research (CCORs) held a meeting to review how cardiovascular outcomes research had evolved in the decade since the National Heart, Lung, and Blood Institute 2004 working group report and to consider future directions. The conference involved representatives from governmental agencies, outcomes research thought leaders, and public and private healthcare partners. The main purposes of this meeting were to (1) advance collaborative high-yield, high-impact outcomes research; (2) identify priorities and barriers to important cardiovascular outcomes research; and (3) define future needs for the field. This report highlights the key topics covered during the meeting, including an examination of the recent history of outcomes research, an evaluation of the current academic climate, and a vision for the future of cardiovascular outcomes research.

Disparities in access to emergency general surgery care in the United States

BACKGROUND

As fewer surgeons take emergency general surgery call and hospitals decrease emergency services, a crisis in access looms in the United States. We examined national emergency general surgery capacity and county-level determinants of access to emergency general surgery care with special attention to disparities.

METHODS

To identify potential emergency general surgery hospitals, we queried the database of the American Hospital Association for "acute care general hospital," with "surgical services," and "emergency department," and ≥1 "operating room." Internet search and direct contact confirmed emergency general surgery services that covered the emergency room 7 days a week, 24 hours a day. Geographic and population-level emergency general surgery access was derived from Geographic Information Systems and US Census.

RESULTS

Of the 6,356 hospitals in the 2013 American Hospital Association database, only 2,811 were emergency general surgery hospitals. Counties with greater percentages of black, Hispanic, uninsured, and low-education individuals and rural counties disproportionately lacked access to emergency general surgery care. For example, counties above the 75th percentile of African American population (10.2%) had >80% odds of not having an emergency general surgery hospital compared with counties below the 25th percentile of African American population (0.6%).

CONCLUSION

Gaps in access to emergency general surgery services exist across the United States, disproportionately affecting underserved, rural communities. Policy initiatives need to increase emergency general surgery capacity nationwide.

Geographic Diffusion and Implementation of Acute Care Surgery: An Uneven Solution to the National Emergency General Surgery Crisis

Importance

Owing to lack of adequate emergency care infrastructure and decline in general surgery workforce, the United States faces a crisis in access to emergency general surgery (EGS) care. Acute care surgery (ACS), an organized system of trauma, general surgery, and critical care, is a proposed solution; however, ACS diffusion remains poorly understood.

Objective

To investigate geographic diffusion of ACS models of care and characterize the communities in which ACS implementation is lagging.

Design, Setting, and Participants

A national survey on EGS practices was developed, tested, and administered at all 2811 US acute care hospitals providing EGS to adults between August 2015 and October 2015. Surgeons responsible for EGS coverage at these hospitals were approached. If these surgeons failed to respond to the initial survey implementation, secondary surgeons or chief medical officers at hospitals with only 1 general surgeon were approached.

Interventions

Survey responses on ACS implementation were linked with geocoded hospital data and national census data to determine geographic diffusion of and access to ACS.

Main Outcomes and Measures

We measured the distribution of hospitals with ACS models of care vs those without over time (diffusion) and by US counties characterized by sociodemographic characteristics of county residents (access).

Results

Survey response rate was 60% (n = 1690); 272 responding hospitals had implemented ACS by 2015, steadily increasing from 34 in 2001 to 125 in 2010. Acute care surgery implementation has not been uniform. Rural regions have limited ACS access, with hospitals in counties with greater than the 75th percentile population having 5.4 times higher odds (95% CI, 1.66-7.35) of implementing ACS than hospitals in counties with less than 25th percentile population. Communities with greater percentages of adults without a college degree also have limited ACS access (OR, 3.43; 95% CI, 1.81-6.48). However, incorporating EGS into ACS models may be a potential equalizer for poor, black, and Hispanic communities.

Conclusions and Relevance

Understanding and addressing gaps in ACS implementation across communities will be crucial to ensuring health equity for US residents experiencing general surgery emergencies.

Training cardiovascular outcomes researchers: A survey of mentees and mentors to identify critical training gaps and needs

BACKGROUND

Many young investigators are interested in cardiovascular (CV) outcomes research; however, the current training experience of early investigators across the United States is uncertain.

METHODS

From April to November 2014, we surveyed mentees and mentors of early-stage CV outcomes investigators across the United States. We contacted successful grantees of government agencies, members of professional organizations, and trainees in CV outcomes training programs.

RESULTS

A total of 185 (of 662) mentees and 76 (of 541) mentors completed the survey. Mentees were equally split by sex; most had completed training >3 years before completing the survey and were clinicians. Mentors were more likely women, mostly ≥20 years posttraining, and at an associate/full professor rank. Mentors reported devoting more time currently to clinical work than when they were early in their career and mentoring 2-4 people simultaneously. More than 80% of mentees started training to become academicians and completed training with the same goal. More than 70% of mentees desired at least 50% research time in future jobs. More than 80% of mentors believed that future investigators would need more than 50% time dedicated to research. Most mentees (80%) were satisfied with their relationship with their mentor and reported having had opportunities to develop independently. Mentors more frequently than mentees reported that funding cutbacks had negatively affected mentees' ability to succeed (84% vs 58%). Across funding mechanisms, mentees were more optimistic than mentors about securing funding. Both mentees and mentors reported greatest preparedness for job/career satisfaction (79% for both) and publications (84% vs 92%) and least preparedness for future financial stability (48% vs 46%) and work-life balance (47% vs 42%).

CONCLUSIONS

Survey findings may stimulate future discourse and research on how best to attract, train, and retain young investigators in CV outcomes research. Insights may help improve existing training programs and inform the design of new ones.

How well does early-career investigators' cardiovascular outcomes research training align with funded outcomes research?

BACKGROUND

Outcomes research training programs should prepare trainees to successfully compete for research funding. We examined how early-career investigators' prior and desired training aligns with recently funded cardiovascular (CV) outcomes research.

METHODS

We (1) reviewed literature to identify 13 core competency areas in CV outcomes research; (2) surveyed early-career investigators to understand their prior and desired training in each competency area; (3) examined recently funded grants commonly pursued by early-career outcomes researchers to ascertain available funding in competency areas; and (4) analyzed alignment between investigator training and funded research in each competency area. We evaluated 185 survey responses from early-career investigators (response rate 28%) and 521 funded grants from 2010 to 2014.

RESULTS

Respondents' prior training aligned with funded grants in the areas of clinical epidemiology, observational research, randomized controlled trials, and implementation/dissemination research. Funding in community-engaged research and health informatics was more common than prior training in these areas. Respondents' prior training in biostatistics and systematic review was more common than funded grants focusing on these specific areas. Respondents' desired training aligned similarly with funded grants, with some exceptions; for example, desired training in health economics/cost-effectiveness research was more common than funded grants in these areas. Restricting to CV grants (n=132) and National Heart, Lung, and Blood Institute-funded grants (n=170) produced similar results.

CONCLUSIONS

Identifying mismatch between funded grants in outcomes research and early-career investigators' prior/desired training may help efforts to harmonize investigator interests, training, and funding. Our findings suggest a need for further consideration of how to best prepare early-career investigators for funding success.

Underuse of Effective Cardiac Medications Among Women, Middle-Aged Adults, and Racial/Ethnic Minorities With Coronary Artery Disease (from the National Health and Nutrition Examination Survey 2005 to 2014)

Given the proven effectiveness of several cardiac medications for patients with coronary artery disease (CAD), we examined the national use of 4 classes of effective medications, overall and by age, sex, and race/ethnicity in 2005 to 2014. We used data from the National Health and Nutrition Examination Survey, including a self-reported diagnosis of CAD and independently verified medication use. Weighting procedures extrapolated our data to the adult US population with CAD. Analyses included 1,789 US adults aged ≥45 years with a history of CAD. The average age of this population was 68 years; 40% were women and 79% were non-Hispanic whites. In 2005 to 2014, 53.2% (standard error [SE] = 1.5) reported use of angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, 58.5% (SE = 1.5) β blockers, and 67.2% (SE = 1.4) statins. Two of these medications were used by 64.1% (SE = 1.5) of the study population and all 3 by 29.1% (SE = 1.3). In 2011 to 2014, 68.5% (SE = 2.4) of American adults with a history of CAD reported use of aspirin. The use of statins increased from 63.1% in 2005/2006 to 76.8% in 2013/2014. Adults aged 45 to 64 years old, women, and racial/ethnic minorities had lower use of effective cardiac medications compared with older adults, men, and non-Hispanic whites. In conclusion, the use of statins, but not other medications, has increased over the past 10 years among American adults with previously diagnosed CAD. Continued targeted efforts are needed to increase the receipt of effective cardiac medications among all US adults with CAD, especially those aged 45 to 64 years, women, and racial/ethnic minorities.

Social Determinants of Health in Managed Care Payment Formulas

IMPORTANCE

Managed care payment formulas commonly allocate more money for medically complex populations, but ignore most social determinants of health (SDH).

OBJECTIVE

To add SDH variables to a diagnosis-based payment formula that allocates funds to managed care plans and accountable care organizations.

DESIGN, SETTING, AND PARTICIPANTS

Using data from MassHealth, the Massachusetts Medicaid and Children's Health Insurance Program, we estimated regression models predicting Medicaid spending using a diagnosis-based and SDH-expanded model, and compared the accuracy of their cost predictions overall and for vulnerable populations. MassHealth members enrolled for at least 6 months in 2013 in fee-for-service (FFS) programs (n = 357 660) or managed care organizations (MCOs) (n = 524 607).

EXPOSURES

We built cost prediction models from a fee-for-service program. Predictors in the diagnosis-based model are age, sex, and diagnoses from claims. The SDH model adds predictors describing housing instability, behavioral health issues, disability, and neighborhood-level stressors.

MAIN OUTCOMES AND MEASURES

Overall model explanatory power and overpayments and underpayments for subgroups of interest for all Medicaid-reimbursable expenditures excepting long-term support services (mean annual cost = $5590 per member).

RESULTS

We studied 357 660 people who were FFS participants and 524 607 enrolled in MCOs with a combined 806 889 person-years of experience. The FFS program experience included more men (49.6% vs 43.6%), older patients (mean age of 26.1 years vs 21.6 years), and sicker patients (mean morbidity score of 1.16 vs 0.89) than MCOs. Overall, the SDH model performed well, but only slightly better than the diagnosis-based model, explaining most of the spending variation in the managed care population (validated R2 = 62.4) and reducing underpayments for several vulnerable populations. For example, raw costs for the quintile of people living in the most stressed neighborhoods were 9.6% ($537 per member per year) higher than average. Since greater medical morbidity accounts for much of this difference, the diagnosis-based model underpredicts costs for the most stressed quintile by about 2.1% ($130 per member per year). The expanded model eliminates the neighborhood-based underpayment, as well as underpayments of 72% for clients of the Department of Mental Health (observed costs of about $30 000 per year) and of 7% for those with serious mental illness (observed costs of about $16 000 per year).

CONCLUSIONS AND RELEVANCE

Since October 2016, MassHealth has used an expanded model to allocate payments from a prespecified total budget to managed care organizations according to their enrollees' social and medical risk. Extra payments for socially vulnerable individuals could fund activities, such as housing assistance, that could improve health equity.

The association of dietary quality with colorectal cancer among normal weight, overweight and obese men and women: a prospective longitudinal study in the USA

OBJECTIVE

Lower body mass index (BMI) and higher dietary quality reduce the risk of colorectal cancer (CRC). A full understanding of how these associations vary by sex and weight is lacking.

METHODS

We used data from the National Institutes of Health - American Association of Retired Persons (NIH)-AARP) Diet and Health Study for 398 458 persons who were 50-71 years old in 1995-1996 and followed through 2006. Exposures were dietary quality as reflected by the Mediterranean Diet, the Healthy Eating Index-2010 and the Dietary Approaches to Stop Hypertension score, stratified by BMI category. The outcome was CRC diagnosis from cancer registry data. Cox regression models were adjusted for disease risk factors.

RESULTS

Over a mean duration of 123 months of follow-up, there were 6515 new diagnoses of CRC (1953 among the normal weight, 2924 among the overweight and 1638 among the obese; 4483 among men and 2032 among women). For normal weight and overweight men, we found a strong dose-response pattern for the association of increasing quintile of dietary quality with decreasing risk of CRC; this pattern was observed for obese men as well, but less consistently across the three measures of dietary quality. The findings were of smaller magnitude and less consistent for women but still suggesting associations of similar direction.

CONCLUSION

We observed that increased dietary quality was associated with lower risk of incident CRC up to 10 years later for men regardless of baseline weight category.

Association of Changes in Neighborhood-Level Racial Residential Segregation With Changes in Blood Pressure Among Black Adults: The CARDIA Study

Importance

Despite cross-sectional evidence linking racial residential segregation to hypertension prevalence among non-Hispanic blacks, it remains unclear how changes in exposure to neighborhood segregation may be associated with changes in blood pressure.

Objective

To examine the association of changes in neighborhood-level racial residential segregation with changes in systolic and diastolic blood pressure over a 25-year period.

Design, Setting, and Participants

This observational study examined longitudinal data of 2280 black participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective investigation of adults aged 18 to 30 years who underwent baseline examinations in field centers in 4 US locations from March 25, 1985, to June 7, 1986, and then were re-examined for the next 25 years. Racial residential segregation was assessed using the Getis-Ord Gi* statistic, a measure of SD between the neighborhood's racial composition (ie, percentage of black residents) and the surrounding area's racial composition. Segregation was categorized as high (Gi* >1.96), medium (Gi* 0-1.96), and low (Gi* <0). Fixed-effects linear regression modeling was used to estimate the associations of within-person change in exposure to segregation and within-person change in blood pressure while tightly controlling for time-invariant confounders. Data analyses were performed between August 4, 2016, and February 9, 2017.

Main Outcomes and Measures

Within-person changes in systolic and diastolic blood pressure across 6 examinations over 25 years.

Results

Of the 2280 participants at baseline, 974 (42.7%) were men and 1306 (57.3%) were women. Of these, 1861 (81.6%) were living in a high-segregation neighborhood; 278 (12.2%), a medium-segregation neighborhood; and 141 (6.2%), a low-segregation neighborhood. Systolic blood pressure increased by a mean of 0.16 (95% CI, 0.06-0.26) mm Hg with each 1-SD increase in segregation score after adjusting for interactions of time with age, sex, and field center. Of the 1861 participants (81.6%) who lived in high-segregation neighborhoods at baseline, reductions in exposure to segregation were associated with reductions in systolic blood pressure. Mean differences in systolic blood pressure were -1.33 (95% CI, -2.26 to -0.40) mm Hg when comparing high-segregation with medium-segregation neighborhoods and -1.19 (95% CI, -2.08 to -0.31) mm Hg when comparing high-segregation with low-segregation neighborhoods after adjustment for time and interactions of time with baseline age, sex, and field center. Changes in segregation were not associated with changes in diastolic blood pressure.

Conclusions and Relevance

Decreases in exposure to racial residential segregation are associated with reductions in systolic blood pressure. This study adds to the small but growing body of evidence that policies that reduce segregation may have meaningful health benefits.

Is low iodine a risk factor for cardiovascular disease in Americans without thyroid dysfunction? Findings from NHANES

BACKGROUND AND AIMS

Low body iodine levels are associated with cardiovascular disease, in part through alterations in thyroid function. While this association suggested from animal studies, it lacks supportive evidence in humans. This study examined the association between urine iodine levels and presence of coronary artery disease (CAD) and stroke in adults without thyroid dysfunction.

METHODS AND RESULTS

This cross-sectional study included 2440 adults (representing a weighted n = 91,713,183) aged ≥40 years without thyroid dysfunction in the nationally-representative 2007-2012 National Health and Nutrition Examination Survey. The age and sex-adjusted urine iodine/creatinine ratio (aICR) was categorized into low (aICR<116 μg/day), medium (116 μg/day ≤ aICR < 370μg/day), and high (aICR ≥ 370μg/day) based on lowest/highest quintiles. Stroke and CAD were from self-reported physician diagnoses. We examined the association between low urine aICR and CAD or stroke using multivariable logistic regression modeling. The mean age of this population was 56.0 years, 47% were women, and three quarters were non-Hispanic whites. Compared with high urine iodine levels, multivariable adjusted odds ratios aOR (95% confidence intervals) for CAD were statistically significant for low, aOR = 1.97 (1.08-3.59), but not medium, aOR = 1.26 (0.75-2.13) urine iodine levels. There was no association between stroke and low, aOR = 1.12 (0.52-2.44) or medium, aOR = 1.48 (0.88-2.48) urine iodine levels.

CONCLUSION

The association between low urine iodine levels and CAD should be confirmed in a prospective study with serial measures of urine iodine. If low iodine levels precede CAD, then this potential and modifiable new CAD risk factor might have therapeutic implications.

Life Years Gained From Smoking-Cessation Counseling After Myocardial Infarction

INTRODUCTION

Hospitalization for acute myocardial infarction (AMI) is an opportune time to counsel smokers to quit. Studies have demonstrated lower short-term mortality for counseled versus non-counseled smokers; yet, little is known about the long-term survival benefits of post-AMI smoking-cessation counseling (SCC).

METHODS

Data from the Cooperative Cardiovascular Project, a prospective cohort study of elderly patients with AMI between 1994 and 1996 with >17 years of follow-up, were used to evaluate the association of SCC with short- and long-term mortality in smokers with AMI. Life expectancy and years of potential life gained were used to quantify the long-term survival benefits of SCC. Cox proportional hazards models with exponential extrapolation were used to estimate life expectancy.

RESULTS

The analysis included 13,815 smokers, of whom 5,695 (41.2%) received SCC. Non-counseled smokers had higher crude mortality than counseled smokers over all 17 years of follow-up. After adjustment for patient and hospital characteristics, SCC was associated with a 22.6% lower 30-day mortality and a 7.5% lower mortality over 17 years. These survival differences produced higher life expectancy estimates for counseled smokers than non-counseled smokers at all ages, which resulted in average gains in life years of 0.13 (95% CI=-0.31, 0.56) to 0.58 (95% CI=0.25, 0.91) years, with the largest gains observed in older smokers.

CONCLUSIONS

SCC is associated with longer life expectancy and gains in life years in elderly smokers with AMI, supporting the importance of post-AMI counseling efforts.

Performance of the GRACE Risk Score 2.0 Simplified Algorithm for Predicting 1-Year Death After Hospitalization for an Acute Coronary Syndrome in a Contemporary Multiracial Cohort

The GRACE Risk Score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome (ACS). GRACE Risk Score 2.0 substitutes several variables that may be unavailable to clinicians and, thus, limit use of the GRACE Risk Score. GRACE Risk Score 2.0 performed well in the original GRACE cohort. We sought to validate its performance in a contemporary multiracial ACS cohort, in particular in black patients with ACS. We evaluated the performance of the GRACE Risk Score 2.0 simplified algorithm for predicting 1-year mortality in 2,131 participants in Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE), a multiracial cohort of patients discharged alive after an ACS in 2011 to 2013 from 6 hospitals in Massachusetts and Georgia. The median age of study participants was 61 years, 67% were men, and 16% were black. Half (51%) of the patients experienced a non-ST-segment elevation myocardial infarction (NSTEMI) and 18% STEMI. Eighty patients (3.8%) died within 12 months of discharge. The GRACE Risk Score 2.0 simplified algorithm demonstrated excellent model discrimination for predicting 1-year mortality after hospital discharge in the TRACE-CORE cohort (c-index = 0.77). The c-index was 0.94 in patients with STEMI, 0.78 in those with NSTEMI, and 0.87 in black patients with ACS. In conclusion, the GRACE Risk Score 2.0 simplified algorithm for predicting 1-year mortality exhibited excellent model discrimination across the spectrum of ACS types and racial/ethnic subgroups and, thus, may be a helpful tool to guide routine clinical care for patients with ACS.