Abstract 135: Change in Cognition, Depression, and Anxiety Following Catheter Ablation

Background: Patients with atrial fibrillation (AF) commonly experience symptoms such as palpitations, shortness of breath and chest discomfort. The severity of AF-related symptoms is associated with psychosocial factors such as anxiety and depression. Limited data suggests that catheter ablation, a treatment option in symptomatic patients with AF, reduces depression and anxiety but its effect on cognitive function remains unclear.

Methods: Participants were 38 AF patients (mean age = 63 years ±8; 68% male, 66% paroxysmal AF) undergoing an index catheter ablation for AF at the University of Massachusetts Medical Center and interviewed pre-ablation and post ablation (1-week, 1 month and 3 months) as part of an ongoing study of AF treatment and psychosocial factors. A total of 150 ablation patients will be included in the final sample. Cognitive function was assessed using the Montreal Cognitive Assessment Battery (impairment = score <27 on the 30 point scale), depression by the Patient Health Questionnaire (PHQ) and anxiety by the Generalized Anxiety Score (GAD). Trajectories of depressive symptoms, anxiety and cognitive function were modeled before and after catheter ablation using linear mixed models adjusting for age, sex, AF type (paroxysmal vs other), and history of coronary artery disease or diabetes.

Results: Patients reported high levels of depressive symptoms and anxiety and many (>50%) were cognitively impaired prior to ablation. Cognitive function increased following ablation, with improvements observed as early as one week after catheter ablation and continued to improve at 3-months post procedure (Table). Symptoms of depression and anxiety declined immediately following ablation and continued to decline through 3-months post procedure but changes were not statistically significant and may have been limited by power.

Conclusions: Catheter-based ablation was associated with improved symptoms of depression and anxiety as well as cognitive function among patients with symptomatic AF. Knowledge of the patient-centered, as well as clinical, benefits of the various treatments for AF will guide patients, their families and their physicians make informed treatment choices.

Abstract 126: In-hospital Depression Predicts Early Hospital Readmission after an Acute Coronary Syndrome: Preliminary Data from TRACE-CORE

Background: Hospital systems, patients and providers seek to avert rehospitalizations within 30 days for patients admitted with an acute coronary syndrome (ACS). Rehospitalizations within 30 days of discharge are often considered preventable and to reflect poor in-hospital management or discharge practices. However, independent associations of psychosocial factors with early rehospitalization in patients admitted with an ACS have not been examined.

Methods: A multi-racial cohort of 1,540 patients admitted with an ACS reported psychosocial factors via standardized questionnaires in an in-hospital interview. One month following discharge, patients were interviewed via phone and reported hospital readmissions. We used logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the association between in-hospital psychosocial characteristics (depression, anxiety, and perceived stress), health literacy and numeracy, and cognitive status, with self-reported readmission within 30 days.

Results: Participants were 34% female and 17% non-white, with a mean age of 62 years and a mean length of stay of 4.1 days. Rehospitalization was reported for 14% (n=208) of participants, 77% of which were due to CVD. In univariate analyses, in-hospital severe depression, anxiety, and high stress were associated with higher odds of early readmission, whereas low health numeracy was associated with lower odds of early readmission (Table 1). Severe depression remained associated with higher odds and low health numeracy remained associated with lower odds of early readmission in a multivariable model including covariates associated on univariate testing with rehospitalization.

Conclusions: Early readmission after hospitalization for an ACS was common and associated with in-hospital depression and health numeracy. Notably, depression and health numeracy were the only predictors independently associated with readmission in multivariable analyses. We speculate that the lower likelihood of readmission for those with low numeracy may be related to less engagement with the healthcare system. In-hospital screening for depression and characterization of health numeracy may help stratify risk for early rehospitalization after an ACS.

Abstract 146: Demographic and Clinical Characteristics Associated with Patient Perceptions of Being Cured Following Hospitalization for Acute Coronary Syndromes: Preliminary Results from TRACE-CORE and TRACE-CARE

Background: Recent decades have seen improvements in treatment for acute coronary syndromes (ACS), reduced mortality, and shortened hospital stays. Limited evidence suggests that some patients may leave the hospital with the perception that they are cured.

Objective: To describe demographic and clinical characteristics associated with patient perceptions that their heart condition is cured at one week following hospitalization for ACS.

Methods: We analyzed data from 397 patients interviewed during hospitalization for ACS in 2011-2013 as part of the Transitions, Risks, and Actions in Coronary Events: Centers for Outcomes Research and Education (TRACE-CORE), and again at one week post-discharge as part of an ancillary study, TRACE-CARE. At one week, patients were asked “How true or false is this statement for you: My heart condition is cured. Would you say that this is definitely true, mostly true, neutral, mostly false, or definitely false?” We considered patients who responded “definitely true” or “mostly true” to perceive that their heart condition was cured. We calculated 6-month GRACE risk scores using clinical data from medical records. We used multivariable logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations with cure perceptions.

Results: Participants were 26% (n=105) female and 89% (n=350) non-Hispanic white with mean age 60.7±11.0 years. Sixteen percent (n=63) were hospitalized with unstable angina, 69% (n=266) with NSTEMI, and 14% (n=55) with STEMI; 31% (n=124) had a history of CHD; and the average GRACE risk score was 93.6 (SD: 26.6). Seventy-three percent (n=289) received PCI during hospitalization and 11% (n=43) CABG. Discharge occurred the same or next day for 19% (n=76) and within 2-3 days for 54% (n=214). One week post-discharge, 30% (n=120) perceived their heart condition was cured. In a multivariable model, male sex, unstable angina, no history of CHD, and receipt of CABG were associated with greater odds of perceiving oneself cured (Table).

Conclusions: One week post-discharge for ACS, 3 in 10 patients perceived their heart condition was cured. Future research should examine additional patient factors related to cure perceptions, and whether these perceptions influence engagement in recommended secondary prevention strategies.

Abstract 129: Severity of Symptoms from Atrial Fibrillation is Associated with Depression and Anxiety: Preliminary Data from the InRhythm Study

Background: Atrial fibrillation (AF) affects approximately 4 million Americans, and two out of three AF patients are affected by troublesome symptoms. Symptomatic AF often leads to hospitalization, diminishes quality of life, and imposes considerable stress on affected individuals. Depression and anxiety are exceedingly common in AF, affecting up to one-half of these patients. Nevertheless, few investigations have examined the association between severity and type of AF-related symptoms with depression or anxiety.

Methods: A cohort of 113 ambulatory patients treated for symptomatic AF in the University of Massachusetts Medical Center’s AF Treatment Program were assessed for depression using the Patient Health Questionnaire (PHQ), anxiety by the Generalized Anxiety Score (GAD), and health-related quality of life using the Atrial Fibrillation Effect on Quality of Life (AFEQT) as part of an ongoing study of AF treatment and psychosocial factors. We used logistic regression models to examine the association between severity of AF symptoms in four symptom classes (palpitations, dizziness, pauses in heart activity, and irregularity) and severity of depression or anxiety.

Results: Participants were 34% female with a mean age of 64 years. Seventy-six percent had paroxysmal AF, and the average AFEQT score was 67 ± 23 (range 0-100, 100 = no disability). Twenty-five percent (n=28) reported moderate or severe anxiety and 40% (n=46) had moderate or severe depression. In multivariable analyses adjusting for age, sex, race, AF type, history of heart failure and coronary artery disease, participants with severe palpitations (23%) and dizziness (25%) were 3 to 5 times more likely to report moderate or severe symptoms of depression and anxiety ( Table , p for all <0.05). Those with severe pauses (9%) and moderate irregularity (29%) were 3 to 7 times more likely to report high depressive symptoms, but not anxiety, than participants with minimal or no symptoms ( Table , p for all <0.05).

Conclusion: Participants with AF commonly had symptoms, and the severity of symptoms was positively associated with depression and anxiety. In light of the known association between AF, depression and anxiety, rhythm control strategies such as catheter ablation for AF might improve quality of life as well as symptoms of depression or anxiety.

Psychometric evaluation of the Care Transition Measure in TRACE-CORE: do we need a better measure?

Background

The quality of transitional care is associated with important health outcomes such as rehospitalization and costs. The widely used Care Transitions Measure (CTM‐15) was developed with a classic test theory approach; its short version (CTM‐3) was included in the CAHPS Hospital Survey. We conducted a psychometric evaluation of both measures and explored whether item response theory (IRT) could produce a more precise measure.

Methods and Results

As part of the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education, 1545 participants were interviewed during an acute coronary syndrome hospitalization, providing information on general health status (Short Form‐36), CTM‐15, health utilization, and care process questions at 1 month postdischarge. We used classic and IRT analyses and compared the measurement precision of CTM‐15–, CTM‐3–, and CTM‐IRT–based score using relative validity.

Participants were 79% non‐Hispanic white and 67% male, with an average age of 62 years. The CTM‐15 had good internal consistency (Cronbach's α=0.95) but demonstrated acquiescence bias (8.7% participants responded “Strongly agree” and 19% responded “Agree” to all items) and limited score variability. These problems were more pronounced for the CTM‐3. The CTM‐15 differentiated between patient groups defined by self‐reported health status, health care utilization, and care transition process indicators. Differences between groups were small (2 to 3 points). There was no gain in measurement precision from IRT scoring. The CTM‐3 was not significantly lower for patients reporting rehospitalization or emergency department visits.

Conclusion

We identified psychometric challenges of the CTM, which may limit its value in research and practice. These results are in line with emerging evidence of gaps in the validity of the measure.

Rates of insurance for injured patients before and after health care reform in Massachusetts: a possible case of double jeopardy

OBJECTIVES

We determined how preinjury insurance status and injury-related outcomes among able-bodied, community-dwelling adults treated at a Level I Trauma Center in central Massachusetts changed after health care reform.

METHODS

We compared insurance status at time of injury among non-Medicare-eligible adult Massachusetts residents before (2004-2005) and after (2009-2010) health care reform, adjusted for demographic and injury covariates, and modeled associations between insurance status and trauma outcomes.

RESULTS

Among 2148 patients before health care reform and 2477 patients after health care reform, insurance rates increased from 77% to 84% (P < .001). Younger patients, men, minorities, and penetrating trauma victims were less likely to be insured irrespective of time period. Uninsured patients were more likely to be discharged home without services (adjusted odds ratio = 3.46; 95% confidence interval = 2.65, 4.52) compared with insured patients.

CONCLUSIONS

Preinjury insurance rates increased for trauma patients after health care reform but remained lower than in the general population. Certain Americans may be in "double jeopardy" of both higher injury incidence and worse outcomes because socioeconomic factors placing them at risk for injury also present barriers to compliance with an individual insurance mandate.

Sociodemographic differences in fast food price sensitivity

IMPORTANCE

Fiscal food policies (eg, taxation) are increasingly proposed to improve population-level health, but their impact on health disparities is unknown.

OBJECTIVE

To estimate subgroup-specific effects of fast food price changes on fast food consumption and cardiometabolic outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-year follow-up (5 examinations) in a biracial US prospective cohort: Coronary Artery Risk Development in Young Adults (CARDIA) (1985/1986-2005/2006, baseline N = 5115). Participants were aged 18 to 30 years at baseline; design indicated equal recruitment by race (black vs white), educational attainment, age, and sex. Community-level price data from the Council for Community and Economic Research were temporally and geographically linked to study participants' home address at each examination.

MAIN OUTCOMES AND MEASURES

Participant-reported number of fast food eating occasions per week, body mass index (BMI), and homeostasis model assessment insulin resistance (HOMA-IR) from fasting glucose and insulin concentrations. Covariates included individual-level and community-level social and demographic factors.

RESULTS

In repeated measures regression analysis, multivariable-adjusted associations between fast food price and consumption were nonlinear (quadratic, P < .001), with significant inverse estimated effects on consumption at higher prices; estimates varied according to race (interaction P = .04), income (P = .07), and education (P = .03). At the 10th percentile of price ($1.25/serving), blacks and whites had mean fast food consumption frequency of 2.20 (95% CI, 2.07-2.33) and 1.55 (1.45-1.65) times/wk, respectively, whereas at the 90th percentile of price ($1.53/serving), respective mean consumption estimates were 1.86 (1.75-1.97) and 1.50 (1.41-1.59) times/wk. We observed differential price effects on HOMA-IR (inverse for lower educational status only [interaction P = .005] and at middle income only [interaction P = .02]) and BMI (inverse for blacks, less education, and middle income; positive for whites, more education, and high income [all interaction P < .001]).

CONCLUSIONS AND RELEVANCE

We found greater fast food price sensitivity on fast food consumption and insulin resistance among sociodemographic groups that have a disproportionate burden of chronic disease. Our findings have implications for fiscal policy, particularly with respect to possible effects of fast food taxes among populations with diet-related health disparities.

Perceived weight discrimination in the CARDIA study: differences by race, sex, and weight status

OBJECTIVE

To examine self-reported weight discrimination and differences based on race, sex, and BMI in a biracial cohort of community-based middle-aged adults.

DESIGN AND METHODS

Participants (3,466, mean age = 50 years, mean BMI = 30 kg/m²) of the Coronary Artery Risk Development in Young Adults (CARDIA) Study who completed the 25-year examination of this epidemiological investigation in 2010-2011 were reported. The sample included normal weight, overweight, and obese participants. CARDIA participants are distributed into four race-sex groups, with about half being African-American and half White. Participants completed a self-reported measure of weight discrimination.

RESULTS

Among overweight/obese participants, weight discrimination was lowest for White men (12.0%) and highest for White women (30.2%). The adjusted odds ratio (95% CI) for weight discrimination in those with class 2/3 obesity (BMI ≥ 35 kg/m²) versus the normal-weight was most pronounced: African American men, 4.59 (1.71-12.34); African American women, 7.82 (3.57-17.13); White men, 6.99 (2.27-21.49); and White women, 18.60 (8.97-38.54). Being overweight (BMI = 25-29.9 kg/m²) vs. normal weight was associated with increased discrimination in White women only: 2.10 (1.11-3.96).

CONCLUSIONS

Novel evidence for a race-sex interaction on perceived weight discrimination, with White women more likely to report discrimination at all levels of overweight and obesity was provided. Pychosocial mechanisms responsible for these differences deserve exploration.

Weight-based discrimination and medication adherence among low-income African Americans with hypertension: how much of the association is mediated by self-efficacy?

OBJECTIVES

Much of the excessive morbidity and mortality from cardiovascular disease among African Americans results from low adherence to anti-hypertensive medications. Therefore, we examined the association between weight-based discrimination and medication adherence.

METHODS

We used cross-sectional data from low-income African Americans with hypertension. Ordinal logistic regression estimated the odds of medication non-adherence in relation to weight-based discrimination adjusted for age, sex, education, income, and weight.

RESULTS

Of all participants (n = 780), the mean (SD) age was 53.7 (9.9) years and the mean (SD) weight was 210.1 (52.8) lbs. Reports of weight-based discrimination were frequent (28.2%). Weight-based discrimination (but not weight itself) was associated with medication non-adherence (OR: 1.94; 95% CI: 1.41-2.67). A substantial portion 38.9% (95% CI: 19.0%-79.0%) of the association between weight-based discrimination and medication non-adherence was mediated by medication self-efficacy.

CONCLUSION

Self-efficacy is a potential explanatory factor for the association between reported weight-based discrimination and medication non-adherence. Future research should develop and test interventions to prevent weight-based discrimination at the societal, provider, and institutional levels.

Relapse among cigarette smokers: the CARDIA longitudinal study - 1985-2011

RATIONALE

There is little information about long-term relapse patterns for cigarette smokers.

OBJECTIVE

To describe long-term prevalence of relapse and related smoking patterns by sex, race, age, and education level among a community-based cohort of young adults followed for 25 years.

METHODS

We examined 25 years of data from Coronary Artery Risk Development in Young Adults (CARDIA), an ongoing study of a community-based cohort of 5115 men and women aged 18 to 30 years at baseline with periodic re-examinations. At each examination smoking, quitting, and relapse were queried. We examined prevalence of smoking relapse among 3603 participants who attended at least 6 of the 8 examinations.

RESULTS

About 53% of 3603 participants never reported smoking on a regular basis. Among the remaining 1682 ever smokers, 52.8% of those who reported current smoking at baseline were still smoking by the end of the study, compared to 10.7% of those who initiated smoking by year 5. Among those classified as former smokers at baseline, 39% relapsed at least once; of these, 69.5% had quit again by the end of the study. Maximum education level attained, age at study baseline, and race were associated with failure to quit smoking by the end of the study and relapse among those who did quit. Maximum education level attained and age at study baseline were also associated with ability to successfully quit after a relapse.

CONCLUSIONS

Smoking relapse after quitting is common, especially in those with lower education level. Education was the strongest predictor of all three outcomes. Improvements in access to treatment and treatment options, especially for underserved populations, are needed to prevent relapse when smokers quit.

The neighborhood energy balance equation: does neighborhood food retail environment + physical activity environment = obesity? The CARDIA study

BACKGROUND

Recent obesity prevention initiatives focus on healthy neighborhood design, but most research examines neighborhood food retail and physical activity (PA) environments in isolation. We estimated joint, interactive, and cumulative impacts of neighborhood food retail and PA environment characteristics on body mass index (BMI) throughout early adulthood.

METHODS AND FINDINGS

We used cohort data from the Coronary Artery Risk Development in Young Adults (CARDIA) Study [n=4,092; Year 7 (24-42 years, 1992-1993) followed over 5 exams through Year 25 (2010-2011); 12,921 person-exam observations], with linked time-varying geographic information system-derived neighborhood environment measures. Using regression with fixed effects for individuals, we modeled time-lagged BMI as a function of food and PA resource density (counts per population) and neighborhood development intensity (a composite density score). We controlled for neighborhood poverty, individual-level sociodemographics, and BMI in the prior exam; and included significant interactions between neighborhood measures and by sex. Using model coefficients, we simulated BMI reductions in response to single and combined neighborhood improvements. Simulated increase in supermarket density (from 25(th) to 75(th) percentile) predicted inter-exam reduction in BMI of 0.09 kg/m(2) [estimate (95% CI): -0.09 (-0.16, -0.02)]. Increasing commercial PA facility density predicted BMI reductions up to 0.22 kg/m(2) in men, with variation across other neighborhood features [estimate (95% CI) range: -0.14 (-0.29, 0.01) to -0.22 (-0.37, -0.08)]. Simultaneous increases in supermarket and commercial PA facility density predicted inter-exam BMI reductions up to 0.31 kg/m(2) in men [estimate (95% CI) range: -0.23 (-0.39, -0.06) to -0.31 (-0.47, -0.15)] but not women. Reduced fast food restaurant and convenience store density and increased public PA facility density and neighborhood development intensity did not predict reductions in BMI.

CONCLUSIONS

Findings suggest that improvements in neighborhood food retail or PA environments may accumulate to reduce BMI, but some neighborhood changes may be less beneficial to women.

A qualitative analysis of acute care surgery in the United States: it's more than just "a competent surgeon with a sharp knife and a willing attitude"

BACKGROUND

Since acute care surgery (ACS) was conceptualized a decade ago, the specialty has been adopted widely; however, little is known about the structure and function of ACS teams.

METHODS

We conducted 18 open-ended interviews with ACS leaders (representing geographic [New England, Northeast, Mid-Atlantic, South, West, Midwest] and practice [Public/Charity, Community, University] diversity). Two independent reviewers analyzed transcribed interviews using an inductive approach (NVivo qualitative analysis software).

RESULTS

All respondents described ACS as a specialty treating "time-sensitive surgical disease" including trauma, emergency general surgery (EGS), and surgical critical care (SCC); 11 of 18 combined trauma and EGS into a single clinical team; 9 of 18 included elective general surgery. Emergency orthopedics, emergency neurosurgery, and surgical subspecialty triage were rare (1/18 each). Eight of 18 ACS teams had scheduled EGS operating room time. All had a core group of trauma and SCC surgeons; 13 of 18 shared EGS due to volume, human resources, or competition for revenue. Only 12 of 18 had formal signout rounds; only 2 of 18 had prospective EGS data registries. Streamlined access to EGS, evidence-based protocols, and improved education were considered strengths of ACS. ACS was described as the "last great surgical service" reinvigorated to provide "timely," cost-effective EGS by experts in "resuscitation and critical care" and to attract "young, talented, eager surgeons" to trauma/SCC; however, there was concern that ACS might become the "wastebasket for everything that happens at inconvenient times."

CONCLUSION

Despite rapid adoption of ACS, its implementation varies widely. Standardization of scope of practice, continuity of care, and registry development may improve EGS outcomes and allow the specialty to thrive.

Variations in tobacco control in National Dental PBRN practices: the role of patient and practice factors

We engaged dental practices enrolled in The National Dental Practice-Based Research Network to quantify tobacco screening (ASK) and advising (ADVISE); and to identify patient and practice -characteristics associated with tobacco control. Dental practices (N = 190) distributed patient surveys that measured ASK and ADVISE. Twenty-nine percent of patients were ASKED about tobacco use during visit, 20% were identified as tobacco users, and 41% reported being ADVISED. Accounting for clustering of patients within practices, younger age and male gender were positively associated with ASK and ADVISE. Adjusting for patient age and gender, a higher proportion of non-whites in the practice, preventive services and proportion on public assistance were positively associated with ASK. Proportion of tobacco users in the practice and offering other preventive services were more strongly associated with ASK and ADVISE than other practice characteristics. Understanding variations in performance is an important step toward designing strategies for improving tobacco control in dentistry.

Skin color, sex, and educational attainment in the post-civil rights era

We assess the relationship between skin color and educational attainment for native-born non-Hispanic Black and White men and women, using data from the Coronary Artery Risk Development in Young Adults (CARDIA) Study. CARDIA is a medical cohort study with twenty years of social background data and a continuous measure of skin color, recorded as the percent of light reflected off skin. For Black men and women, we find a one-standard-deviation increase in skin lightness to be associated with a quarter-year increase in educational attainment. For White women, we find an association approximately equal in magnitude to that found for Black respondents, and the pattern of significance across educational transitions suggests that skin color for White women is not simply a proxy for family background. For White men, any relationship between skin color and attainment is not robust and, analyses suggest, might primarily reflect differences in family background. Findings suggest that discrimination on the basis of skin color may be less specific to race than previously thought.

Enrollment of patients with lung and colorectal cancers onto clinical trials

PURPOSE

Only 2% to 5% of adult patients with cancer enroll onto clinical trials. We assessed simultaneously characteristics of patients and their physicians that may be independently associated with participation.

METHODS

CanCORS, a National Cancer Institute (NCI) -funded population-based observational cohort study of newly diagnosed patients with lung and colorectal cancers, sampled patients across five geographic areas, five health care delivery systems, and 15 Veterans Administration hospitals. We linked patient survey and medical record data with physician survey data to examine correlates of trial enrollment.

RESULTS

Among 9,901 patients, 5.3% enrolled onto trials. Of the 9,901 patients, we linked 6,506 patients to one medical oncologist, surgeon, or radiation oncologist (physicians, N = 1,325) who responded to the physician survey and was considered their primary cancer clinician decision maker. Patient age, race, disease stage, geographic region, and health insurance were independently associated with trial enrollment. Physician factors independently associated with patient trial enrollment were being a medical oncologist, practicing at an NCI-designated cancer center, taking the lead in discussing trials with patients, and receiving increased income from trial enrollment. After simultaneously adjusting for patient and physician characteristics, only being a physician practicing at an NCI-designated cancer center (odds ratio [OR], 1.65; 95% CI, 1.19 to 2.27) and patient female sex (OR, 1.36; 95% CI, 1.10 to 1.68), age > 70 versus < 50 years (OR, 0.28; 95% CI, 0.16 to 0.48), and advanced disease (OR, 1.85; 95% CI, 1.45 to 2.37) remained independently associated with trial enrollment.

CONCLUSION

Both practice environment and patient clinical and demographic characteristics are associated with cancer clinical trial enrollment; simultaneous intervention may be required when trying to increase enrollment rates.

Cognitive change in heart failure: a systematic review

BACKGROUND

Cognitive impairment, highly prevalent in patients with heart failure (HF), increases risk for hospitalization and mortality. However, the course of cognitive change in HF is not well characterized. The purpose of this systematic review was to examine the available evidence longitudinal changes in cognitive function in patients with HF.

METHODS AND RESULTS

A literature search of several electronic databases was performed. Studies published from January 1, 1980, to September 30, 2012, that used validated measures to diagnose HF and assess cognitive function ≥2× in adults with HF were eligible for inclusion. Change in cognitive function was examined in the context of HF treatments applied (eg, medication initiation, left ventricular assist device implantation), length of follow-up, and comparison group. Fifteen studies met eligibility criteria. Significant decline in cognitive function was noted among patients with HF followed up for >1 year. Improvements in cognition were observed among patients with HF undergoing interventions to improve cardiac function (eg, heart transplantation) and among patients examined over short time periods (<1 year). Studies comparing patients' cognition over time with their own baseline tended to report improvements, whereas studies using a comparison group without HF tended to report declines or stability in cognition over time among patients with HF.

CONCLUSIONS

Patients with HF are at increased risk for cognitive decline, but this risk seems to be modifiable with cardiac treatment. Further research is needed to identify the mechanisms that cause cognitive changes in HF.

Obesity Modifies the Association of Race/Ethnicity with Medication Adherence in the CARDIA Study

OBJECTIVE

To assess associations between race/ethnicity and medication adherence, and the potential modifying effects of weight category (normal, overweight, obese) in a community-based sample.

STUDY DESIGN AND SETTING

We studied 1355 participants from the CARDIA (Coronary Artery Risk Development in Young Adults) study who were taking prescription medications in 2000-1. Medication adherence, as rated on the four-item Morisky medication adherence scale (score of 4 = maximum adherence), was reported for all participants.

RESULTS

The mean age ± SD of participants was 40 ± 3.6 years; 45% were African American and 36% were male. Overall, Whites had a higher proportion of maximum adherence than African Americans (59 vs 41%, respectively; p = 0.001). However, this difference was statistically significant only for participants within the normal weight category, of whom 54% of Whites were maximally adherent versus 35% of African Americans (p < 0.05). After adjustment for possible confounding covariates, race/ethnicity was associated with adherence only in those of normal weight: the odds ratio for maximum adherence in Whites versus African Americans of normal weight was 1.98 (95% CI 1.13, 3.47). Within race/ethnicity subgroups, weight category was associated with adherence in Whites but not in African Americans.

CONCLUSION

Weight category modifies the association of race/ethnicity with medication adherence. The high levels of non-adherence observed among African Americans and obese and overweight Whites bodes poorly for treatment of obesity-associated diseases such as cardiovascular disease or diabetes mellitus.

Abstract 173: Tailoring Follow-Up Methods for Hard-to-Reach Participants in Outcomes Research: An Example from TRACE-CORE

Aims: Telephone follow-up for longitudinal outcomes research is common, with widely variable response rates. Non-respondents are often different from respondents and come from vulnerable groups, including racial and ethnic minorities, elders, or those with multiple co-morbidities. We aimed to create a comprehensive follow-up strategy to target follow-up resources to the hardest-to-reach participants. These methods could help outcomes researchers retain hard-to-reach patients in longitudinal studies.

Methods: Using interview completion data from the first 614 patients hospitalized with an acute coronary syndrome and enrolled in the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) cohort at our largest enrollment site, we fit a logistic regression model that used socio-demographic characteristics and difficulties with hearing and vision to predict likelihood of non-completion of a 1-month post-hospitalization telephone interview. Patients whose predicted probability of non-completion exceeded a threshold were triaged to a new follow-up protocol with more intensive calling by site-specific staff with access to medical records and follow-up appointment schedules. We compared the post-implementation follow-up completion rates to the expected completion rates based on the model.

Results: The model predicted a completion rate of 69.8% (56 of 80) among the hard-to-reach group; our intervention achieved a 85.0% (68 of 80) completion rate (p=0.002). Increases in response rates were observed across most subgroups, although not all improvements reached statistical significance (Table). Improvements in completion rates were less pronounced for vulnerable groups.

Conclusions: We used a statistical model to prospectively identify a “hard-to-reach” group for more intensive follow-up efforts. The statistical model provided an expected completion rate for patients receiving the new protocol against which the observed rate could be tested, allowing us to conclude that the enhanced protocol worked to improve follow-up in these typically hard-to-reach populations.

Centers for cardiovascular outcomes research: defining a collaborative vision

BACKGROUND

Recognizing the value of outcomes research to understand and bridge translational gaps, to establish evidence in clinical practice and delivery of medicine, and to generate new hypotheses on ongoing questions of treatment and care, the National Heart, Lung, and Blood Institute of the National Institutes of Health established the Centers for Cardiovascular Outcomes Research program in 2010.

METHODS AND RESULTS

The National Heart, Lung, and Blood Institute funded 3 centers and a research coordinating unit. Each center has an independent project focus, including (1) characterizing care transition and predicting clinical events and quality of life for patients discharged after an acute coronary syndrome; (2) identifying center and regional factors associated with better patient outcomes across several cardiovascular conditions and procedures; and (3) examining the impact of healthcare reform in Massachusetts on overall and disparate care and outcomes for several cardiovascular conditions and venous thromboembolism. Cross-program collaborations seek to advance the field methodologically and to develop early-stage investigators committed to careers in outcomes research.

CONCLUSIONS

The Centers for Cardiovascular Outcomes Research program represents a significant investment in cardiovascular outcomes research by the National Heart, Lung, and Blood Institute. The vision of this program is to leverage scientific rigor and cross-program collaboration to advance the science of healthcare delivery and outcomes beyond what any individual unit could achieve alone.

Cluster-randomized trial of a web-assisted tobacco quality improvement intervention of subsequent patient tobacco product use: a National Dental PBRN study

Background

Brief clinician delivered advice helps in tobacco cessation efforts. This study assessed the impact of our intervention on instances of advice given to dental patients during visits on tobacco use quit rates 6 months after the intervention.

Methods

The intervention was cluster randomized trial at the dental practice level. Intervention dental practices were provided a longitudinal technology-assisted intervention, oralcancerprevention.org that included a series of interactive educational cases and motivational email cues to remind dental provides to complete guideline-concordant brief behavioral counseling at the point of care. In all dental practices, exit cards were given to the first 100 consecutive patients, in which tobacco users provided contact information for a six month follow-up telephone survey.

Results

A total of 564 tobacco using dental patients completed a six month follow-up survey. Among intervention patients, 55% reported receiving advice to quit tobacco, and 39% of control practice patients reported receiving advice to quit tobacco (p < 0.01). Six-month tobacco use quit rates were not significantly between the Intervention (9%) and Control (13%) groups, (p = 0.088).

Conclusion

Although we increased rates of cessation advice delivered in dental practices, this study shows no evidence that brief advice by dentist’s increases long-term abstinence in smokers.

Trial registration

ClinicalTrials.gov NCT00627185

Atherosclerotic risk factors and their association with hospital mortality among patients with first myocardial infarction (from the National Registry of Myocardial Infarction)

Few studies have examined associations between atherosclerotic risk factors and short-term mortality after first myocardial infarction (MI). Histories of 5 traditional atherosclerotic risk factors at presentation (diabetes, hypertension, smoking, dyslipidemia, and family history of premature heart disease) and hospital mortality were examined among 542,008 patients with first MIs in the National Registry of Myocardial Infarction (1994 to 2006). On initial MI presentation, history of hypertension (52.3%) was most common, followed by smoking (31.3%). The least common risk factor was diabetes (22.4%). Crude mortality was highest in patients with MI with diabetes (11.9%) and hypertension (9.8%) and lowest in those with smoking histories (5.4%) and dyslipidemia (4.6%). The inclusion of 5 atherosclerotic risk factors in a stepwise multivariate model contributed little toward predicting hospital mortality over age alone (C-statistic = 0.73 and 0.71, respectively). After extensive multivariate adjustments for clinical and sociodemographic factors, patients with MI with diabetes had higher odds of dying (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.20 to 1.26) than those without diabetes and similarly for hypertension (OR 1.08, 95% CI 1.06 to 1.11). Conversely, family history (OR 0.71, 95% CI 0.69 to 0.73), dyslipidemia (OR 0.62, 95% CI 0.60 to 0.64), and smoking (OR 0.85, 95% CI 0.83 to 0.88) were associated with decreased mortality (C-statistic = 0.82 for the full model). In conclusion, in the setting of acute MI, histories of diabetes and hypertension are associated with higher hospital mortality, but the inclusion of atherosclerotic risk factors in models of hospital mortality does not improve predictive ability beyond other major clinical and sociodemographic characteristics.

Transitions, Risks, and Actions in Coronary Events--Center for Outcomes Research and Education (TRACE-CORE): design and rationale

BACKGROUND

Cardiovascular disease continues to cause significant morbidity, mortality, and impaired quality of life, with unrealized health gains from the underuse of available evidence. The Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) aims to advance the science of acute coronary syndromes by examining the determinants and outcomes of the quality of transition from hospital to community and by quantifying the impact of potentially modifiable characteristics associated with decreased quality of life, rehospitalization, and mortality.

METHODS AND RESULTS

TRACE-CORE comprises a longitudinal multiracial cohort of patients hospitalized with acute coronary syndromes, 2 research projects, and development of a nucleus of early stage investigators. We are currently enrolling 2500 adults hospitalized for acute coronary syndromes at 6 hospitals in the northeastern and southeastern United States. We will follow these patients for 24 months after hospitalization through medical record abstraction and 5 patient interviews focusing on quality of life, cardiac events, rehospitalizations, mortality, and medical, behavioral, and psychosocial characteristics. The Transitions Project studies determinants of and disparities in outcomes of the quality of patients' transition from hospital to community. Focusing on potentially modifiable factors, the Action Scores Project will develop and validate action scores to predict recurrent cardiac events, death, and quality of life, describe longitudinal variation in these scores, and develop a dashboard for patient and provider action on the basis of these scores.

CONCLUSIONS

In TRACE-CORE, sound methodologic principles of observational studies converge with outcomes and effectiveness research approaches. We expect that our data, research infrastructure, and research projects will inform the development of novel secondary prevention approaches and underpin the careers of cardiovascular outcomes researchers.

Racial discrimination, racial/ethnic segregation, and health behaviors in the CARDIA study

OBJECTIVE

Racial discrimination has been associated with unhealthy behaviors, but the mechanisms responsible for these associations are not understood and may be related to residential racial segregation. We investigated associations between self-reported racial discrimination and health behaviors before and after controlling for individual- and neighborhood-level characteristics; and potential effect modification of these associations by segregation.

DESIGN

We used data from the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) study for 1169 African-Americans and 1322 whites. To assess racial discrimination, we used a four category variable to capture the extent and persistence of self-reported discrimination between examination at years 7 (1992-1993) and 15 (2000-2001). We assessed smoking status, alcohol consumption, and physical activity at year 20 (2005-2006). Segregation was examined as the racial/ethnic composition at the Census tract level.

RESULTS

Discrimination was more common in African-Americans (89.1%) than in whites (40.0%). Living in areas with high percentage of blacks was associated with less reports of discrimination in African-Americans but more reports in whites. After adjustment for selected characteristics including individual- and neighborhood-level socioeconomic conditions and segregation, we found significant positive associations of discrimination with smoking and alcohol consumption in African-Americans and with smoking in whites. African-Americans experiencing moderate or high discrimination were more physically active than those reporting no discrimination. Whites reporting some discrimination were also more physically active than those reporting no discrimination. We observed no interactions between discrimination and segregation measures in African-Americans or whites for any of the three health behaviors.

CONCLUSIONS

Racial discrimination may impact individuals' adoption of healthy and unhealthy behaviors independent of racial/ethnic segregation. These behaviors may help individuals buffer or reduce the stress of discrimination.

Early life stress and inflammatory mechanisms of fatigue in the Coronary Artery Risk Development in Young Adults (CARDIA) study

Fatigue is highly prevalent and causes serious disruption in quality of life. Although cross-sectional studies suggest childhood adversity is associated with adulthood fatigue, longitudinal evidence of this relationship and its specific biological mechanisms have not been established. This longitudinal study examined the association between early life stress and adulthood fatigue and tested whether this association was mediated by low-grade systemic inflammation as indexed by circulating C-reactive protein (CRP) and interleukin-6 (IL-6). In the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based longitudinal study conducted in 4 US cities, early life stress was retrospectively assessed in 2716 African-American and white adults using the Risky Families Questionnaire at Year 15 examination (2000-2001, ages 33-45 years). Fatigue as indexed by a loss of subjective vitality using the Vitality Subscale of the 12-item Short Form Health Survey was assessed at both Years 15 and 20. While CRP was measured at both Years 15 and 20, IL-6 was measured only at Year 20. Early life stress assessed at Year 15 was associated with adulthood fatigue at Year 20 after adjustment for sociodemographic characteristics, body-mass index, medication use, medical comorbidity, smoking, alcohol consumption, physical activity, current stress, pain, sleep disturbance as well as Year 15 fatigue (adjusted beta 0.047, P=0.007). However, neither CRP nor IL-6 was a significant mediator of this association. In summary, early life stress assessed in adulthood was associated with fatigue 5 years later, but this association was not mediated by low-grade systemic inflammation.

Racial/ethnic and gender differences in the association between self-reported experiences of racial/ethnic discrimination and inflammation in the CARDIA cohort of 4 US communities

Inflammation is etiologically implicated in cardiometabolic diseases for which there are known racial/ethnic disparities. Prior studies suggest there may be an association between self-reported experiences of racial/ethnic discrimination and inflammation, particularly C-reactive protein (CRP). It is not known whether that association is influenced by race/ethnicity and gender. In separate hierarchical linear models with time-varying covariates, we examined that association among 901 Black women, 614 Black men, 958 White women, and 863 White men in the Coronary Artery Risk Development in Young Adults (CARDIA) study in four US communities. Self-reported experiences of racial/ethnic discrimination were ascertained in 1992-93 and 2000-01. Inflammation was measured as log-transformed CRP in those years and 2005-06. All analyses were adjusted for blood pressure, plasma total cholesterol, triglycerides, homeostatic model assessment for insulin resistance (HOMA-IR), age, education, and community. Our findings extend prior research by suggesting that, broadly speaking, self-reported experiences of racial/ethnic discrimination are associated with inflammation; however, this association is complex and varies for Black and White women and men. Black women reporting 1 or 2 experiences of discrimination had higher levels of CRP compared to Black women reporting no experiences of discrimination (β = 0.141, SE = 0.062, P < 0.05). This association was not statistically significant among Black women reporting 3 or more experiences of discrimination and not independent of modifiable risks (smoking and obesity) in the final model. White women reporting 3 or more experiences of discrimination had significantly higher levels of CRP compared to White women reporting no experiences of discrimination independent of modifiable risks in the final model (β = 0.300, SE = 0.113, P < 0.01). The association between self-reported experiences of racial/ethnic discrimination and CRP was not statistically significant among Black and White men reporting 1 or 2 experiences of discrimination. Further research in other populations is needed.