Heat Maps of Hypertension, Diabetes Mellitus, and Smoking in the Continental United States

Trends in Demographic and Geographic Disparities in Stroke Mortality Among Older Adults in the United States

BACKGROUND

Stroke is a leading cause of morbidity and mortality in the United States among older adults. However, the impact of demographic and geographic risk factors remains ambiguous. A clear understanding of these associations and updated trends in stroke mortality can influence health policies and interventions.

METHODS

This study characterizes stroke mortality among older adults (age ≥55) in the US from January 1999 to December 2020, sourcing data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. Segmented regression was used to analyze trends in crude mortality rate and age-adjusted mortality rate (AAMR) per 100,000 individuals stratified by stroke subcategory, sex, ethnicity, urbanization, and state.

RESULTS

A total of 3,691,305 stroke deaths occurred in older adults in the US between 1999 and 2020 (AAMR = 233.3), with an overall decrease in AAMR during these years. The highest mortality rates were seen in nonspecified stroke (AAMR = 173.5), those 85 or older (crude mortality rate1276.7), men (AAMR = 239.2), non-Hispanic African American adults (AAMR = 319.0), and noncore populations (AAMR = 276.1). Stroke mortality decreased in all states from 1999 to 2019 with the greatest and least decreases seen in California (-61.9%) and Mississippi (-35.0%), respectively. The coronavirus pandemic pandemic saw increased stroke deaths in most groups.

CONCLUSIONS

While there's a decline in stroke-related deaths among US older adults, outcome disparities remain across demographic and geographic sectors. The surge in stroke deaths during coronavirus pandemic reaffirms the need for policies that address these disparities.

Hypertension and other vascular risk factors in patients with functional seizures

OBJECTIVE

Recent literature has suggested that functional seizures are associated with an elevated risk for vascular disease and mortality. We investigated the prevalence of risk factors for vascular disease in patients who were admitted to the epilepsy monitoring unit.

METHODS

Patients who were admitted to the epilepsy monitoring unit and received a definitive diagnosis of either functional seizures or epilepsy were identified. Data collected included demographic, clinical characteristics, medication list, comorbidities, and scheduled blood pressure measurements that occurred every 12 h during the admission. The mean blood pressures were calculated and if they were above the American College of Cardiology and the American Heart Association guideline cutoff of 130/80 mm Hg or the patient had a documented history of hypertension the patient was counted as having the condition. A multiple logistic regression model was developed to evaluate the independent association of the patient's diagnosis (i.e., epilepsy or functional seizures) and vascular risk factors that controlled for the number of blood pressure measurements, age, sex, and if the patient was taking antihypertensive medications.

RESULTS

270 patients were included in this study of which 147 patients had epilepsy and 123 had functional seizures. Among those with functional seizures, 57.72 % had either a history of hypertension or a mean blood pressure above 130/80 compared to 38.78 % of those with epilepsy (p = 0.0022). In addition, 30.89 % of functional seizures patients had hyperlipidemia and 63.41 % were obese. The logistic regression model indicated that functional seizures were independently associated with high blood pressure (OR: 2.47, 95 % CI 1.10-5.69), hyperlipidemia (OR: 3.38, 95 % CI 1.35-8.86), and obesity (OR: 4.25, 95 % CI 2.22-8.36) compared to those with epilepsy. There was no significant difference in the prevalence of diabetes (OR: 0.81, 95 % CI 0.24-2.77) or current tobacco use (OR: 1.04, 95 % CI 0.48-2.25) between the groups.

SIGNIFICANCE

Patients with functional seizures had an elevated prevalence of several vascular risk factors. These findings may partially account for complications associated with functional seizures and have implications related to their pathophysiology.

Comorbid Conditions and Physical Function in Adults With Multiple Sclerosis

OBJECTIVE

We examined the total number of comorbid conditions as a correlate of physical function in persons with multiple sclerosis (MS). We further identified the presence of common comorbid conditions and examined physical function outcomes based on presence or absence of the comorbid conditions in persons with MS.

DESIGN

Cross-sectional, comparative study.

SETTING

University-based laboratory.

PARTICIPANTS

Two hundred seven persons with MS (N=207) completed the study.

MAIN OUTCOME MEASURES

Participants provided demographic, clinical, and comorbidity information. Participants then completed the 6-minute walk (6MW), timed 25-foot walk (T25FW), timed Up and Go (TUG), and short physical performance battery (SPPB).

INTERVENTIONS

Not applicable.

RESULTS

The number of comorbid conditions was associated with 6MW, T25FW, TUG, and SPPB scores (all P≤.001). Persons with MS who had hypertension performed worse on the 6MW, T25FW, TUG, and SPPB than persons without hypertension. Persons who had osteoarthritis performed worse on the 6MW, T25FW, and SPPB than persons without osteoarthritis.

CONCLUSIONS

The results demonstrate that persons who report more comorbid conditions have worse physical function, and this may largely be associated with hypertension or osteoarthritis. There are opportunities for the design of behavioral interventions that target physical activity and/or diet for improving physical function via comorbid conditions in persons with MS.

Urban-rural differences in hypertension prevalence, blood pressure control, and systolic blood pressure levels

Higher rates of cardiovascular events have been observed among rural residents compared with urban. Hypertension and lack of blood pressure (BP) control are risk factors for cardiovascular events. We compared the prevalence of hypertension and controlled BP, and the distribution of systolic blood pressure (SBP), by urban-rural residence. Participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, a prospective cohort of Black and White adults aged ≥45 years, were categorized as either urban, large rural, or small-isolated rural, by using the Rural-Urban Commuting Area (RUCA) categorization B system. Oucomes were hypertension prevalence (BP ≥ 140/90 mmHg or antihypertensive use), BP control (BP < 140/90 among participants on antihypertensive medication), and the distribution of SBP. Counfounders were age, race, sex, antihypertensive medication use, and US Census Bureau division. The analysis included 26,133 participants (80.3% urban, 11.6% large-rural, 8.2% small-isolated rural). The unadjusted prevalence of hypertension was not different between groups. However, after adjustment, the odds of hypertension was higher among participants in the large rural group (odds ratio [OR] 1.17; 95% confidence interval [CI], 1.08-1.27) and small-isolated rural group (OR 1.19; 95% CI, 1.08-1.30), compared with the urban group. There was no evidence of an adjusted difference in BP control for those taking antihypertensive medications. Adjusted differences in SBP were greater for both rural groups, compared with urban, at the higher percentiles of SBP. Rural residence was associated with a higher adjusted odds of hypertension and higher SBP.

Birth in the U.S. Plantation South and Racial Differences in all-cause mortality in later life

The American South has been characterized as a Stroke Belt due to high cardiovascular mortality. We examine whether mortality rates and race differences in rates reflect birthplace exposure to Jim Crow-era inequalities associated with the Plantation South. The plantation mode of agricultural production was widespread through the 1950s when older adults of today, if exposed, were children. We use proportional hazards models to estimate all-cause mortality in Non-Hispanic Black and White birth cohorts (1920-1954) in a sample (N = 21,941) drawn from REasons for Geographic and Racial Differences in Stroke (REGARDS), a national study designed to investigate Stroke Belt risk. We link REGARDS data to two U.S. Plantation Censuses (1916, 1948) to develop county-level measures that capture the geographic overlap between the Stroke Belt, two subregions of the Plantation South, and a non-Plantation South subregion. Additionally, we examine the life course timing of geographic exposure: at birth, adulthood (survey enrollment baseline), neither, or both portions of life. We find mortality hazard rates higher for Black compared to White participants, regardless of birthplace, and for the southern-born compared to those not southern-born, regardless of race. Race-specific models adjusting for adult Stroke Belt residence find birthplace-mortality associations fully attenuated among White-except in one of two Plantation South subregions-but not among Black participants. Mortality hazard rates are highest among Black and White participants born in this one Plantation South subregion. The Black-White mortality differential is largest in this birthplace subregion as well. In this subregion, the legacy of pre-Civil War plantation production under enslavement was followed by high-productivity plantation farming under the southern Sharecropping System.

Advances in the management of type 2 diabetes in adults

Type 2 diabetes is a chronic and progressive cardiometabolic disorder that affects more than 10% of adults worldwide and is a major cause of morbidity, mortality, disability, and high costs. Over the past decade, the pattern of management of diabetes has shifted from a predominantly glucose centric approach, focused on lowering levels of haemoglobin A1c (HbA1c), to a directed complications centric approach, aimed at preventing short term and long term complications of diabetes, and a pathogenesis centric approach, which looks at the underlying metabolic dysfunction of excess adiposity that both causes and complicates the management of diabetes. In this review, we discuss the latest advances in patient centred care for type 2 diabetes, focusing on drug and non-drug approaches to reducing the risks of complications of diabetes in adults. We also discuss the effects of social determinants of health on the management of diabetes, particularly as they affect the treatment of hyperglycaemia in type 2 diabetes.

Design of the Equity in Prevention and Progression of Hypertension by Addressing Barriers to Nutrition and Physical Activity Study: A Cluster Randomized Trial

BACKGROUND

High rates of hypertension and poverty in the rural south contribute to health disparities with Black adults experiencing higher rates of cardiovascular disease than White adults, underscoring the need to identify prevention strategies.

METHODS

The equity in prevention and progression of hypertension by addressing barriers to nutrition and physical activity (EPIPHANY) study is a cluster randomized controlled trial testing a multilevel intervention to reduce barriers to a healthy lifestyle to lower blood pressure (BP) among rural, Black adults. Health education fairs offered to 20 churches in the Alabama Black Belt are being used to screen and enroll adults with elevated BP or stage 1 hypertension (systolic BP 120-139 mmHg and diastolic BP < 90 mmHg) who are not recommended for antihypertensive medication, according to the 2017 American College of Cardiology/American Heart Association BP guideline. Participants (n = 240) in churches randomized to the control condition are offered access to online resources including cooking and exercise classes. Participants (n = 240) in churches randomized to the intervention are receiving access to online resources; telephone-based peer support for lifestyle modification; funding for churches to develop programs to address food access and/or barriers to physical activity; and training of church members to serve as church champions to deliver training for church members on lifestyle modification. We will employ a Type 1 hybrid implementation-effectiveness design to assess effectiveness and implementation.

CONCLUSIONS

The EPIPHANY study is designed to prevent hypertension among rural, Black adults by addressing structural and individual barriers to lifestyle modification through peer support.

Trends and Disparities in Firearm Fatalities in the United States, 1990-2021

IMPORTANCE

Firearm fatality rates in the United States have reached a 28-year high. Describing the evolution of firearm fatality rates across intents, demographics, and geography over time may highlight high-risk groups and inform interventions for firearm injury prevention.

OBJECTIVE

To understand variations in rates of firearm fatalities stratified by intent, demographics, and geography in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed firearm fatalities in the US from 1990 to 2021 using data from the Centers for Disease Control and Prevention. Heat maps, maximum and mean fatality rate graphs, and choropleth maps of county-level rates were created to examine trends in firearm fatality rates by intent over time by age, sex, race, ethnicity, and urbanicity of individuals who died from firearms. Data were analyzed from December 2018 through September 2022.

MAIN OUTCOMES AND MEASURES

Rates of firearm fatalities by age, sex, race, ethnicity, urbanicity, and county of individuals killed stratified by specific intent (suicide or homicide) per 100 000 persons per year.

RESULTS

There were a total of 1 110 421 firearm fatalities from 1990 to 2021 (952 984 among males [85.8%] and 157 165 among females [14.2%]; 286 075 among Black non-Hispanic individuals [25.8%], 115 616 among Hispanic individuals [10.4%], and 672 132 among White non-Hispanic individuals [60.5%]). All-intents total firearm fatality rates per 100 000 persons declined to a low of 10.1 fatalities in 2004, then increased to 14.7 fatalities (45.5% increase) by 2021. From 2014 to 2021, male and female firearm homicide rates per 100 000 persons per year increased from 5.9 to 10.9 fatalities (84.7% increase) and 1.1 to 2.0 fatalities (87.0% increase), respectively. Firearm suicide rates were highest among White non-Hispanic men aged 80 to 84 years (up to 46.8 fatalities/100 000 persons in 2021). By 2021, maximum rates of firearm homicide were up to 22.5 times higher among Black non-Hispanic men (up to 141.8 fatalities/100 000 persons aged 20-24 years) and up to 3.6 times higher among Hispanic men (up to 22.8 fatalities/100 000 persons aged 20-24 years) compared with White non-Hispanic men (up to 6.3 fatalities/100 000 persons aged 30-34 years). Males had higher rates of suicide (14.1 fatalities vs 2.0 fatalities per 100 000 persons in 2021) and homicide (10.9 fatalities vs. 2.0 fatalities per 100 000 persons in 2021) compared with females. Metropolitan areas had higher homicide rates than nonmetropolitan areas (6.6 fatalities vs 4.8 fatalities per 100 000 persons in 2021). Firearm fatalities by county level increased over time, spreading from the West to the South. From 1999 to 2011 until 2014 to 2016, fatalities per 100 000 persons per year decreased from 10.6 to 10.5 fatalities in Western states and increased from 12.8 to 13.9 fatalities in Southern states.

CONCLUSIONS AND RELEVANCE

This study found marked disparities in firearm fatality rates by demographic group, which increased over the past decade. These findings suggest that public health approaches to reduce firearm violence should consider underlying demographic and geographic trends and differences by intent.

COVID-19 Vaccination Intention and Factors Associated with Hesitance and Resistance in the Deep South: Montgomery, Alabama

Using COVID-19-related survey data collected from residents in the city of Montgomery, Alabama, this study assessed the prevalence of COVID-19 vaccine acceptance, hesitance, and resistance, and identified factors associated with COVID-19 vaccine hesitance and resistance. To analyze the survey data (n = 1000), a consolidation approach (machine learning modeling and multinomial logistic regression modeling) was used to identify predictors of COVID-19 vaccine hesitancy and resistance. The prevalence of vaccine acceptance, hesitancy, and resistance was 62%, 23%, and 15%, respectively. Female gender and a higher level of trust that friends and family will provide accurate information about the COVID-19 vaccine were positively associated with vaccine hesitancy. Female gender and higher trust that social media will provide accurate information about COVID-19 were positively associated with vaccine resistance. Factors positively associated with COVID-19 vaccine hesitance and resistance in the study's geographical area are worrisome, especially given the high burden of chronic diseases and health disparities that exist in both Montgomery and the Deep South. More research is needed to elucidate COVID-19 vaccination attitudes and reasons for non-acceptance of the COVID-19 vaccine. Efforts to improve acceptance should remain a priority in this respective geographical area and across the general population.

Spatially varying racial inequities in cardiovascular health and the contribution of individual- and neighborhood-level characteristics across the United States: The REasons for geographic and racial differences in stroke (REGARDS) study

Black-White inequities in cardiovascular health (CVH) pose a significant public health challenge, with these disparities also varying geographically across the US. There remains limited evidence of the impact of social determinants of health on these inequities. Using a national population-based cohort from the REasons for Geographic and Racial Differences in Stroke study, we assessed the spatial heterogeneity in Black-White differences in CVH and determined the extent to which individual- and neighborhood-level characteristics explain these inequities. We utilized a Bayesian hierarchical statistical framework to fit spatially varying coefficient models. Results showed overall and spatially varying inequities, where Black participants had significantly poorer CVH. The maps of the state level random effects also highlighted how inequities vary. The evidence produced in this study further highlights the importance of multilevel approaches - at the individual- and neighborhood-levels - that need to be in place to address these geographic and racial differences in CVH.

Geographic, Gender, and Seasonal Variation of Diabetes: A Nationwide Study With 1.4 Million Participants

CONTEXT

China has experienced a rapid increase in the prevalence of diabetes.

OBJECTIVE

We assessed the prevalence of diabetes among Chinese adults who attended preventive physical examinations and analyzed geographical and gender difference in seasonal variation of fasting blood glucose (FBG).

METHODS

The study used data from 1 390 088 participants attending preventive health examination at 430 health screening centers in 220 cities. Diagnosis of diabetes and prediabetes were based on FBG and glycated hemoglobin A1c and self-reported physician's diagnosis. We calculated age- and sex-standardized prevalence of diabetes according to the sixth Chinese population census data in 2010. Geographical distribution of diabetes and prediabetes were represented on a country map. FBG levels were analyzed to detect seasonal variation adjusted for age and gender by geographic location.

RESULTS

The standardized prevalence of diabetes was 8.70% (95% CI, 8.22%-9.19%), 10.7% in men and 6.61% in women. Among those with diabetes, 43.7% (95% CI, 40.9%-46.5%) were aware of their conditions and 38.5% (95% CI, 36.0%-41.1%) were treated. Only 49.3% (95% CI, 47.0%-51.6%) of treated patients achieved glycemic control. The mean level of FBG was higher in winter than summer and in the northern than the southern region.

CONCLUSION

The prevalence of diabetes was high while the percentages of awareness, treatment, and glycemic control were low among adults. Effective measures are needed to prevent and manage diabetes in China. Geographic and seasonal variation of diabetes should be considered for its prevention and control.

Peer coach delivered storytelling program improved diabetes medication adherence: A cluster randomized trial

BACKGROUND

Because medication adherence is linked to better diabetes outcomes, numerous interventions have aimed to improve adherence. However, suboptimal adherence persists and necessitate continued research into intervention strategies. This study evaluated the effectiveness of an intervention that combined storytelling and peer support to improve medication adherence and health outcomes in adults with diabetes.

METHODS

Living Well with Diabetes was a cluster randomized controlled trial. Intervention participants received a six-month, 11-session peer-delivered behavioral diabetes self-care program over the phone. Control participants received a self-paced general health program. Outcomes were changes in medication adherence and physiologic measures (hemoglobin A1c, systolic blood pressure, low-density lipoprotein cholesterol, body mass index).

RESULTS

Of the 403 participants with follow-up data, mean age was 57 (±SD 11), 78% were female, 91% were African American, 56.4% had high school education or less, and 70% had an annual income of < $20,000. At follow-up, compared to controls, intervention participants had greater improvement in medication adherence (β = -0.25 [95% CI -0.35, -0.15]). Physiologic measures did not change significantly in either group. Intervention participants had significant improvements in beliefs about the necessity of medications (β = 0.87 [95% CI 0.27, 1.47]) concerns about the negative effects of medication (β = -0.91 [95% CI -1.35, -0.47]), and beliefs that medications are harmful (β = -0.50 [95% CI -0.89, -0.10]). In addition, medication use self-efficacy significantly improved in intervention participants (β = 1.0 [95% CI 0.23, 1.76]). 473 individuals were enrolled in the study and randomized.

DISCUSSION

Living Well intervention resulted in improved medication adherence, medication beliefs, and medication use self-efficacy but not improved risk factor levels.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association of Cardiometabolic Multimorbidity and Depression With Cardiovascular Events in Early-Onset Adult Type 2 Diabetes: A Multiethnic Study in the U.S

OBJECTIVE

To evaluate the temporal patterns of cardiometabolic multimorbidity (CM) and depression in White Caucasians (WCs) and African Americans (AAs) with early-onset type 2 diabetes and their impact on long-term atherosclerotic cardiovascular disease (ASCVD).

RESEARCH DESIGN AND METHODS

From U.S. electronic medical records, 101,104 AA and 505,336 WC subjects with type 2 diabetes diagnosed between 2000 and 2017 were identified (mean follow-up 5.3 years). Among those without ASCVD at diagnosis, risk of ASCVD and three-point major adverse cardiovascular events (MACE-3) (heart failure, myocardial infarction, or stroke) was evaluated between ethnicities by age-groups.

RESULTS

The proportion of patients diagnosed at <50 years of age increased during 2012-2017 (AA 34-38%, WC 26-29%). Depression prevalence increased during 2000-2017 (AA 15-23%, WC 20-34%), with an increasing trend for CM at diagnosis in both groups. Compared with WC, the adjusted MACE-3 risk was significantly higher in AA across all age-groups, more pronounced in the 18-39-year age-group (hazard ratio 95% CI 1.42, 1.88), and in patients with and without depression. AAs had a 17% (1.05, 1.31) significantly higher adjusted ASCVD risk in the 18-39-year age-group only. Depression was independently associated with ASCVD and MACE-3 risk in both ethnic groups across all age-groups. Other comorbidities were independently associated with ASCVD and MACE-3 risk only among WCs.

CONCLUSIONS

AAs have higher cardiovascular risk compared with WCs, particularly in early-onset type 2 diabetes. CM and depression at diabetes diagnosis have been increasing over the past two decades in both ethnic groups. Strategies for screening and optimal management of CM and depression, particularly in early-onset type 2 diabetes, may result in a lower cardiovascular risk.

Hypertension and diabetes mellitus: highlights of a complex relationship

PURPOSE OF REVIEW

Herein, we provide a review of the recent literature on the epidemiological and pathophysiological relationship between hypertension (HTN) and diabetes mellitus, along with prognostic implications and current treatment concepts.

RECENT FINDINGS

Diabetes mellitus affects ∼10% of US adults. The prevalence of HTN in adults with diabetes mellitus was 76.3% or 66.0% based on the definitions used by guidelines. There exist differences among major society guidelines regarding the definition of HTN and target blood pressure (BP) levels. Recent basic and clinical research studies have shed light on pathophysiologic and genetic links between HTN and diabetes mellitus. Randomized controlled trials over the past 5 years have confirmed the favorable BP and cardiovascular risk reduction by antidiabetic agents.

SUMMARY

HTN and diabetes mellitus are 'silent killers' with rising global prevalence. The development of HTN and diabetes mellitus tracks each other over time. The coexistence of both clinical entities synergistically contributes to micro- and macro-vasculopathy along with cardiovascular and all-cause mortality. Various shared mechanisms underlie the pathophysiological relationship between HTN and diabetes mellitus. Moreover, BP reduction with lifestyle interventions and antihypertensive agents is a primary target for reducing cardiovascular risk among patients with HTN and diabetes mellitus.

Regional differences in the management of cardiovascular risk factors among adults with diabetes: An evaluation of the Diabetes Collaborative Registry

AIMS

To compare cardiovascular risk factor control in adults with diabetes participating in a national diabetes registry to those in the general population and to ascertain regional differences in diabetes care.

METHODS

Adults with diagnosed diabetes in the Diabetes Collaborative Registry (DCR) were compared with those in the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2016; standardized mean difference (SMD) > 0.2 defined significance. Regional differences were assessed in the DCR cohort; p < .05 defined significance.

RESULTS

The DCR cohort was older (61 vs. 57 years, SMD = 0.38), more insured (99.7% vs. 91.0%, SMD = 0.42), and less ethnically diverse (83% non-Hispanic white vs. 76%, SMD = 0.30) compared with NHANES. The proportion of overweight/obesity, A1c < 7% (<53 mmol/mol), and BP < 140/90 were similar, but DCR participants had higher proportion with LDL < 2.59 mmol/L (61% vs. 41%, SMD = 0.39) and fewer tobacco users (17% vs. 32%, SMD = 0.35). Regionally, obesity, lack of glycaemic control, and tobacco use were highest in the Midwest, BP control was the lowest in the South, and LDL control was lowest in the Northeast.

CONCLUSIONS

Significant regional differences in diabetes care delivery and outcomes were identified using a national diabetes registry. Serial analyses of the DCR may supplement national evaluations to deepen our understanding of diabetes care in the US.

Trends in ambulatory blood pressure monitoring use for confirmation or monitoring of hypertension and resistant hypertension among the commercially insured in the U.S., 2008-2017

Background

Ambulatory blood pressure monitoring (ABPM) has been increasingly recommended for diagnosis confirmation and monitoring in patients with new-onset hypertension and apparent treatment-resistant hypertension (aTRH). We assessed insurance claims submitted for ABPM among a nationally representative sample of commercially insured U.S. patients.

Methods

We conducted a retrospective cross-sectional analysis using the IBM MarketScan® commercial claims database from January 2008-December 2017, including 2 populations: those with incident treated hypertension (ITH; first antihypertensive filled) or aTRH (first overlapping use of 4 antihypertensive agents). We identified ABPM claims filed within 6 months before to 6 months after the qualifying antihypertensive fill and determined prevalence of ABPM use overall and by year in each population.

Results

In total, 2,820,303 patients met ITH criteria and 298,049 met aTRH criteria. Of those with ITH, 7650 (2.7 per 1000 persons) had ≥1 ABPM claim submitted, and annual ABPM prevalence ranged from 2.0 to 3.7 per 1000 persons, increasing over time (P _trend<0.0001). Among those with aTRH, 630 (2.1 per 1000 persons) had ≥1 ABPM claim submitted, and annual ABPM prevalence ranged from 1.6 to 2.7 per 1000 persons, decreasing over time (P _trend = 0.054). Timing of ABPM claims suggested they were used primarily for diagnosis confirmation in ITH, and more evenly distributed between diagnosis confirmation and monitoring in aTRH.

Conclusions

Despite guideline recommendations for more widescale use, ABPM appears to be used rarely in the U.S., with fewer than 0.5% of commercially insured patients with newly treated hypertension or aTRH having ABPM claims submitted to their insurance.

Assessing the spatial heterogeneity in black-white differences in optimal cardiovascular health and the impact of individual- and neighborhood-level risk factors: The Multi-Ethnic Study of Atherosclerosis (MESA)

Racial disparities in cardiovascular health (CVH) continue to remain a public health concern in the United States. We use unique population-based data from the Multi-Ethnic Study of Atherosclerosis cohort to explore the black-white differences in optimal CVH. Utilizing geographically weighted regression methods, we assess the spatial heterogeneity in black-white differences in optimal CVH and the impact of both individual- and neighborhood-level risk factors. We found evidence of significant spatial heterogeneity in black-white differences that varied within and between the five sites. Initial models showed decreased odds of optimal CVH for blacks that ranged from 60% to 70% reduced odds - with noticeable variation of these decreased odds within each site. Adjusting for risk factors resulted in reductions in the black-white differences in optimal CVH. Further understanding of the reasons for spatial heterogeneities in black-white differences in nationally representative cohorts may provide important clues regarding the drivers of these differences.

Exploring the Spatial Patterning in Racial Differences in Cardiovascular Health Between Blacks and Whites Across the United States: The REGARDS Study

Background

Cardiovascular health (CVH) disparities between blacks and whites have persisted in the United States for some time, and although there have been remarkable improvements in addressing cardiovascular disease, it still remains the leading cause of death in the United States. In addition, well‐documented disparities are unfortunately widening incidence gaps across certain regions of the United States. Our focus was on answering the following questions: (1) How much spatial heterogeneity exists in the racial differences in CVH between blacks and whites across this country? and (2) Is the spatial heterogeneity in the racial differences significantly explained by living in the Stroke Belt?

Methods and Results

To explore the spatial patterning in the racial differences in CVH between blacks and whites across the country, we used geographically weighted regression methods, which result in local estimates of the racial differences in CVH. Using data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study, we found significant spatial patterning in these racial differences, even beyond the well‐known Stroke Belt and Stroke Buckle. All of the estimated differences indicated blacks consistently having diminishing CVH compared with whites, where this difference was largely noted in pockets of the Stroke Belt and Stroke Buckle, in addition to moderate to large disparities noted in the Great Lakes region, portions of the Northeast, and along the West coast.

Conclusions

Efforts to improve CVH and ultimately reduce disparities between blacks and whites require culturally competent methods, with a strong focus on geography‐based interventions and policies.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Polypharmacy and Incident Frailty in a Longitudinal Community-Based Cohort Study

OBJECTIVES

Polypharmacy may affect frailty, a common and costly condition among older adults. Frailty prevalence is elevated among racial/ethnic minorities and persons living in the US South, and research is needed to inform future pharmacologic interventions in these populations. Our aim was to quantify the prevalence of frailty and polypharmacy, and to estimate the association between polypharmacy and incident frailty.

DESIGN

Prospective cohort study.

SETTING

A community-based cohort study of adults residing in Johnston County, North Carolina.

PARTICIPANTS

White and African American adults aged 50 to 95 years (n=1697).

MEASUREMENTS

At each study visit, all prescription and over-the-counter medications were recorded. We calculated annual polypharmacy (5-9 medications) and excessive polypharmacy (≥10 medications) prevalence at the 2006-2010 visit (n = 1697) and operationalized the Fried frailty phenotype to describe prevalent and incident frailty at two consecutive visits (2006-2010 and 2013-2015). We estimated risk ratios (RRs) and 95% confidence intervals (CIs) for the association between polypharmacy and incident frailty using weighted log-binomial regression to account for measured confounding and attrition using inverse probability of treatment and attrition weights, respectively.

RESULTS

At the 2006-2010 visit, 678 (41%) and 260 (16%) participants were exposed to polypharmacy and excessive polypharmacy, respectively. Overall, 353 (21%) participants and 180 (21%) participants were frail at the 2006-2010 and 2013-2015 visits, respectively. Frailty was more common among participants identifying as white, women, and having less educational attainment relative to those without these characteristics. Incident frailty at the 2013-2015 visit was 15% (mean follow-up = 5.5 years). Our results suggest that polypharmacy is positively associated with incident frailty (weighted RR = 1.4; 95% CI = .9-2.0), yet estimates are imprecise and should be interpreted with caution.

CONCLUSION

Consistent with the current weight of evidence, our results suggest an association between polypharmacy and incident frailty. Prospective studies evaluating deprescribing interventions are needed to clarify whether reducing polypharmacy decreases frailty incidence. J Am Geriatr Soc 67:2482-2489, 2019.

Determinants of cigarette smoking status in a national cohort of black and white adult ever smokers in the USA: a cross-sectional analysis of the REGARDS study

OBJECTIVES

While awareness of cigarette smoking's harmful effects has increased, determinants associated with smoking status remain understudied, including potential racial differences. We aim to examine factors associated with former versus current smoking status and assess whether these associations differed by race.

SETTING

We performed a cross-sectional analysis using the population-based Reasons for Geographic and Racial Differences in Stroke(REGARDS)study.

OUTCOME MEASURES

Logistic regression was used to calculate the OR of former smoking status compared with current smoking status with risk factors of interest. Race interactions were tested using multiplicative interaction terms.

RESULTS

16 463 participants reported smoking at least 100 cigarettes in their lifetime. Seventy-three per cent (n=12 067) self-reported former-smoker status. Physical activity (reference (REF) <3×/week; >3×/week: OR=1.26, 95% CI 1.11 to 1.43), adherence to Mediterranean diet (REF: low; medium: OR=1.46, 95% CI 1.27 to 1.67; high: OR=2.20, 95% CI 1.84 to 2.64), daily television viewing time (REF: >4 hours; <1 hour: OR=1.32, 95% CI 1.10 to 1.60) and abstinence from alcohol use (REF: heavy; none: OR=1.50, 95% CI 1.18 to 1.91) were associated with former-smoker status. Male sex, higher education and income $35 000-$74 000 (REF: <$20 000) were also associated with former-smoker status. Factors associated with lower odds of reporting former-smoker status were younger age (REF: ≥65 years; 45-64 years: OR=0.34, 95% CI 0.29 to 0.39), black race (OR=0.62, 95% CI 0.53 to 0.72) and single marital status (REF: married status; OR=0.66, 95% CI 0.51 to 0.87), being divorced (OR=0.60, 95% CI 0.50 to 0.72) or widowed (OR=0.70, 95% CI 0.57 to 0.85). Significant interactions were observed between race and alcohol use and dyslipidaemia, such that black participants had higher odds of reporting former-smoker status if they were abstinent from alcohol (OR=2.32, 95% CI 1.47 to 3.68) or had a history of dyslipidaemia (OR=1.31, 95% CI 1.06 to 1.62), whereas these relationships were not statistically significant in white participants.

CONCLUSION

Efforts to promote tobacco cessation should consist of targeted behavioural interventions that incorporate racial differences.

The Landscape of US Lung Cancer Screening Services

BACKGROUND

Low adoption of lung cancer screening is potentially caused by inadequate access to a comprehensive lung cancer screening registry (LCSR), currently a requirement for reimbursement by the Centers for Medicare and Medicaid Services. However, variations in LCSR facilities have not been extensively studied.

METHODS

We applied a hierarchical clustering method to a comprehensive database integrating state-level LCSR facility density, defined as the number of facilities per 100,000 at-risk persons, lung cancer outcomes including mortality and stage-specific incidence, and socioeconomic and behavioral factors.

RESULTS

We found three distinct clusters of LCSR facilities roughly corresponding to the northern (cluster 1), southeastern (cluster 2), and southwestern (cluster 3) states. The southeastern states had the lowest total number of facilities (67 ± 44 in cluster 2, 74 ± 69 in cluster 1, 80 ± 100 in cluster 3), the slowest increase in facilities (23 ± 20 in cluster 2, 26 ± 28 in cluster 1, 27 ± 32 in cluster 3) between 2016 and 2018, and the highest lung cancer burden and current smokers. They ranked second in terms of facility density (2.9 ± 1.0 in cluster 3, 3.8 ± 1.3 in cluster 2, 6.3 ± 2.8 in cluster 1) and increase in facility density (1.1 ± 0.3 in cluster 3, 1.3 ± 0.7 in cluster 2, 2.5 ± 2.5 in cluster 1).

CONCLUSIONS

We found substantial state-level variability in LCSR facilities tied to lung cancer burden, socioeconomic characteristics, and behavioral characteristics. Given the known risk factors of lung cancer, correcting a suboptimal distribution of screening programs will likely lead to improved lung cancer outcomes.

Modeled state-level estimates of hypertension prevalence and undiagnosed hypertension among US adults during 2013-2015

Hypertension affects about one in three US adults, from recent surveillance, or four in nine based on the 2017 ACC/AHA Hypertension Guideline; about half of them have their blood pressure controlled, and nearly one in six are unaware of their hypertension status. National estimates of hypertension awareness, treatment, and control in the United States are traditionally based on measured BP from National Health and Nutrition Examination Survey (NHANES); however, at the state level, only self-reported hypertension awareness and treatment are available from BRFSS. We used national- and state-level representative samples of adults (≥20 years) from NHANES 2011-2014 and BRFSS 2013 and 2015, respectively. The authors generated multivariable logistic regression models using NHANES to predict the probability of hypertension and undiagnosed hypertension and then applied the fitted model parameters to BRFSS to generate state-level estimates. The predicted prevalence of hypertension was highest in Mississippi among adults (42.4%; 95% CI: 41.8-43.0) and among women (42.6%; 41.8-43.4) and highest in West Virginia among men (43.4%; 42.2-44.6). The predicted prevalence was lowest in Utah 23.7% (22.8-24.6), 26.4% (25.0-27.7), and 21.0% (20.0-22.1) for adults, men, and women, respectively. Hypertension predicted prevalence was higher in most Southern states and higher among men than women in all states except Mississippi and DC. The predicted prevalence of undiagnosed hypertension ranged from 4.1% (3.4-4.8; Kentucky) to 6.5% (5.5-7.5; Hawaii) among adults, from 5.0% (4.0-5.9; Kentucky) to 8.3% (6.9-9.7; Hawaii) among men, and from 3.3% (2.5-4.1; Kentucky) to 4.8% (3.4-6.1; Vermont) among women. Undiagnosed hypertension was more prevalent among men than women in all states and DC.

Using Indirect Measures to Identify Geographic Hot Spots of Poor Glycemic Control: Cross-sectional Comparisons With an A1C Registry

OBJECTIVE

Focusing health interventions in places with suboptimal glycemic control can help direct resources to neighborhoods with poor diabetes-related outcomes, but finding these areas can be difficult. Our objective was to use indirect measures versus a gold standard, population-based A1C registry to identify areas of poor glycemic control.

RESEARCH DESIGN AND METHODS

Census tracts in New York City (NYC) were characterized by race, ethnicity, income, poverty, education, diabetes-related emergency visits, inpatient hospitalizations, and proportion of adults with diabetes having poor glycemic control, based on A1C >9.0% (75 mmol/mol). Hot spot analyses were then performed, using the Getis-Ord Gi* statistic for all measures. We then calculated the sensitivity, specificity, positive and negative predictive values, and accuracy of using the indirect measures to identify hot spots of poor glycemic control found using the NYC A1C Registry data.

RESULTS

Using A1C Registry data, we identified hot spots in 42.8% of 2,085 NYC census tracts analyzed. Hot spots of diabetes-specific inpatient hospitalizations, diabetes-specific emergency visits, and age-adjusted diabetes prevalence estimated from emergency department data, respectively, had 88.9%, 89.6%, and 89.5% accuracy for identifying the same hot spots of poor glycemic control found using A1C Registry data. No other indirect measure tested had accuracy >80% except for the proportion of minority residents, which had 86.2% accuracy.

CONCLUSIONS

Compared with demographic and socioeconomic factors, health care utilization measures more accurately identified hot spots of poor glycemic control. In places without a population-based A1C registry, mapping diabetes-specific health care utilization may provide actionable evidence for targeting health interventions in areas with the highest burden of uncontrolled diabetes.

Hypertension in Florida: Data From the OneFlorida Clinical Data Research Network

Introduction

Hypertension is highly prevalent in Florida, but surveillance through the Behavioral Risk Factor Surveillance System (BRFSS) is limited to self-reported hypertension and does not capture data on undiagnosed hypertension or measure blood pressure. We aimed to characterize the hypertensive population in the OneFlorida Clinical Research Consortium by using electronic health records and provide proof-of-concept for using routinely collected clinical data to augment surveillance efforts.

Methods

We identified patients with hypertension, defined as having at least 1 outpatient visit from January 2012 through June 2016 with an ICD-9-CM or ICD-10-CM diagnosis code for hypertension, or in the absence of a diagnosis, an elevated blood pressure (systolic ≥140 mm Hg or diastolic ≥90 mm Hg) recorded in the electronic health record at the most recent visit. The hypertensive population was characterized and mapped by zip code of patient residence to county prevalence.

Results

Of 838,469 patients (27.9% prevalence) who met the criteria for hypertension, 68% had received a diagnosis and 61% had elevated blood pressure. The geographic distribution of hypertension differed between diagnosed hypertension (highest prevalence in northern Florida) and undiagnosed hypertension (highest prevalence along eastern coast, in southern Florida, and in some rural western Panhandle counties). Uncontrolled hypertension was concentrated in southern Florida and the western Panhandle.

Conclusion

Our use of clinical data, representing usual care for Floridians, allows for identifying cases of uncontrolled hypertension and potentially undiagnosed cases, which are not captured by existing surveillance methods. Large-scale pragmatic research networks, like OneFlorida, may be increasingly important for tailoring future health care services, trials, and public health programs.

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.