1
|
Choi E, Mizuno H, Wang Z, Fang C, Mefford MT, Reynolds K, Ghazi L, Shimbo D, Muntner P. Antihypertensive medication persistence and adherence among non-Hispanic Asian US patients with hypertension and fee-for-service Medicare health insurance. PLoS One 2024; 19:e0300372. [PMID: 38507422 PMCID: PMC10954118 DOI: 10.1371/journal.pone.0300372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Less than 50% of non-Hispanic Asian adults taking antihypertensive medication have controlled blood pressure. METHODS We compared non-persistence and low adherence to antihypertensive medication between non-Hispanic Asian and other race/ethnicity groups among US adults ≥66 years who initiated antihypertensive medication between 2011 and 2018 using a 5% random sample of Medicare beneficiaries (non-Hispanic Asian, n = 2,260; non-Hispanic White, n = 56,000; non-Hispanic Black, n = 5,792; Hispanic, n = 4,212; and Other, n = 1,423). Non-persistence was defined as not having antihypertensive medication available to take in the last 90 of 365 days following treatment initiation. Low adherence was defined as having antihypertensive medication available to take on <80% of the 365 days following initiation. RESULTS In 2011-2012, 2013-2014, 2015-2016 and 2017-2018, the proportion of non-Hispanic Asian Medicare beneficiaries with non-persistence was 29.1%, 25.6%, 25.4% and 26.7% (p-trend = 0.381), respectively, and the proportion with low adherence was 58.1%, 54.2%, 53.4% and 51.6%, respectively (p-trend = 0.020). In 2017-2018, compared with non-Hispanic Asian beneficiaries, non-persistence was less common among non-Hispanic White beneficiaries (risk ratio 0.74 [95%CI, 0.64-0.85]), non-Hispanic Black beneficiaries (0.80 [95%CI 0.68-0.94]) and those reporting Other race/ethnicity (0.68 [95%CI, 0.54-0.85]) but not among Hispanic beneficiaries (1.04 [95%CI, 0.88-1.23]). Compared to non-Hispanic Asian beneficiaries, non-Hispanic White beneficiaries and beneficiaries reporting Other race/ethnicity were less likely to have low adherence to antihypertensive medication (relative risk 0.78 [95%CI 0.72-0.84] and 0.84 [95%CI 0.74-0.95], respectively); there was no association for non-Hispanic Black or Hispanic beneficiaries. CONCLUSIONS Non-persistence and low adherence to antihypertensive medication were more common among older non-Hispanic Asian than non-Hispanic White adults.
Collapse
Affiliation(s)
- Eunhee Choi
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York, United Kingdom
| | - Hiroyuki Mizuno
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York, United Kingdom
- Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Zhixin Wang
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Chloe Fang
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York, United Kingdom
| | - Matthew T. Mefford
- Department of Research and Evaluation, Kaiser Permanente of Southern California, Pasadena, California, United States of America
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente of Southern California, Pasadena, California, United States of America
- Department of Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California, United States of America
| | - Lama Ghazi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Daichi Shimbo
- The Columbia Hypertension Center and Lab, Columbia University Irving Medical Center, New York, New York, United Kingdom
| | - Paul Muntner
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| |
Collapse
|
2
|
Rivera AS, Pak K, Mefford MT, Hechter RC. Changes in Glomerular Filtration Rate After Switching From Tenofovir Disoproxil Fumarate to Tenofovir Alafenamide Fumarate for Human Immunodeficiency Virus Preexposure Prophylaxis. Open Forum Infect Dis 2024; 11:ofad695. [PMID: 38352151 PMCID: PMC10863550 DOI: 10.1093/ofid/ofad695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/27/2023] [Indexed: 02/16/2024] Open
Abstract
Background Tenofovir alafenamide fumarate (TAF) was promoted as a safer alternative to tenofovir disoproxil fumarate (TDF) for human immunodeficiency virus oral preexposure prophylaxis (PrEP). It is unknown if switching from TDF to TAF translates to improved renal function. We used electronic health record (EHR) data to assess changes in creatinine-estimated glomerular filtration rate (eGFR) after switching from TDF to TAF. Methods We conducted a retrospective cohort study using EHR data from Kaiser Permanente Southern California. We identified individuals who switched from TDF to TAF between October 2019 and May 2022 and used time-varying propensity score matching to identify controls who were on TDF ("nonswitchers"). We then used Bayesian longitudinal modeling to compare differences in eGFR between switching and nonswitching scenarios. Results Among 5246 eligible individuals, we included 118 TDF to TAF switchers and 114 nonswitchers. Compared to nonswitchers, switchers had older age of starting TDF but similar body weights at index date. A higher proportion of switchers were White, on Medicare or Medicaid, and had dyslipidemia at index date. Switching to TAF was associated with a higher eGFR compared to staying on TDF in 3-15 months post-switch, but the differences were not statistically significant (eg, month 9 difference: 1.27 [95% credible interval, -1.35 to 3.89]). While most of the estimated changes showed eGFR increase associated with switching, most were <2 eGFR units. Sensitivity analyses to address missingness or nonadherence showed similar results. Conclusions Switching from TDF to TAF for PrEP was associated with a nonsignificant increase in eGFR. Findings need to be confirmed using larger cohorts.
Collapse
Affiliation(s)
- Adovich S Rivera
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Katherine Pak
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Matthew T Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| |
Collapse
|
3
|
Mefford MT, Zhou M, Zhou H, Derakhshan H, Harrison TN, Zia M, Kanter MH, Scott RD, Imley TM, Sanders MA, Timmins R, Reynolds K. Safety Net Program to Improve Statin Initiation Among Adults With High Low-Density Lipoprotein Cholesterol. Am J Prev Med 2023; 65:687-695. [PMID: 37100184 DOI: 10.1016/j.amepre.2023.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Despite their effectiveness in reducing low-density lipoprotein cholesterol and cardiovascular disease risk, high-intensity statins are underutilized among adults with low-density lipoprotein cholesterol ≥190 mg/dL. This study determined whether a safety net program (SureNet) facilitating medication and laboratory test orders improved statin initiation and laboratory test completions after (SureNet period: April 2019-September 2021) and before implementation (pre-SureNet period: January 2016-September 2018). METHODS Kaiser Permanente Southern California members aged 20-60 years with low-density lipoprotein cholesterol ≥190 mg/dL and no statin use in previous 2-6 months were included in this retrospective cohort study. Statin orders within 14 days and statin fills, laboratory test completions, and improved low-density lipoprotein cholesterol within 180 days of the high low-density lipoprotein cholesterol (pre-SureNet) or outreach (SureNet period) were compared. Analyses were conducted in 2022. RESULTS Overall, 3,534 and 3,555 adults were eligible for statin initiation during the pre-SureNet and SureNet periods, respectively. Overall, 759 (21.5%) and 976 (27.5%) had a statin approved by their physician during pre-SureNet and SureNet periods, respectively (p<0.001). After multivariable adjustment for demographics and clinical characteristics, adults during the SureNet period had a higher likelihood of receiving a statin order (prevalence ratio=1.36, 95% CI=1.25, 1.48), filling their statin (prevalence ratio=1.32, 95% CI=1.26, 1.38), completing their laboratories (prevalence ratio=1.41, 95% CI=1.26, 1.58), and improving low-density lipoprotein cholesterol (prevalence ratio=1.21, 95% CI=1.07, 1.37) than in pre-Surenet period. CONCLUSIONS The SureNet program was able to improve prescription orders, fills, laboratory test completions, and lower low-density lipoprotein cholesterol. Optimizing both physician adherence to treatment guidelines; and patient adherence to the program may improve low-density lipoprotein cholesterol lowering.
Collapse
Affiliation(s)
- Matthew T Mefford
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, California.
| | - Matt Zhou
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, California
| | - Hui Zhou
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, California; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Hananeh Derakhshan
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, California
| | - Teresa N Harrison
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, California
| | - Mona Zia
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, California
| | - Michael H Kanter
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, California; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Ronald D Scott
- Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California
| | - Tracy M Imley
- Quality and Clinical Analysis, Southern California Permanente Medical Group, Pasadena, California
| | - Mark A Sanders
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Royann Timmins
- Regional SureNet, Complete Care Support Programs, Southern California Permanente Medical Group, Pasadena, California
| | - Kristi Reynolds
- Department of Research & Evaluation, Southern California Permanente Medical Group, Pasadena, California; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| |
Collapse
|
4
|
Rivera AS, Pak KJ, Mefford MT, Hechter RC. Use of Tenofovir Alafenamide Fumarate for HIV Pre-Exposure Prophylaxis and Incidence of Hypertension and Initiation of Statins. JAMA Netw Open 2023; 6:e2332968. [PMID: 37695583 PMCID: PMC10495863 DOI: 10.1001/jamanetworkopen.2023.32968] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/02/2023] [Indexed: 09/12/2023] Open
Abstract
Importance Pre-exposure prophylaxis (PrEP) is an important tool for preventing HIV infection. However, PrEP's impact on cardiometabolic health is understudied. Objective To examine the risk of incident hypertension and statin initiation among adult (age ≥18 years) health plan members starting PrEP with tenofovir alafenamide fumarate (TAF) compared with propensity score-matched adults taking tenofovir disoproxil fumarate (TDF). Design, Setting, and Participants This retrospective cohort study used electronic health records (EHRs) from Kaiser Permanente Southern California. Adult members starting PrEP in Kaiser Permanente Southern California between October 2019 and May 2022 were included. Propensity score matching with multiple imputation (50 matched data sets) was conducted to generate 1 TAF:4 TDF matched data sets with balanced baseline covariates. Exposures PrEP initiation with either TAF or TDF during the study period. Main Outcomes and Measures Incident hypertension and statin initiation within 2 years of PrEP initiation were ascertained through blood pressure and outpatient pharmacy records, respectively. Risk differences and odds ratios (ORs) were estimated using logistic regression and g-computation. Results A total of 6824 eligible individuals were identified (mean [SD] age, 33.9 [10.3] years; 6618 [97%] male). This pool was used to generate 2 cohorts without baseline hypertension or statin use for matching (hypertension: n = 5523; statin: n = 6149) In both cohorts, those starting PrEP with TAF were older and were more likely to be non-Hispanic White compared with those starting with TDF. In matched analysis adjusting for baseline covariates, TAF use was associated with elevated risk of incident hypertension (TAF: n = 371; risk difference, 0.81 [95% CI, 0.12-1.50]; OR, 1.64 [95% CI, 1.05-2.56]). TAF use was also associated with elevated risk of statin initiation (TAF: n = 382; risk difference, 0.85 [95% CI, 0.37-1.33]; OR, 2.33 [95% CI, 1.41-3.85]). Subgroup analyses restricted to individuals 40 years and older at PrEP initiation showed similar results with larger risk difference in statin initiation (risk difference, 4.24 [95% CI, 1.82-6.26]; OR, 3.05 [95% CI, 1.64-5.67]). Conclusions and Relevance In this study of people taking PrEP, TAF use was found to be associated with higher incident hypertension and statin initiation compared with TDF use, especially in those 40 years or older. Continued monitoring of blood pressure and lipids for TAF users is warranted.
Collapse
Affiliation(s)
- Adovich S. Rivera
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Katherine J. Pak
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Matthew T. Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Rulin C. Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
- Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| |
Collapse
|
5
|
Mefford MT, Wei R, Lustigova E, Martin JP, Reynolds K. Incidence of Diabetes Among Youth Before and During the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e2334953. [PMID: 37733344 PMCID: PMC10514735 DOI: 10.1001/jamanetworkopen.2023.34953] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/15/2023] [Indexed: 09/22/2023] Open
Abstract
Importance Prior research found increases in diabetes among youth during the COVID-19 pandemic, but few studies examined variation across sociodemographics. Objective To examine diabetes incidence rates among a diverse population of youth in the US before and during the COVID-19 pandemic. Design, Setting, and Participants This cohort study included data from Kaiser Permanente Southern California (KPSC) between January 1, 2016, and December 31, 2021. KPSC members aged from birth to 19 years with no history of diabetes were included. Individuals were followed up using electronic health records for diabetes incidence defined using diagnoses, laboratory values, and medications. Analyses were conducted between November 2022 and January 2023. Main Outcome and Measures Age- and sex-standardized annual and quarterly incidence rates per 100 000 person-years (PYs) were calculated for type 1 diabetes and type 2 diabetes between 2016 and 2021. Rates were calculated within strata of age (<10 and 10-19 years), sex, and race and ethnicity (Asian/Pacific Islander, Hispanic, non-Hispanic Black, non-Hispanic White, and other/multiple/unknown). Using Poisson regression with robust error variances, incidence rate ratios (IRR) comparing 2020 to 2021 with 2016 to 2019 were calculated by diabetes type and within age, sex, and race and ethnicity strata and adjusting for health care utilization. Results Between 2016 to 2021, there were 1200, 1100, and 63 patients with type 1 diabetes (mean [SD] age, 11.0 [4.5] years; 687 [57.3%] male), type 2 diabetes (mean [SD] age, 15.7 [2.7] years; 516 [46.9%] male), and other diabetes, respectively. Incidence of type 1 diabetes increased from 18.5 per 100 000 PYs in 2016 to 2019 to 22.4 per 100 000 PYs from 2020 to 2021 with increased IRRs among individuals aged 10 to 19 years, male individuals, and Hispanic individuals. Incidence of type 2 diabetes increased from 14.8 per 100 000 PYs from 2016 to 2019 to 24.7 per 100 000 PYs from 2020 to 2021 with increased IRRs among individuals aged 10 to 19 years, male and female individuals, and those with Black, Hispanic, and other/unknown race and ethnicity. Conclusions and Relevance In this cohort study of youth in KPSC, incidence of diabetes increased during the COVID-19 pandemic and was more pronounced in specific racial and ethnic groups. Future research to understand differential impacts of physiologic and behavioral risk factors is warranted.
Collapse
Affiliation(s)
- Matthew T. Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Eva Lustigova
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| |
Collapse
|
6
|
Jensen ET, Rigdon J, Rezaei KA, Saaddine J, Lundeen EA, Dabelea D, Dolan LM, D’Agostino R, Klein B, Meuer S, Mefford MT, Reynolds K, Marcovina SM, Mottl A, Mayer-Davis B, Lawrence JM. Prevalence, Progression, and Modifiable Risk Factors for Diabetic Retinopathy in Youth and Young Adults With Youth-Onset Type 1 and Type 2 Diabetes: The SEARCH for Diabetes in Youth Study. Diabetes Care 2023; 46:1252-1260. [PMID: 37043887 PMCID: PMC10234751 DOI: 10.2337/dc22-2503] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/21/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVE To determine the prevalence, progression, and modifiable risk factors associated with the development of diabetic retinopathy (DR) in a population-based cohort of youth-onset diabetes. RESEARCH DESIGN AND METHODS We conducted a multicenter, population-based prospective cohort study (2002-2019) of youth and young adults with youth-onset type 1 diabetes (n = 2,519) and type 2 diabetes (n = 447). Modifiable factors included baseline and change from baseline to follow-up in BMI z score, waist/height ratio, systolic and diastolic blood pressure z score, and A1C. DR included evidence of mild or moderate nonproliferative DR or proliferative retinopathy. Prevalence estimates were standardized to estimate the burden of DR, and inverse probability weighting for censoring was applied for estimating risk factors for DR at two points of follow-up. RESULTS DR in youth-onset type 1 and type 2 diabetes is highly prevalent, with 52% of those with type 1 diabetes and 56% of those with type 2 diabetes demonstrating retinal changes at follow-up (mean [SD] 12.5 [2.2] years from diagnosis). Higher baseline A1C, increase in A1C across follow-up, and increase in diastolic and systolic blood pressure were associated with the observation of DR at follow-up for both diabetes types. Increase in A1C across follow-up was associated with retinopathy progression. BMI z score and waist/height ratio were inconsistently associated, with both positive and inverse associations noted. CONCLUSIONS Extrapolated to all youth-onset diabetes in the U.S., we estimate 110,051 cases of DR developing within ∼12 years postdiagnosis. Tight glucose and blood pressure management may offer the opportunity to mitigate development and progression of DR in youth-onset diabetes.
Collapse
Affiliation(s)
- Elizabeth T. Jensen
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Kasra A. Rezaei
- Department of Ophthalmology, University of Washington, Seattle, WA
| | - Jinan Saaddine
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Elizabeth A. Lundeen
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Lawrence M. Dolan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ralph D’Agostino
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Barbara Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI
| | - Stacy Meuer
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI
| | - Matthew T. Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Amy Mottl
- Departments of Nutrition and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Beth Mayer-Davis
- Departments of Nutrition and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jean M. Lawrence
- Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| |
Collapse
|
7
|
Mefford MT, Zhou H, Fan D, Fang MC, Prasad PA, Go AS, Portugal C, Chang JM, Reynolds K. Health Literacy and Treatment Satisfaction Among Patients with Venous Thromboembolism. J Gen Intern Med 2023; 38:1585-1592. [PMID: 36326991 PMCID: PMC10212857 DOI: 10.1007/s11606-022-07852-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) treatment requires complex management, and patients with limited health literacy (HL) may perceive higher burden and lower benefits associated with their treatment. OBJECTIVE To examine the association of HL with treatment satisfaction among patients with VTE. DESIGN Retrospective cohort study PARTICIPANTS: Kaiser Permanente Southern and Northern California members who were taking oral anticoagulants (OAC) for incident VTE between 2015 and 2018 were surveyed. Main Measures HL was assessed using a 3-item HL assessment and dichotomized as having adequate or limited HL. High treatment burden and low treatment benefit were defined as Anti-Clot Treatment Scale (ACTS) scores below the 25th percentile of the distributions for ACTS Burdens and Benefits survey components, respectively. Using Poisson regression, multivariable adjusted risk ratios (RR) and 95% confidence intervals (CI) were calculated for the association of HL with high treatment burden and low treatment benefits. RESULTS Among 2154 respondents, 397 (18.4%) had limited HL. Patients with limited vs adequate HL were older (47.9% vs 27.5% aged ≥ 75 years, p<0.001), more likely to use a non-English language when discussing their health (10.8% vs 1.7%, p<0.001), to have less than high school education (10.1% vs 1.7%, p<0.001), and to self-rate their health as fair or poor (47.6% vs 25.5%, p<0.001). After multivariable adjustment, patients with limited HL were more likely to have higher perceived treatment burden (RR 1.24, 95% CI 1.07, 1.45) and lower perceived treatment benefits (RR 1.21, 95% CI 1.08, 1.37). CONCLUSIONS Limited HL was associated with lower OAC treatment satisfaction, though absolute differences in satisfaction scores were small. Further examination of the intersection of HL with VTE treatment satisfaction and compliance among older and non-English speaking patients is warranted.
Collapse
Affiliation(s)
- Matthew T Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
| | - Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Margaret C Fang
- Divison of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Priya A Prasad
- Divison of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Alan S Go
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- Departments of Medicine, Health Research and Policy, Stanford University, Palo Alto, CA, USA
| | - Cecilia Portugal
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - John M Chang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| |
Collapse
|
8
|
Mefford MT, Zhou H, Zhou M, Derakhshan H, Harrison TN, Rojas M, Kanter MH, Scott RD, Imley T, Sanders M, Timmins R, Reynolds K. Abstract P367: Automated Outreach to Improve Statin Initiation and Follow-Up of Lipid Panels Among Patients With High LDL-C. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Background:
Despite their effectiveness in reducing low-density lipoprotein-cholesterol (LDL-C) and cardiovascular disease (CVD) risk, high-intensity statins are underutilized among patients with LDL-C ≥ 190 mg/dL. We aimed to determine if a patient outreach program (KP Sure Net) automating high-intensity statin orders and lipid panels improved statin initiation and lab completions.
Methods:
Kaiser Permanente Southern California adults 20-60 years of age with LDL-C ≥ 190 mg/dL and no recent statin use were compared pre- (January 2016-September 2018, n=3,534) and post- (April 2019-July 2021, n=3,555) program implementation to examine statin prescriptions and fills, lab completions, and improved LDL-C (<190 mg/dL) at 6 months. Using Poisson regression with robust variance, we calculated relative risks (RR) and 95% confidence intervals (CI) for the association of program implementation with statin prescriptions, fills, lab completions, and improved LDL-C, separately, adjusting for sociodemographics, insurance, comorbidity burden, and non-statin medication use.
Results:
Among adults identified during pre- and post-implementation, 759 (21.5%) and 976 (27.5%), respectively, received a statin prescription. Adults with a prescription post- versus pre-implementation were more likely to be younger, identify as Black or Asian ethnicity, be English-speaking and have higher income, but were similar by sex, education, insurance, and comorbidity burden. (Table) After multivariable adjustment, adults post- versus pre-implementation had a higher likelihood of receiving a statin prescription (RR 1.36, 95% CI 1.25, 1.48), filling their statin (RR 1.32, 95% CI 1.26, 1.38), completing their lipid panel (RR 1.60, 95% CI 1.44, 1.78), and improving LDL-C (RR 1.36, 95% CI 1.20, 1.53).
Conclusion:
Automating statin orders and lipid panels for high-risk adults improved prescription rates, fills and LDL-C. Understanding facilitators and barriers to adherence is an important next step in improving patients’ health.
Collapse
Affiliation(s)
| | - Hui Zhou
- Kaiser Permanente Southern California, Pasadena, CA
| | | | | | | | | | | | | | - Tracy Imley
- Kaiser Permanente Southern California, Pasadena, CA
| | | | | | | |
Collapse
|
9
|
Shah NS, Shimbo D, Muntner P, Huffman MD, Kandula NR, Mefford MT, Lloyd-Jones DM, Khan SS. Hypertension-Related Cardiovascular Mortality in Asian American Subgroups. Am J Prev Med 2023:S0749-3797(23)00003-X. [PMID: 36759227 DOI: 10.1016/j.amepre.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Asian American subgroups experience heterogeneity in cardiovascular disease, but differences in hypertension-related cardiovascular disease mortality between Asian American subgroups is not known. METHODS Among 1,194,648 deaths in the United States in 2018-2021 with cardiovascular disease as an underlying cause and hypertension-related diseases as contributing cause, sex-specific age-standardized mortality rates, proportional mortality, and proportional mortality ratios for non-Hispanic Asian and Asian subgroups, Hispanic, and non-Hispanic Black individuals were compared with non-Hispanic White individuals. The analysis was conducted in August 2022. RESULTS There were 37,746; 95,404; 193,899; and 867,599 hypertension-related cardiovascular disease deaths in non-Hispanic Asian; Hispanic; non-Hispanic Black; and non-Hispanic White groups, respectively. Among non-Hispanic Asian females, mortality rates ranged from 41.6 (95% CI 40.0-43.3) per 100,000 population in Japanese to 52.6 (51.0-54.2) per 100,000 in Filipina individuals. Among non-Hispanic Asian males, mortality rates ranged from 45.8 (43.3-48.2) per 100,000 in Korean to 81.0 (78.5-83.5) per 100,000 in Filipino individuals. Proportional mortality was higher for all Asian American subgroups compared to non-Hispanic White individuals. Proportional mortality ratios ranged from 1.11 (in Korean males, proportional mortality was 10.2% [95% CI 9.7-10.8] of all deaths) to 1.38 (in Filipino males, proportional mortality was 12.7% [12.4-13.1] of all deaths; in Chinese females, proportional mortality was 11.9% [11.6-12.3]; and in Filipina females, proportional mortality was 11.9% [12.3-13.0]). CONCLUSIONS There was up to two-fold variation in hypertension-related cardiovascular disease mortality among Asian American subgroups. All subgroups experienced higher proportional mortality for hypertension-related cardiovascular disease compared with non-Hispanic White individuals.
Collapse
Affiliation(s)
- Nilay S Shah
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Daichi Shimbo
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Paul Muntner
- Department of Epidemiology, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark D Huffman
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Global Health Center, Institute for Public Health, Washington University School of Medicine in St. Louis, St. Louis, Missouri; The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Namratha R Kandula
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matthew T Mefford
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Donald M Lloyd-Jones
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sadiya S Khan
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
10
|
Mefford MT, Liu R, Bruxvoort K, Qian L, Doris JM, Koyama SY, Tseng HF, Reynolds K. Influenza vaccination and mortality among adults with heart failure in an integrated healthcare delivery system, 2009-2018. J Gen Intern Med 2022; 37:2405-2412. [PMID: 34379280 PMCID: PMC9360203 DOI: 10.1007/s11606-021-07068-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 07/22/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Influenza infection can result in decompensation or exacerbation of heart failure (HF) symptoms, hospitalization, and death. OBJECTIVE To examine the association of influenza vaccination with mortality and hospitalization during influenza and non-influenza seasons between 2009 and 2018. DESIGN, SETTING, AND PARTICIPANTS In this prospective, observational cohort study, we included Kaiser Permanente Southern California members with a HF diagnosis prior to September 1 each year from 2009 to 2017. EXPOSURE The first influenza vaccination in each season (September 1 to May 31) was recorded. Vaccinated/unvaccinated patients were matched 1:1 on age, sex, and ejection fraction at the vaccination date (n-total = 74,870). MAIN OUTCOMES Patients were followed through the end of each influenza season for all-cause mortality. Secondary outcomes included cardiovascular mortality and all-cause hospitalization. In a sensitivity analysis, we examined mortality in the non-influenza season. RESULTS Influenza vaccinated vs unvaccinated patients had more comorbidities and higher healthcare utilization. After multivariable adjustment for utilization, sociodemographics, comorbidities, and medications, influenza vaccinated vs unvaccinated patients had a lower risk of all-cause mortality and cardiovascular mortality during the influenza season (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.63, 0.70 and HR 0.68, 95% CI 0.63, 0.74, respectively) but a higher risk of all-cause hospitalization (HR 1.27, 95% CI 1.21, 1.31). There was no association between influenza vaccination and all-cause or cardiovascular mortality during the non-influenza season (HR 0.99, 95% CI 0.89, 1.09 and HR 1.00, 95% CI 0.84, 1.21, respectively). CONCLUSIONS Influenza vaccination in HF patients was associated with a lower risk of mortality during the influenza season. Our findings provide support for recommendations of universal influenza vaccination in patients with HF.
Collapse
Affiliation(s)
- Matthew T Mefford
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
| | - Ran Liu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Katia Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Lei Qian
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jonathan M Doris
- Department of Cardiac Electrophysiology, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | - Sandra Y Koyama
- Internal Medicine, Kaiser Permanente Southern California, Baldwin Park, CA, USA
| | - Hung Fu Tseng
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| |
Collapse
|
11
|
Mefford MT, Silverberg MJ, Leong TK, Hechter RC, Towner WJ, Go AS, Horberg M, Hu H, Harrison TN, Sung SH, Reynolds K. Multimorbidity Burden and Incident Heart Failure Among People With and Without HIV: The HIV-HEART Study. Mayo Clin Proc Innov Qual Outcomes 2022; 6:218-227. [PMID: 35539894 PMCID: PMC9079699 DOI: 10.1016/j.mayocpiqo.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To examine the association between multimorbidity burden and incident heart failure (HF) among people with HIV (PWH) and people without HIV (PWoH). Patients and Methods The HIV-HEART study is a retrospective cohort study that included adult PWH and PWoH aged 21 years or older at Kaiser Permanente between 2000 and 2016. Multimorbidity burden was defined by the baseline prevalence of 22 chronic conditions and was categorized as 0-1, 2-3, and 4 or more comorbidities on the basis of distribution of the overall population. People with HIV and PWoH were followed for a first HF event, all-cause death, or up to the end of follow-up on December 31, 2016. Using Cox proportional hazard regression, hazard ratios and 95% CIs were calculated to examine the association between multimorbidity burden and incident HF among PWH and PWoH, separately. Results The prevalences of 0-1, 2-3, and 4 or more comorbidities were 83.3%, 13.0%, and 3.7% in PWH (n=38,868), and 82.2%, 14.3%, and 3.5% in PWoH (n=386,586), respectively. After multivariable adjustment, compared with people with 0-1 comorbidities, the hazard ratios of incident HF associated with 2-3 and 4 or more comorbidities were 1.33 (95% CI, 1.04-1.71) and 2.41 (95% CI, 1.78-3.25) in PWH and 2.10 (95% CI, 1.92-2.29) and 4.09 (95% CI, 3.64-4.61) in PWoH, respectively. Conclusion Multimorbidity was associated with a higher risk of incident HF among PWH and PWoH, with more prominent associations in PWoH and certain patient subgroups. The identification of specific multimorbidity patterns that contribute to higher HF risk in PWH may lead to future preventative strategies.
Collapse
Affiliation(s)
- Matthew T Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.,Departments of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Thomas K Leong
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.,Department of Epidemiology, University of California Los Angeles, Los Angeles, CA
| | - William J Towner
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.,Department of Infectious Disease, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.,Departments of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA.,Department of Medicine, University of California, San Francisco, CA.,Department of Medicine, Stanford University, Palo Alto, CA
| | - Michael Horberg
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.,Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Haihong Hu
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| |
Collapse
|
12
|
Mefford MT, Koyama SY, De Jesus J, Wei R, Fischer H, Harrison TN, Woo P, Reynolds K. Comparability Of The GALACTIC-HF Clinical Trial Population To Real-world Patients Having Heart Failure With Reduced Ejection Fraction. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Mefford MT, Rana JS, Reynolds K, Ranasinghe O, Mittleman MA, Liu JY, Qian L, Zhou H, Harrison TN, Geller AC, Sloan RP, Mostofsky E, Williams DR, Sidney S. Association of the 2020 US Presidential Election With Hospitalizations for Acute Cardiovascular Conditions. JAMA Netw Open 2022; 5:e228031. [PMID: 35442454 PMCID: PMC9021908 DOI: 10.1001/jamanetworkopen.2022.8031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Prior studies found a higher risk of acute cardiovascular disease (CVD) around population-wide psychosocial or environmental stressors. Less is known about acute CVD risk in relation to political events. OBJECTIVE To examine acute CVD hospitalizations following the 2020 presidential election. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined acute CVD hospitalizations following the 2020 presidential election. Participants were adult members aged 18 years or older at Kaiser Permanente Southern California and Kaiser Permanente Northern California, 2 large, integrated health care delivery systems. Statistical analysis was performed from March to July 2021. EXPOSURE 2020 US presidential election. MAIN OUTCOMES AND MEASURES Hospitalizations for acute CVD around the 2020 presidential election were examined. CVD was defined as hospitalizations for acute myocardial infarction (AMI), heart failure (HF), or stroke. Rate ratios (RR) and 95% CIs were calculated comparing rates of CVD hospitalization in the 5 days following the 2020 election with the same 5-day period 2 weeks prior. RESULTS Among 6 396 830 adults (3 970 077 [62.1%] aged 18 to 54 years; 3 422 479 [53.5%] female; 1 083 128 [16.9%] Asian/Pacific Islander, 2 101 367 [32.9%] Hispanic, and 2 641 897 [41.3%] White), rates of hospitalization for CVD following the election (666 hospitalizations; rate = 760.5 per 100 000 person-years [PY]) were 1.17 times higher (95% CI, 1.05-1.31) compared with the same 5-day period 2 weeks prior (569 hospitalizations; rate = 648.0 per 100 000 PY). Rates of AMI were significantly higher following the election (RR, 1.42; 95% CI, 1.13-1.79). No significant difference was found for stroke (RR, 1.02; 95% CI, 0.86-1.21) or HF (RR, 1.18; 95% CI, 0.98-1.42). CONCLUSIONS AND RELEVANCE Higher rates of acute CVD hospitalization were observed following the 2020 presidential election. Awareness of the heightened risk of CVD and strategies to mitigate risk during notable political events are needed.
Collapse
Affiliation(s)
- Matthew T. Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jamal S. Rana
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, California
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Omesh Ranasinghe
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Murray A. Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer Y. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Teresa N. Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Alan C. Geller
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Richard P. Sloan
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Elizabeth Mostofsky
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David R. Williams
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of African and African American Studies, Harvard University, Cambridge, Massachusetts
| | - Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, Oakland
| |
Collapse
|
14
|
Mefford MT, Koyama SY, De Jesus J, Wei R, Fischer H, Harrison TN, Woo P, Reynolds K. Representativeness of the GALACTIC-HF Clinical Trial in Patients Having Heart Failure With Reduced Ejection Fraction. J Am Heart Assoc 2022; 11:e023766. [PMID: 35322672 PMCID: PMC9075481 DOI: 10.1161/jaha.121.023766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Randomized clinical trials in populations with heart failure with reduced ejection fraction may not be reflective of the general population with heart failure with reduced ejection fraction. Our study assessed the representativeness of the GALACTIC‐HF (Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure) patient population in Kaiser Permanente Southern California. Methods and Results We identified 9770 patients with a diagnosis of heart failure with reduced ejection fraction from 2014 to 2018 using electronic health records. Four mutually exclusive cohorts were created, including GALACTIC‐HF–ineligible cohorts: (1) not taking guideline‐directed medical therapy (GDMT) and (2) taking GDMT; and GALACTIC‐HF–eligible cohorts with: (3) ejection fraction (EF) ≤28% and (4) EF 29% to 35%. Patients were followed for 30‐day and 1‐year mortality and 30‐day, 180‐day, and 1‐year hospitalization. Overall, 3626 (37.1%) met GALACTIC‐HF inclusion criteria with EF ≤35%, and 2367 (65.3%) of those individuals had EF ≤28%. The risk of 1‐year mortality was lower among all cohorts versus the GALACTIC‐HF–ineligible cohort not taking GDMT (hazard ratio, 0.80 [95% CI, 0.70–0.91], 0.84 [95% CI, 0.72–0.98], and 0.62 [95% CI, 0.51–0.75] for the GALACTIC‐HF–ineligible cohort taking GDMT and GALACTIC‐HF‐eligible cohorts with EF ≤28% and 29%–35%, respectively). Compared with the GALACTIC‐HF–ineligible cohort not taking GDMT, the short‐term hospitalization risk at 30 and 180 days were similar for both GALACTIC‐HF–eligible cohorts and the hospitalization risk at 1 year was similar for the GALACTIC‐HF–eligible cohort with EF ≤28%. Conclusions A large portion of patients with heart failure with reduced ejection fraction with low EF met inclusion criteria for the GALACTIC‐HF trial and, despite being on GDMT, had hospitalization rates similar to those not taking GDMT, suggesting potential benefits from other innovative treatments.
Collapse
Affiliation(s)
- Matthew T Mefford
- Department of Research & Evaluation Kaiser Permanente Southern California Pasadena CA
| | - Sandra Y Koyama
- Internal Medicine Kaiser Permanente Southern California Baldwin Park CA
| | - Justine De Jesus
- Department of Research & Evaluation Kaiser Permanente Southern California Pasadena CA
| | - Rong Wei
- Department of Research & Evaluation Kaiser Permanente Southern California Pasadena CA
| | - Heidi Fischer
- Department of Research & Evaluation Kaiser Permanente Southern California Pasadena CA
| | - Teresa N Harrison
- Department of Research & Evaluation Kaiser Permanente Southern California Pasadena CA
| | - Pauline Woo
- Department of Cardiology Kaiser Permanente Southern California Baldwin Park CA
| | - Kristi Reynolds
- Department of Research & Evaluation Kaiser Permanente Southern California Pasadena CA.,Department of Health Systems Science Kaiser Permanente Bernard J. Tyson School of Medicine Pasadena CA
| |
Collapse
|
15
|
Mefford MT, An J, Gupta N, Harrison TN, Jacobsen SJ, Lee MS, Muntner P, Nkonde-Price C, Qian L, Reynolds K. Rates of Acute Myocardial Infarction During the COVID-19 Pandemic. Perm J 2021; 25. [PMID: 35348103 DOI: 10.7812/tpp/21.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND During the early phases of the COVID-19 pandemic pandemic, stay-at-home orders and fear of acquiring COVID-19 may have led to an avoidance of care for medical emergencies, including acute myocardial infarction (AMI). We evaluated whether a decline in rates of AMI occurred during the COVID-19 stay-at-home order. METHODS Rates of AMI per 100,000 member-weeks were calculated for Kaiser Permanente Southern California patients from January 1 to March 3, 2020 (prepandemic period) and from March 20 to July 31, 2020 (pandemic period), and during the same periods in 2019. Rate ratios (RRs) were calculated comparing the time periods using Poisson regression. Case fatality rates (CFRs) were also compared. RESULTS Rates of AMI were lower during the pandemic period of 2020 compared to the same period of 2019 [3.20 vs 3.76/100,000 member-weeks; RR, 0.85; 95% confidence interval (CI) 0.80-0.90]. There was no evidence that rates of AMI differed during the 2020 prepandemic period compared to the same period in 2019 (4.45 vs 4.24/100,000 member-weeks; RR, 0.95; 95% CI, 0.88-1.03). AMI rates were lower during the early pandemic period (March 20-May 7: RR, 0.70; 95% CI, 0.66-0.77), but not during the later pandemic period (May 8-July 31: RR, 0.95; 95% CI, 0.88-1.02) compared to 2019. In-hospital and 30-day case fatality rates were higher during the pandemic period of 2020 compared to 2019 (8.8% vs 6.1% and 6.5% vs 5.0%, respectively). CONCLUSION AMI rates were lower during the COVID-19 pandemic compared to the same period in 2019. During stay-at-home orders, public health campaigns that encourage people to seek care for medical emergencies are warranted.
Collapse
Affiliation(s)
- Matthew T Mefford
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Jaejin An
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Nigel Gupta
- Department of Cardiac Electrophysiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Teresa N Harrison
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Steven J Jacobsen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Paul Muntner
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Chileshe Nkonde-Price
- Department of Cardiology, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, CA.,Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Lei Qian
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| |
Collapse
|
16
|
Mefford MT, Chen L, Lewis CE, Muntner P, Sidney S, Launer LJ, Monda KL, Ruzza A, Kassahun H, Rosenson RS, Carson AP. Long-Term Levels of LDL-C and Cognitive Function: The CARDIA Study. J Int Neuropsychol Soc 2021; 27:1048-1057. [PMID: 33563358 PMCID: PMC8353005 DOI: 10.1017/s1355617721000059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES It is uncertain if long-term levels of low-density lipoprotein-cholesterol (LDL-C) affect cognition in middle age. We examined the association of LDL-C levels over 25 years with cognitive function in a prospective cohort of black and white US adults. METHODS Lipids were measured at baseline (1985-1986; age: 18-30 years) and at serial examinations conducted over 25 years. Time-averaged cumulative LDL-C was calculated using the area under the curve for 3,328 participants with ≥3 LDL-C measurements and a cognitive function assessment. Cognitive function was assessed at the Year 25 examination with the Digit Symbol Substitution Test [DSST], Rey Auditory Visual Learning Test [RAVLT], and Stroop Test. A brain magnetic resonance imaging (MRI) sub-study (N = 707) was also completed at Year 25 to assess abnormal white matter tissue volume (AWMV) and gray matter cerebral blood flow volume (GM-CBFV) as secondary outcomes. RESULTS There were 15.6%, 32.9%, 28.9%, and 22.6% participants with time-averaged cumulative LDL-C <100 mg/dL, 101-129 mg/dL, 130-159 mg/dL, and ≥160 mg/dL, respectively. Standardized differences in all cognitive function test scores ranged from 0.16 SD lower to 0.09 SD higher across time-averaged LDL-C categories in comparison to those with LDL-C < 100 mg/dL. After covariate adjustment, participants with higher versus lower time-averaged LDL-C had a lower RAVLT score (p-trend = 0.02) but no differences were present for DSST, Stroop Test, AWMV, or GM-CBFV. CONCLUSION Cumulative LDL-C was associated with small differences in memory, as assessed by RAVLT scores, but not other cognitive or brain MRI measures over 25 years of follow-up.
Collapse
Affiliation(s)
| | - Ligong Chen
- University of Alabama at Birmingham, Birmingham, AL
| | | | - Paul Muntner
- University of Alabama at Birmingham, Birmingham, AL
| | | | - Lenore J. Launer
- Intramural Research Program, National Institute on Aging, Bethesda, MD
| | - Keri L. Monda
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA
| | - Andrea Ruzza
- Global Clinical Development, Cardiovascular and Metabolic Therapeutic Area, Amgen Inc., Thousand Oaks, CA
| | - Helina Kassahun
- Global Clinical Development, Cardiovascular and Metabolic Therapeutic Area, Amgen Inc., Thousand Oaks, CA
| | | | | |
Collapse
|
17
|
An J, Zhou H, Wei R, Luong TQ, Gould MK, Mefford MT, Harrison TN, Creekmur B, Lee MS, Sim JJ, Brettler JW, Martin JP, Ong-Su AL, Reynolds K. COVID-19 morbidity and mortality associated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers use among 14,129 patients with hypertension from a US integrated healthcare system. Int J Cardiol Hypertens 2021; 9:100088. [PMID: 34155486 PMCID: PMC8204813 DOI: 10.1016/j.ijchy.2021.100088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/07/2021] [Accepted: 05/14/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Although recent evidence suggests no increased risk of severe COVID-19 outcomes associated with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) use, the relationship is less clear among patients with hypertension and diverse racial/ethnic groups. This study evaluates the risk of hospitalization and mortality among patients with hypertension and COVID-19 in a large US integrated healthcare system. METHODS Patients with hypertension and COVID-19 (between March 1- September 1, 2020) on ACEIs or ARBs were compared with patients on other frequently used antihypertensive medications. RESULTS Among 14,129 patients with hypertension and COVID-19 infection (mean age 60 years, 48% men, 58% Hispanic), 21% were admitted to the hospital within 30 days of COVID-19 infection. Of the hospitalized patients, 24% were admitted to intensive care units, 17% required mechanical ventilation, and 10% died within 30 days of COVID-19 infection. Exposure to ACEIs or ARBs prior to COVID-19 infection was not associated with an increased risk of hospitalization or all-cause mortality (rate ratios for ACEIs vs other antihypertensive medications = 0.98, 95% CI: 0.88, 1.08; ARBs vs others = 1.00, 95% CI: 0.90, 1.11) after applying inverse probability of treatment weights. These associations were consistent across racial/ethnic groups. Use of ACEIs or ARBs during hospitalization was associated with a lower risk of all-cause mortality (odds ratios for ACEIs or ARBs vs others = 0.50, 95% CI: 0.34, 0.72). CONCLUSION Our study findings support continuation of ACEI or ARB use for patients with hypertension during the COVID-19 pandemic and after COVID-19 infection.
Collapse
Affiliation(s)
- Jaejin An
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Hui Zhou
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Rong Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Tiffany Q. Luong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael K. Gould
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Matthew T. Mefford
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Teresa N. Harrison
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Beth Creekmur
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Ming-Sum Lee
- Southern California Permanente Medical Group, Pasadena, CA, USA
| | - John J. Sim
- Southern California Permanente Medical Group, Pasadena, CA, USA
| | | | - John P. Martin
- Southern California Permanente Medical Group, Pasadena, CA, USA
| | | | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| |
Collapse
|
18
|
Mefford MT, Zhuang Z, Liang Z, Chen W, Koyama SY, Taitano MT, Watson HL, Lee MS, Sidney S, Reynolds K. Temporal trends in heart failure mortality in an integrated healthcare delivery system, California, and the US, 2001-2017. BMC Cardiovasc Disord 2021; 21:261. [PMID: 34039262 PMCID: PMC8157708 DOI: 10.1186/s12872-021-02075-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 05/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In recent years, decreases in mortality rates attributable to cardiovascular diseases have slowed but mortality attributable to heart failure (HF) has increased. METHODS Between 2001-2017, trends in age-adjusted mortality with HF as an underlying cause for Kaiser Permanente Southern California (KPSC) members were derived through linkage with state death files and compared with trends among California residents and the US. Average annual percent change (AAPC) and 95% confidence intervals (CI) were calculated using Joinpoint regression. Analyses were repeated examining HF as a contributing cause of death. RESULTS In KPSC, the age-adjusted HF mortality rates were comparable to California but lower than the US, increasing from 23.9 per 100,000 person-years (PY) in 2001 to 44.7 per 100,000 PY in 2017, representing an AAPC of 1.3% (95% CI 0.0%, 2.6%). HF mortality also increased in California from 33.9 to 46.5 per 100,000 PY (AAPC 1.5%, 95% CI 0.3%, 2.7%), while remaining unchanged in the US at 57.9 per 100,000 PY in 2001 and 2017 (AAPC 0.0%, 95% CI - 0.5%, 0.5%). Trends among KPSC members ≥ 65 years old were similar to the overall population, while trends among members 45-64 years old were flat between 2001-2017. Small changes in mortality with HF as a contributing cause were observed in KPSC members between 2001 and 2017, which differed from California and the US. CONCLUSION Lower rates of HF mortality were observed in KPSC compared to the US. Given the aging of the US population and increasing prevalence of HF, it will be important to examine individual and care-related factors driving susceptibility to HF mortality.
Collapse
Affiliation(s)
- Matthew T Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA.
| | - Zimin Zhuang
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - Zhi Liang
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - Wansu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - Sandra Y Koyama
- Internal Medicine, Kaiser Permanente Southern California, Baldwin Park, CA, USA
| | | | - Heather L Watson
- Complete Care Support Programs, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| |
Collapse
|
19
|
Mefford MT, Liu R, Qian L, Harrison TN, Jacobsen SJ, An J, Lee M, Gupta N, Price CN, Muntner P, Reynolds K. Abstract MP41: Rates Of Acute Myocardial Infarction Around The Covid-19 Pandemic And Comparable Time Periods In 2019 In An Integrated Healthcare Delivery System. Circulation 2021. [DOI: 10.1161/circ.143.suppl_1.mp41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Stay at home orders and fear of acquiring COVID-19 may have led to an avoidance of care for medical emergencies including acute myocardial infarction (AMI). We sought to examine rates of confirmed AMI cases between January 1-June 30, 2019 and 2020.
Methods:
We identified Kaiser Permanente Southern California members ≥ 18 years old with a hospitalization or emergency department visit for AMI, defined by ICD-10 primary diagnosis codes. Rates of AMI per 100,000 member-weeks were calculated for pre-pandemic and pandemic periods of January 1-March 3, 2020 and March 20-June 30, 2020, respectively, and in the same periods of 2019 overall and for ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI), separately. March 4-19, 2020 was considered a washout period given the gradual rollout of stay-at-home orders. Rate ratios (RR) and 95% confidence intervals (CI) were calculated comparing pre-pandemic and pandemic periods of 2020 to 2019 using Poisson regression.
Results:
The mean age of patients presenting with AMI during the 2020 (n=3,029) and 2019 (n=3,518) periods was 69 years, and a majority of events occurred among men (62%) and whites (47%). Rates of AMI in the pre-pandemic period of 2020 and same period in 2019 were 4.23 and 4.45 per 100,000 member weeks, respectively. During the pandemic period of 2020 and the same period in 2019, rates were 3.04 and 3.85 per 100,000 member-weeks, respectively. (Figure) There was no evidence rates of AMI were different during the pre-pandemic period of 2020 compared to the same period in 2019 (RR 0.95, 95% CI 0.88, 1.03). In contrast, rates of AMI were lower during the pandemic period of 2020 compared to the same period of 2019 (RR 0.79, 95% CI 0.74, 0.85), and among NSTEMI (RR 0.80, 95% CI 0.74, 0.86) and STEMI (0.74, 95% CI 0.66, 0.84) cases.
Conclusion:
AMI rates were lower during the COVID-19 pandemic compared to the year prior. Public health messaging is important to ensure people seek care for medical emergencies.
Collapse
Affiliation(s)
| | - Ran Liu
- Kaiser Permanente Southern California, Pasadena, CA
| | - Lei Qian
- Kaiser Permanente Southern California, Pasadena, CA
| | | | | | - JaeJin An
- Kaiser Permanente Southern California, Pasadena, CA
| | - Mingsum Lee
- Southern California Permanente Med Group, Los Angeles, CA
| | - Nigel Gupta
- Southern California Permanente Med Group, Los Angeles, CA
| | | | | | | |
Collapse
|
20
|
An J, Wei R, Zhou H, Luong TQ, Gould MK, Mefford MT, Harrison TN, Creekmur B, Lee M, Sim JJ, Brettler JW, Martin JP, Ong‐Su AL, Reynolds K. Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Use and COVID-19 Infection Among 824 650 Patients With Hypertension From a US Integrated Healthcare System. J Am Heart Assoc 2021; 10:e019669. [PMID: 33307964 PMCID: PMC7955437 DOI: 10.1161/jaha.120.019669] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Previous reports suggest that the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may upregulate angiotensin-converting enzyme 2 receptors and increase severe acute respiratory syndrome coronavirus 2 infectivity. We evaluated the association between ACEI or ARB use and coronavirus disease 2019 (COVID-19) infection among patients with hypertension. Methods and Results We identified patients with hypertension as of March 1, 2020 (index date) from Kaiser Permanente Southern California. Patients who received ACEIs, ARBs, calcium channel blockers, beta blockers, thiazide diuretics (TD), or no therapy were identified using outpatient pharmacy data covering the index date. Outcome of interest was a positive reverse transcription polymerase chain reaction test for COVID-19 between March 1 and May 6, 2020. Patient sociodemographic and clinical characteristics were identified within 1 year preindex date. Among 824 650 patients with hypertension, 16 898 (2.0%) were tested for COVID-19. Of those tested, 1794 (10.6%) had a positive result. Overall, exposure to ACEIs or ARBs was not statistically significantly associated with COVID-19 infection after propensity score adjustment (odds ratio [OR], 1.06; 95% CI, 0.90-1.25) for ACEIs versus calcium channel blockers/beta blockers/TD; OR, 1.10; 95% CI, 0.91-1.31 for ARBs versus calcium channel blockers/beta blockers/TD). The associations between ACEI use and COVID-19 infection varied in different age groups (P-interaction=0.03). ACEI use was associated with lower odds of COVID-19 among those aged ≥85 years (OR, 0.30; 95% CI, 0.12-0.77). Use of no antihypertensive medication was significantly associated with increased odds of COVID-19 infection compared with calcium channel blockers/beta blockers/TD (OR, 1.32; 95% CI, 1.11-1.56). Conclusions Neither ACEI nor ARB use was associated with increased likelihood of COVID-19 infection. Decreased odds of COVID-19 infection among adults ≥85 years using ACEIs warrants further investigation.
Collapse
Affiliation(s)
- Jaejin An
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA,Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
| | - Rong Wei
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Hui Zhou
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Tiffany Q. Luong
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Michael K. Gould
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA,Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
| | | | | | - Beth Creekmur
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Ming‐Sum Lee
- Southern California Permanente Medical GroupPasadenaCA
| | - John J. Sim
- Southern California Permanente Medical GroupPasadenaCA
| | | | | | | | - Kristi Reynolds
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA,Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
| |
Collapse
|
21
|
Blackston JW, Safford MM, Mefford MT, Freeze E, Howard G, Howard VJ, Naftel DC, Brown TM, Levitan EB. Cardiovascular Disease Events and Mortality After Myocardial Infarction Among Black and White Adults: REGARDS Study. Circ Cardiovasc Qual Outcomes 2020; 13:e006683. [PMID: 33302710 PMCID: PMC7853403 DOI: 10.1161/circoutcomes.120.006683] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite improvements in prognosis following myocardial infarction (MI), racial disparities persist. The objective of this study was to examine disparities between Black and White adults in cardiovascular disease (CVD), coronary heart disease, stroke, heart failure (HF), and mortality after MI and characteristics that may explain the disparities. METHODS This prospective cohort study included 1122 REGARDS (Reasons for Geographic and Racial Differences in Stroke) study participants with incident MI between 2003 and 2016. We followed participants for subsequent CVD events (MI, stroke, HF hospitalization, or death from CVD; n=431), coronary heart disease events (MI or death from coronary heart disease; (n=277), stroke (n=68), HF events (HF hospitalization or death from HF; n=191), and all-cause mortality (n=527; 3-year median follow-up after MI). RESULTS Among 1122 participants with incident MI, 37.5% were Black participants, 45.4% were women, and mean age was 73.2 (SD, 9.5) years. The unadjusted hazard ratio for CVD events comparing Black to White participants was 1.42 (95% CI, 1.17-1.71). Adjusting for sociodemographic characteristics did not attenuate the association (1.41 [95% CI, 1.14-1.73]), but further adjusting for pre-MI health status (1.25 [95% CI, 1.00-1.56]) and characteristics of the MI (1.01 [95% CI, 0.80-1.27]) resulted in substantial attenuation. Similar patterns were observed for the other outcomes, although the number of strokes was small. CONCLUSIONS Black individuals had a higher risk of CVD events and mortality after MI than White individuals. The disparities were explained by health status before MI and characteristics of the MI. These findings suggest that both primordial prevention of risk factors and improved acute treatment strategies are needed to reduce disparities in post-MI outcomes.
Collapse
Affiliation(s)
- J Walker Blackston
- Department of Epidemiology (J.W.B., M.T.M., V.J.H., E.B.L.), University of Alabama at Birmingham School of Public Health
| | - Monika M Safford
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, Cornell University, New York (M.M.S.)
| | - Matthew T Mefford
- Department of Epidemiology (J.W.B., M.T.M., V.J.H., E.B.L.), University of Alabama at Birmingham School of Public Health
| | - Elizabeth Freeze
- Department of Infection Prevention (E.F.), University of Alabama at Birmingham School of Medicine
| | - George Howard
- Department of Biostatistics (G.H.), University of Alabama at Birmingham School of Public Health
| | - Virginia J Howard
- Department of Epidemiology (J.W.B., M.T.M., V.J.H., E.B.L.), University of Alabama at Birmingham School of Public Health
| | - David C Naftel
- The James and John Kirklin Institute for Research in Surgical Outcomes, Department of Surgery (D.C.N.), University of Alabama at Birmingham School of Medicine
| | - Todd M Brown
- Division of Cardiovascular Disease, Department of Medicine (T.M.B.), University of Alabama at Birmingham School of Medicine
| | - Emily B Levitan
- Department of Epidemiology (J.W.B., M.T.M., V.J.H., E.B.L.), University of Alabama at Birmingham School of Public Health
| |
Collapse
|
22
|
Bittner V, Colantonio LD, Dai Y, Woodward M, Mefford MT, Rosenson RS, Muntner P, Monda KL, Kilgore ML, Jaeger BC, Levitan EB. Association of Region and Hospital and Patient Characteristics With Use of High-Intensity Statins After Myocardial Infarction Among Medicare Beneficiaries. JAMA Cardiol 2020; 4:865-872. [PMID: 31339519 DOI: 10.1001/jamacardio.2019.2481] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Importance High-intensity statin use after myocardial infarction (MI) varies by patient characteristics, but little is known about differences in use by hospital or region. Objective To explore the relative strength of associations of region and hospital and patient characteristics with high-intensity statin use after MI. Design, Setting, and Participants This retrospective cohort analysis used Medicare administrative claims and enrollment data to evaluate fee-for-service Medicare beneficiaries 66 years or older who were hospitalized for MI from January 1, 2011, through June 30, 2015, with a statin prescription claim within 30 days of discharge. Data were analyzed from January 4, 2017, through May 12, 2019. Exposures Beneficiary characteristics were abstracted from Medicare data. Hospital characteristics were obtained from the 2014 American Hospital Association Survey and Hospital Compare quality metrics. Nine regions were defined according to the US Census. Main Outcomes and Measures Intensity of the first statin claim after discharge characterized as high (atorvastatin calcium, 40-80 mg, or rosuvastatin calcium, 20-40 mg/d) vs low to moderate (all other statin types and doses). Trends in high-intensity statins were examined from 2011 through 2015. Associations of region and beneficiary and hospital characteristics with high-intensity statin use from January 1, 2014, to June 15, 2015, were examined using Poisson distribution mixed models. Results Among the 139 643 fee-for-service beneficiaries included (69 968 men [50.1%] and 69 675 women [49.9%]; mean [SD] age, 76.7 [7.5] years), high-intensity statin use overall increased from 23.4% in 2011 to 55.6% in 2015, but treatment gaps persisted across regions. In models considering region and beneficiary and hospital characteristics, region was the strongest correlate of high-intensity statin use, with 66% higher use in New England than in the West South Central region (risk ratio [RR], 1.66; 95% CI, 1.47-1.87). Hospital size of at least 500 beds (RR, 1.15; 95% CI, 1.07-1.23), medical school affiliation (RR, 1.11; 95% CI, 1.05-1.17), male sex (RR, 1.10; 95% CI, 1.07-1.13), and patient receipt of a stent (RR, 1.35; 95% CI, 1.31-1.39) were associated with greater high-intensity statin use. For-profit hospital ownership, patient age older than 75 years, prior coronary disease, and other comorbidities were associated with lower use. Conclusions and Relevance This study's findings suggest that geographic region is the strongest correlate of high-intensity statin use after MI, leading to large treatment disparities.
Collapse
Affiliation(s)
- Vera Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham
| | | | - Yuling Dai
- Department of Epidemiology, University of Alabama at Birmingham
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,The George Institute for Global Health, University of Oxford, Oxford, United Kingdom.,Department of Epidemiology, The Johns Hopkins University, Baltimore, Maryland
| | | | | | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham
| | - Keri L Monda
- Center for Observational Research, Amgen, Inc, Thousand Oaks, California
| | - Meredith L Kilgore
- Department of Health Care Organization and Policy, University of Alabama at Birmingham
| | - Byron C Jaeger
- Department of Biostatistics, University of Alabama at Birmingham
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham
| |
Collapse
|
23
|
Tanner RM, Colantonio LD, Kilgore ML, Mefford MT, Chachappan DT, Mues KE, Safford MM, Rosenson RS, Muntner P. Low-density lipoprotein cholesterol levels among individuals experiencing statin-associated symptoms: Data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. J Clin Lipidol 2020; 14:720-729. [PMID: 32680814 PMCID: PMC9668077 DOI: 10.1016/j.jacl.2020.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 05/22/2020] [Accepted: 06/07/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Guidelines recommend adults who discontinue statin therapy because of statin-associated symptoms be reinitiated. Low-density lipoprotein cholesterol (LDL-C) levels achieved after statin reinitiation are unknown. OBJECTIVE The objective of this study was to determine LDL-C levels after statin reinitiation. METHODS We analyzed data from 5498 participants in the REasons for Geographic And Racial Differences in Stroke study who reported ever taking a statin. We categorized participants according to their pattern of statin use including those taking a statin who did not experience statin-associated symptoms and continued treatment, and those who discontinued statins because of statin-associated symptoms and were not reinitiated, reinitiated and remained on treatment, and discontinued treatment after being reinitiated. Mortality and vascular event reduction with statin reinitiation was estimated using data from the Cholesterol-Lowering Treatment Trialists Collaboration. RESULTS After multivariable adjustment, LDL-C was 14.1 (95% CI: 9.9-18.3) mg/dL higher among participants reinitiated and taking a statin compared with those without statin-associated symptoms who continued statin therapy. Mean LDL-C was 18.1 mg/dL (95% CI: 13.0-23.1) and 27.5 mg/dL (95% CI: 20.7-34.4) lower among participants reinitiated and taking a statin compared with those who discontinued statin therapy and were not reinitiated and those who discontinued statins after being reinitiated, respectively. An LDL-C reduction of 18.1 mg/dL with statin reinitiation was projected to reduce all-cause and coronary heart disease mortality by 5.6% and 8.9%, respectively, and myocardial infarction or coronary heart disease death and major vascular events by 10.7% and 9.8%, respectively, over 5 years. CONCLUSION Reinitiating individuals who discontinue statin therapy may reduce LDL-C and cardiovascular risk.
Collapse
Affiliation(s)
- Rikki M Tanner
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Lisandro D Colantonio
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Meredith L Kilgore
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew T Mefford
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dayl T Chachappan
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Katherine E Mues
- The Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Robert S Rosenson
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul Muntner
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
24
|
Mefford MT, Goyal P, Howard G, Durant RW, Dunlap NE, Safford MM, Muntner P, Levitan EB. The association of hypertension, hypertension duration, and control with incident heart failure in black and white adults. J Clin Hypertens (Greenwich) 2020; 22:857-866. [PMID: 32282123 PMCID: PMC7359908 DOI: 10.1111/jch.13856] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/17/2020] [Accepted: 03/03/2020] [Indexed: 12/25/2022]
Abstract
Associations between hypertension and some cardiovascular diseases are stronger in black vs white adults. We examined associations of hypertension, hypertension duration, and control with incident heart failure (HF) in black and white REasons for Geographic And Racial Differences in Stroke study participants (n = 25 770) who were followed for incident HF hospitalization (n = 947) from enrollment in 2003-2007 through 2015. Hypertension was defined, using updated US guidelines, as systolic or diastolic blood pressure (BP) ≥130/80 mm Hg or antihypertensive medication use. Duration was assessed at baseline, and control was defined as treated BP < 130/80 mm Hg. Compared with no hypertension, hypertension was associated with higher risk of incident HF (HRwhites 1.90 [95% CI 1.49, 2.41], HRblacks 2.36 [95% CI 1.53, 3.65]), HF with preserved ejection fraction (HRwhites 2.01 [95% CI 1.34, 3.01], HRblacks 2.70 [95% CI 1.25, 2.53]), and HF with reduced/mid-range ejection fraction (HRwhites 1.69 [95% CI 1.23, 2.33], HRblacks 2.29 [95% CI 1.26, 4.15]). Hypertension duration <10 years and ≥10 years were associated with higher risk for incident HF compared with no hypertension. Although risk of incident HF was highest among participants with uncontrolled BP, even controlled BP vs no hypertension was associated with increased risk of HF (HRwhites 1.93 [95% CI 1.44, 2.58], HRblacks 2.01 [95% CI 1.22, 3.29]). Interactions with race were not statistically significant. The risk of HF associated with hypertension, even with shorter duration or controlled BP, suggests that both prevention and therapeutic management of hypertension are important in reducing HF risk.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Paul Muntner
- University of Alabama at BirminghamBirminghamALUSA
| | | |
Collapse
|
25
|
Goyal P, Mefford MT, Chen L, Sterling MR, Durant RW, Safford MM, Levitan EB. Assembling and validating a heart failure-free cohort from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. BMC Med Res Methodol 2020; 20:53. [PMID: 32126970 PMCID: PMC7055019 DOI: 10.1186/s12874-019-0890-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 12/18/2019] [Indexed: 01/01/2023] Open
Abstract
Background Studies examining incident heart failure (HF) have been limited to select populations. To examine incident HF with broader generalizability, there is need to assemble a HF-free cohort using a geographically-diverse sample. We aimed to develop and validate a simple medication-based strategy for assembling a HF-free cohort from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Methods We examined REGARDS participants with ≥6 months of Medicare inpatient and outpatient claims data at the time of the baseline in-home study examination. To assemble a HF-free cohort, we identified and excluded participants taking HF-specific medications. To validate this approach, we evaluated event rates among this cohort and assessed diagnostic performance using Medicare claims-based definitions of HF as the referent standard. Results Among 28,884 eligible participants, 3125 were excluded from the proposed HF-free cohort, leaving a total of 25,759 (89%) participants. Depending on the Medicare definition used as the referent, the negative predictive value of this approach ranged from 95.0–99.2%. Negative predictive value was stable across age, sex, and race strata. Conclusions The approach to assemble a HF-free cohort in REGARDS can serve as the basis for future studies to examine incident HF in REGARDS and similar studies.
Collapse
Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Matthew T Mefford
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ligong Chen
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Raegan W Durant
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
26
|
Mefford MT, Li BH, Qian L, Reading SR, Harrison TN, Scott RD, Cavendish JJ, Jacobsen SJ, Kanter MH, Woodward M, Reynolds K. Sex-Specific Trends in Acute Myocardial Infarction Within an Integrated Healthcare Network, 2000 Through 2014. Circulation 2020; 141:509-519. [DOI: 10.1161/circulationaha.119.044738] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
In recent decades, the rates of incident acute myocardial infarction (AMI) have declined in the United States, yet disparities by sex remain. In an integrated healthcare delivery system, we examined temporal trends in incident AMI among women and men.
Methods:
We identified hospitalized AMI among members ≥35 years of age in Kaiser Permanente Southern California. The first hospitalization for AMI overall, and for ST-segment–elevation MI and non–ST-segment–elevation MI was identified by
International Classification of Diseases, Ninth Revision, Clinical Modification
primary discharge diagnosis codes in each calendar year from 2000 through 2014. Age- and sex-standardized incidence rates per 100 000 person-years were calculated by using direct adjustment to the 2010 US Census population. Average annual percent changes (AAPCs) and period percent changes were calculated, and trend tests were conducted using Poisson regression.
Results:
We identified 45 331 AMI hospitalizations between 2000 and 2014. Age- and sex-standardized incidence rates of AMI declined from 322.4 (95% CI, 311.0–333.9) in 2000 to 174.6 (95% CI, 168.2–181.0) in 2014, representing an AAPC of –4.4% (95% CI, –4.2 to –4.6) and a period percent change of –46.6%. The AAPC for AMI in women was –4.6% (95% CI, –4.1 to –5.2) between 2000 and 2009 and declined to –2.3% (95% CI, –1.2 to –3.4) between 2010 and 2014. The AAPC for AMI in men was stable over the study period (–4.7% [95% CI, –4.4 to –4.9]). The AAPC for ST-segment–elevation MI hospitalization overall was –8.3% (95% CI, –8.0% to –8.6%).The AAPC in ST-segment–elevation MI changed among women in 2009 (2000–2009: –10.2% [95% CI, –9.3 to –11.1] and in 2010–2014: –5.2% [95% CI, –3.1 to –7.3]) while remaining stable among men (–8.0% [95% CI, –7.6 to –8.4]). The AAPC for non–ST-segment–elevation MI hospitalization was smaller than for ST-segment–elevation MI among both women and men (–1.9% [95% CI, –1.5 to –2.3] and –2.8% [95% CI, –2.5 to –3.2], respectively).
Conclusions:
These results suggest that the incidence of hospitalized AMI declined between 2000 and 2014; however, declines in AMI have slowed among women in comparison with men in recent years. Determining unmet care needs among women may reduce these sex-based AMI disparities.
Collapse
Affiliation(s)
- Matthew T. Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (M.T.M., B.H.L., L.Q., S.R.R., T.N.H., S.J.J., K.R.)
| | - Bonnie H. Li
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (M.T.M., B.H.L., L.Q., S.R.R., T.N.H., S.J.J., K.R.)
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (M.T.M., B.H.L., L.Q., S.R.R., T.N.H., S.J.J., K.R.)
| | - Stephanie R. Reading
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (M.T.M., B.H.L., L.Q., S.R.R., T.N.H., S.J.J., K.R.)
- Center for Observational Research, Amgen, Inc, Thousand Oaks, CA (S.R.R.)
| | - Teresa N. Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (M.T.M., B.H.L., L.Q., S.R.R., T.N.H., S.J.J., K.R.)
| | - Ronald D. Scott
- Southern California Permanente Medical Group, West Los Angeles (R.D.S.)
| | - Jeffrey J. Cavendish
- Southern California Permanente Medical Group, San Diego Medical Center, San Diego (J.J.C.)
| | - Steven J. Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (M.T.M., B.H.L., L.Q., S.R.R., T.N.H., S.J.J., K.R.)
- Department of Health Systems Science (S.J.J., K.R.), Kaiser Permanente School of Medicine, Pasadena, CA
| | - Michael H. Kanter
- Department of Clinical Science (M.H.K.), Kaiser Permanente School of Medicine, Pasadena, CA
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.W.)
- The George Institute for Global Health, University of Oxford, United Kingdom (M.W.)
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD (M.W.)
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (M.T.M., B.H.L., L.Q., S.R.R., T.N.H., S.J.J., K.R.)
- Department of Health Systems Science (S.J.J., K.R.), Kaiser Permanente School of Medicine, Pasadena, CA
| |
Collapse
|
27
|
Mefford MT, Rosenson RS, Deng L, Tanner RM, Bittner V, Safford MM, Coll B, Mues KE, Monda KL, Muntner P. Trends in Statin Use Among US Adults With Chronic Kidney Disease, 1999-2014. J Am Heart Assoc 2020; 8:e010640. [PMID: 30651020 PMCID: PMC6497356 DOI: 10.1161/jaha.118.010640] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The 2013 American College of Cardiology/American Heart Association cholesterol guidelines recognize cardiovascular disease and diabetes mellitus but not chronic kidney disease ( CKD ) as high-risk conditions warranting statin therapy. Statin use may be lower for adults with CKD compared with adults with conditions that have guideline indications for statin use. Methods and Results We analyzed data from the National Health and Nutrition Examination Surveys from 1999-2002 through 2011-2014 to determine trends in the percentage of US adults ≥20 years of age with and without CKD taking statins. CKD was defined by an estimated glomerular filtration rate <60 mL/min per 1.73m2 or albumin-to-creatinine ratio ≥30 mg/g. Statin use was identified through a medication inventory. Between 1999-2002 and 2011-2014, the percentage of adults taking statins increased from 17.6% to 35.7% among those with CKD and from 6.8% to 14.7% among those without CKD . After multivariable adjustment, adults with CKD were not more likely to be taking statins compared with those without CKD (prevalence ratio, 1.01; 95% CI] 0.96-1.08). Among adults without a history of cardiovascular disease, those with CKD but not diabetes mellitus were less likely to be taking statins compared with those with diabetes mellitus but not CKD (prevalence ratio, 0.54; 95% CI , 0.44-0.66). Among adults with a history of cardiovascular disease, there was no difference in statin use between those with CKD but not diabetes mellitus versus those with diabetes mellitus but not CKD (prevalence ratio, 0.95; 95% CI , 0.79-1.15). Conclusions CKD does not appear to be a major stimulus for statin use among US adults.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Blai Coll
- Center for Observational ResearchAmgen IncThousand OaksCA
| | | | - Keri L. Monda
- Center for Observational ResearchAmgen IncThousand OaksCA
| | | |
Collapse
|
28
|
Mefford MT, Marcovina SM, Bittner V, Cushman M, Brown TM, Farkouh ME, Tsimikas S, Monda KL, López JAG, Muntner P, Rosenson RS. PCSK9 loss-of-function variants and Lp(a) phenotypes among black US adults. J Lipid Res 2019; 60:1946-1952. [PMID: 31511398 DOI: 10.1194/jlr.p119000173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/26/2019] [Indexed: 12/24/2022] Open
Abstract
The pharmacologic inhibition of proprotein convertase subtilisin-kexin type 9 (PCSK9) lowers lipoprotein (a) [Lp(a)] concentrations. However, the impact of genetic PCSK9 loss-of-function variants (LOFVs) on Lp(a) is uncertain. We determined the association of PCSK9 LOFVs with Lp(a) measures among black adults. Genotyping for PCSK9 LOFVs was conducted in 10,196 black Reasons for Geographic and Racial Differences in Stroke study participants. Among 241 participants with and 723 randomly selected participants without PCSK9 LOFVs, Lp(a) concentations, apo(a) kringle IV (KIV) repeats (a proxy for isoform size), and oxidized phospholipid (OxPL) apoB levels were measured using validated methods. Median Lp(a) concentrations among participants with and without PCSK9 LOFVs were 63.2 and 80.4 nmol/l, respectively (P = 0.016). After adjusting for age, sex, estimated glomerular filtration rate, LDL cholesterol, and statin use, participants with versus without a PCSK9 LOFV had a lower median Lp(a) concentration [Δ = -18.8 nmol/l (95% CI: -34.2, -3.3)]. Median apo(a) isoform sizes were 24 and 23 KIV repeats (P = 0.12) among participants with and without PCSK9 LOFVs, respectively [Δ = 1.1 (95% CI: 0.2, 2.0) after adjustment]. Median OxPL-apoB levels among participants with and without PCSK9 LOFVs were 3.4 and 4.1 nM (P = 0.20), respectively [Δ = -1.2 nM (95% CI -2.4, -0.04) after adjustment]. Among black adults, PCSK9 LOFVs were associated with lower Lp(a) concentration and OxPL-apoB levels.
Collapse
Affiliation(s)
- Matthew T Mefford
- Deparment of Research and Evaluation, Kaiser Permante Southern California, Pasadena, CA .,Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Santica M Marcovina
- Department of Medicine, Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle, WA
| | - Vera Bittner
- Division of Cardiovascular Disease University of Alabama at Birmingham, Birmingham, AL
| | - Mary Cushman
- Departments of Medicine and Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Todd M Brown
- Division of Cardiovascular Disease University of Alabama at Birmingham, Birmingham, AL
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada
| | - Sotirios Tsimikas
- Department of Medicine, University of California San Diego, La Jolla, CA
| | - Keri L Monda
- Center for Observational Research Amgen Inc., Thousand Oaks, CA
| | | | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | | |
Collapse
|
29
|
Tajeu GS, Kent ST, Huang L, Bress AP, Cuffee Y, Halpern MT, Kronish IM, Krousel-Wood M, Mefford MT, Shimbo D, Muntner P. Antihypertensive Medication Nonpersistence and Low Adherence for Adults <65 Years Initiating Treatment in 2007-2014. Hypertension 2019; 74:35-46. [PMID: 31132956 PMCID: PMC6914333 DOI: 10.1161/hypertensionaha.118.12495] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 04/25/2019] [Indexed: 02/07/2023]
Abstract
Previous evidence suggests modest improvements in antihypertensive medication adherence occurred from 2007 to 2012 among US adults ≥65 years of age. Whether adherence improved over time among adults <65 years of age is unknown. We assessed trends in antihypertensive medication nonpersistence and low adherence among 379 658 commercially insured adults <65 years of age initiating treatment in 2007-2014 using MarketScan claims. Nonpersistence was defined as having no days of medication available to take during the final 90 days of the 365 days following initiation. Among beneficiaries who were persistent to treatment, low adherence was defined by having antihypertensive medication available to take for <80% of the days in the 365 days following initiation (ie, proportion of days covered <80%). In 2007 and 2014, 23.3% and 23.5% of patients were nonpersistent to treatment, respectively, and 42.3% and 40.2% had low adherence, respectively. The relative risks for nonpersistence and low adherence were lower among beneficiaries initiating treatment with an angiotensin-converting enzyme inhibitor (0.95; 95% CI, 0.94-0.97 and 0.97; 95% CI, 0.96-0.98, respectively), angiotensin receptor blocker (0.86; 95% CI, 0.85-0.88 and 0.99; 95% CI, 0.97-1.00, respectively), or multiclass regimen (0.82; 95% CI, 0.80-0.84 and 0.88; 95% CI, 0.86-0.89, respectively), prescribed 90-day versus 30-day prescriptions (0.67; 95% CI, 0.66-0.68 and 0.70; 95% CI, 0.69-0.71, respectively), or who received medications by mail versus at the pharmacy (0.93; 95% CI, 0.90-0.95 and 0.90; 95% CI, 0.88-0.92, respectively). In conclusion, several modifiable factors were associated with lower rates of both antihypertensive medication nonpersistence and low adherence among adults <65 years of age initiating treatment in 2007-2014.
Collapse
Affiliation(s)
- Gabriel S. Tajeu
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA
| | | | - Lei Huang
- Department of Epidemiology, University of Alabama at Birmingham
| | - Adam P. Bress
- Department of Population Health Sciences, University of Utah
| | | | - Michael T. Halpern
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA
| | - Ian M. Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center
| | - Marie Krousel-Wood
- Department of Medicine, Tulane School of Medicine, Department of Epidemiology, Tulane School of Public Health and Tropical Medicine; Research Division-Center for Applied Health Services Research, Ochsner Health System
| | | | - Daichi Shimbo
- Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham
| |
Collapse
|
30
|
Mefford MT, Sephel A, Van Dyke MK, Chen L, Durant RW, Brown TM, Fifolt M, Maya J, Goyal P, Safford MM, Levitan EB. Medication-Taking Behaviors and Perceptions Among Adults With Heart Failure (from the REasons for Geographic And Racial Differences in Stroke Study). Am J Cardiol 2019; 123:1667-1674. [PMID: 30879609 PMCID: PMC6488419 DOI: 10.1016/j.amjcard.2019.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 01/07/2023]
Abstract
Medication regimens in adults with heart failure (HF) are complex which can complicate patient adherence. Individuals with HF frequently use beta blockers (BBs) for multiple indications, including hypertension and HF, but BBs can have significant side effects that may affect their use. We examined medication-taking behaviors and perceptions in individuals with HF with a particular focus on BBs. A mailed survey on medication use was administered to US adults with HF enrolled in the REasons for Geographic And Racial Differences in Stroke study. Among 518 respondents, 357 (69%) reported taking a BB. Nearly half (42%) reported taking ≥10 medications per day. However, 45% indicated that they did not miss any days taking medications, and over 85% reported willingness to take additional medications to prevent further healthcare encounters. Participants' perceptions of BB symptoms varied, but 56% of those who reported experiencing symptoms did not discuss this with their healthcare providers. Adults who experienced HF hospitalization had higher odds of reporting taking BBs to treat HF (odds ratio 1.51, 95% confidence interval 1.19, 1.91). Adults with hypertension were also likely to report taking BBs to treat high blood pressure (odds ratio 2.42, 95% confidence interval 1.79, 3.26). In conclusion, despite extensive medication regimens, individuals with HF were willing to take additional medications for their disease. Participant recognition of BB use for treating HF and co-morbidities was high, yet many do not report side effects to healthcare providers. In conclusion, better understanding of patients' medication-taking behaviors and perceptions may facilitate optimization of HF treatments.
Collapse
Affiliation(s)
| | - Alysse Sephel
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Ligong Chen
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Todd M Brown
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Matthew Fifolt
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Juan Maya
- Amgen Inc., Thousand Oaks, California
| | | | | | | |
Collapse
|
31
|
Mefford MT, Tajeu GS, Tanner RM, Colantonio LD, Monda KL, Dent R, Farkouh ME, Rosenson RS, Safford MM, Muntner P. Willingness to be Reinitiated on a Statin (from the REasons for Geographic and Racial Differences in Stroke Study). Am J Cardiol 2018; 122:768-774. [PMID: 30057227 DOI: 10.1016/j.amjcard.2018.05.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/14/2018] [Accepted: 05/18/2018] [Indexed: 10/14/2022]
Abstract
Guidelines recommend attempting to reinitiate statins in patients who discontinue treatment. Previous experiences while taking a statin, including side effects, may reduce a patient's willingness to reinitiate treatment. We determined the percentage of adults who are willing to reinitiate statin therapy after treatment discontinuation. Factors associated with willingness to reinitiate a statin were also examined. A statin questionnaire was administered and study examination conducted in black and white US adults enrolled in the nationwide REasons for Geographic And Racial Differences in Stroke study from 2013 to 2017. In participants who self-reported ever having taken a statin (n = 7,216, mean age 72 years, 53% women, 34% black), 1,081 (15%) reported having discontinued treatment. Among those who discontinued treatment, statin side effects, perceived lack of need for a statin, and cost were reported by 66%, 31%, and 3% of participants, respectively. Overall, 37% of participants who had discontinued treatment were willing to reinitiate statin therapy. Participants who discontinued treatment due to cost (prevalence ratio [PR] 1.61; 95% confidence interval (CI) 1.01, 2.57) were more likely to report a willingness to reinitiate therapy. Participants with a low-density lipoprotein-cholesterol ≥130 mg/dl versus <100 mg/dl (PR 0.69; 95% CI 0.53, 0. 88) and who discontinued treatment due to side effects (PR 0.51; 95% CI 0.41, 0.64) were less likely to report willingness to reinitiate statin therapy. In conclusion, a substantial proportion of participants who discontinued statin therapy were willing to reinitiate treatment. Healthcare providers should discuss reinitiation of statin therapy with their patients who have discontinued treatment.
Collapse
|
32
|
Mefford MT, Rosenson RS, Cushman M, Farkouh ME, McClure LA, Wadley VG, Irvin MR, Bittner V, Safford MM, Somaratne R, Monda KL, Muntner P, Levitan EB. PCSK9 Variants, Low-Density Lipoprotein Cholesterol, and Neurocognitive Impairment: Reasons for Geographic and Racial Differences in Stroke Study (REGARDS). Circulation 2017; 137:1260-1269. [PMID: 29146683 DOI: 10.1161/circulationaha.117.029785] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite concerns about adverse neurocognitive events raised by prior trials, pharmacological PCSK9 (proprotein convertase subtilisin/kexin type-9) inhibition was not associated with neurocognitive effects in a recent phase 3 randomized trial. PCSK9 loss-of-function (LOF) variants that result in lifelong exposure to lower levels of low-density lipoprotein cholesterol can provide information on the potential long-term effects of lower low-density lipoprotein cholesterol on neurocognitive impairment and decline. METHODS We investigated the association between PCSK9 LOF variants and neurocognitive impairment and decline among black REGARDS study (Reasons for Geographic and Racial Differences in Stroke) participants with (n=241) and without (n=10 454) C697X or Y142X LOF variants. Neurocognitive tests included the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) battery (Word List Learning, World List Delayed Recall, Semantic Animal Fluency) and Six-Item Screener (SIS) assessments, administered longitudinally during follow-up. Neurocognitive impairment was defined as a score ≥1.5 SD below age, sex, and education-based stratum-specific means on 2 or 3 CERAD assessments or, separately, a score <5 on any SIS assessment at baseline or during follow-up. Neurocognitive decline was assessed using standardized continuous scores on individual neurocognitive tests. RESULTS The mean sample age was 64 years (SD, 9), 62% were women, and the prevalence of neurocognitive impairment at any assessment was 6.3% by CERAD and 15.4% by SIS definitions. Adjusted odds ratios for neurocognitive impairment for participants with versus without PCSK9 LOF variants were 1.11 (95% confidence interval [CI], 0.58-2.13) using the CERAD battery and 0.89 (95% CI, 0.61-1.30) using the SIS assessment. Standardized average differences in individual neurocognitive assessment scores over the 5.6-year (range, 0.1-9.1) study period ranged between 0.07 (95% CI, -0.06 to 0.20) and -0.07 (95% CI, -0.18 to 0.05) among participants with versus without PCSK9 LOF variants. Patterns of neurocognitive decline were similar between participants with and without PCSK9 LOF variants (all P>0.10). Odds ratios for neurocognitive impairment per 20 mg/dL low-density lipoprotein cholesterol decrements were 1.02 (95% CI, 0.96-1.08) and 0.99 (95% CI, 0.95-1.02) for the CERAD and SIS definitions of impairment, respectively. CONCLUSIONS These results suggest that lifelong exposure to low PCSK9 levels and cumulative exposure to lower levels of low-density lipoprotein cholesterol are not associated with neurocognitive effects in blacks.
Collapse
Affiliation(s)
- Matthew T Mefford
- Department of Epidemiology (M.T.M., M.R.I., P.M., E.B.L.).,University of Alabama at Birmingham (M.T.M., M.R.I., P.M., E.B.L.)
| | - Robert S Rosenson
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, New York, NY (R.S.R.)
| | - Mary Cushman
- Division of Hematology/Oncology, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington (M.C.)
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Ontario, Canada (M.E.F.)
| | - Leslie A McClure
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, PA (L.A.M.)
| | | | - Marguerite R Irvin
- Department of Epidemiology (M.T.M., M.R.I., P.M., E.B.L.).,University of Alabama at Birmingham (M.T.M., M.R.I., P.M., E.B.L.)
| | | | | | - Ransi Somaratne
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA (R.S., K.L.M.)
| | - Keri L Monda
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA (R.S., K.L.M.)
| | - Paul Muntner
- Department of Epidemiology (M.T.M., M.R.I., P.M., E.B.L.).,University of Alabama at Birmingham (M.T.M., M.R.I., P.M., E.B.L.)
| | - Emily B Levitan
- Department of Epidemiology (M.T.M., M.R.I., P.M., E.B.L.) .,University of Alabama at Birmingham (M.T.M., M.R.I., P.M., E.B.L.)
| |
Collapse
|
33
|
Love DM, Mefford MT, Ramer JC. Validation of the BioPRYN enzyme-linked immunosorbent assay for detection of pregnancy-specific protein-B (PSPB) and diagnosis of pregnancy in American bison (Bison bison). Reprod Domest Anim 2017; 52:791-797. [PMID: 28406529 DOI: 10.1111/rda.12980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/13/2017] [Indexed: 11/30/2022]
Abstract
This study assessed the accuracy of the commercial BioPRYN® ELISA for the detection of pregnancy-specific protein-B (PSPB) using a single blood sample to determine pregnancy status in American bison (Bison bison). A total of 49 bison cows were used in the study, and sampled at two time-points during the gestation period, fall and spring, correlating with early- to mid-term gestation (average 62.9 days post-mating) and mid- to late-term gestation (average 229.2 days post-mating), respectively. Sensitivity of the test during early- to mid-term gestation sampling period (fall) was 87.1%, while specificity was 100%; sensitivity of the test during late-term gestation sampling period (spring) was 96.3%, while specificity remained at 100%. In total, the test showed a total sensitivity of 91.4%, specificity of 100% and total accuracy of 93.8%, similar to domestic cattle. Use of the single-sample BioPRYN® ELISA in American Bison for pregnancy diagnosis is economical and practical, minimizing animal handling time, frequency and subsequent stress while providing accurate results for pregnancy diagnosis at 62 days post-mating. This method should be considered over more traditional pregnancy diagnosis methods for use in managed bison herds.
Collapse
Affiliation(s)
- D M Love
- Department of Conservation Medicine, The Wilds, Cumberland, USA
| | - M T Mefford
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - J C Ramer
- Department of Conservation Medicine, The Wilds, Cumberland, USA
| |
Collapse
|
34
|
Singletary BA, Do AN, Donnelly JP, Huisingh C, Mefford MT, Modi R, Mondesir FL, Ye Y, Owsley C, McGwin G. Self-reported vs state-recorded motor vehicle collisions among older community dwelling individuals. Accid Anal Prev 2017; 101:22-27. [PMID: 28167421 PMCID: PMC5347974 DOI: 10.1016/j.aap.2017.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 01/04/2017] [Accepted: 01/29/2017] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Motor vehicle collisions (MVCs) continue to place an increased burden on both individuals and health care systems. Self-reported and state-recorded police reports are the most common methods for MVC evaluation in epidemiologic studies, with varying degrees of agreement of information when compared in previous studies. The objective of the current study is to address the differences in MVC reporting and provide a more robust measure of the agreement between self-reported and state-recorded MVCs in a community dwelling population of older adults. METHODS A three-year prospective study was conducted in a population-based sample of 2000 licensed drivers aged 70 and older. At annual visits, participants were asked to self-report information on any MVC that occurred over the prior year where police were called to the scene. Information on police-reported MVCs was also ascertained from Alabama official state-recorded databases. The kappa coefficient was calculated to determine overall agreement between any self-reported and state-recorded crashes, as well as the raw number of crashes reported. In addition, agreement was stratified by demographics, health status, medication use, functional status (i.e. vision, cognition), and driving habits. RESULTS 1747 participants who completed three years of follow up were involved in 225 state-recorded MVCs and 208 self-reported MVCs yielding overall substantial agreement between any self-report and state-recorded MVC (kappa=0.64). Cumulative number of self-reported and state-recorded MVCs was also compared, with agreement slightly reduced (kappa=0.55). The clinical characteristic resulting in the greatest variation in agreement with drivers was impaired contrast sensitivity showing better agreement between self-reported and state-recorded MVCs (kappa=0.9) than those with non-impaired contrast sensitivity (kappa=0.6). CONCLUSION Study results showed substantial agreement between self-reported and state-recorded MVCs for any MVC involvement among the study population. When examining the reporting of the total number of MVCs over the three year period, agreement was reduced to a moderate level. There was consistency in agreement across MVC risk factors except among individuals with contrast sensitivity. These findings have implications for the design and analytic planning of epidemiologic and clinical research focused on MVCs.
Collapse
Affiliation(s)
- B A Singletary
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA
| | - A N Do
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA
| | - J P Donnelly
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA
| | - C Huisingh
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA; Department of Ophthalmology, School of Medicine/Eye Foundation Hospital, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA
| | - M T Mefford
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA
| | - R Modi
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA
| | - F L Mondesir
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA
| | - Y Ye
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA
| | - C Owsley
- Department of Ophthalmology, School of Medicine/Eye Foundation Hospital, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA
| | - G McGwin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA; Department of Ophthalmology, School of Medicine/Eye Foundation Hospital, University of Alabama at Birmingham, Birmingham, AL 35294-0009, USA.
| |
Collapse
|