Correlates of physical activity and sedentary behavior among cancer survivors and cancer-free women: The Women's Health Accelerometry Collaboration

BACKGROUND

Describing correlates of physical activity (PA) and sedentary behavior (SB) among postmenopausal cancer survivors can help identify risk profiles and can be used to support development of targeted interventions to improve PA and reduce SB in this population.

OBJECTIVE

To describe PA/SB and identify correlates of PA/SB among cancer and cancer-free post-menopausal women.

METHODS

Women from the Women's Health Study (N = 16,629) and Women's Health Initiative/Objective Physical Activity and Cardiovascular Health Study (N = 6,079) were asked to wear an accelerometer on the hip for 7 days. Multiple mixed-effects linear regression models were used to identify sociodemographic-, health-, and chronic condition-related correlates (independent variables) associated with PA and SB (dependent variables) among women with (n = 2,554) and without (n = 20,154) a history of cancer. All correlates were mutually adjusted for each other.

RESULTS

In unadjusted analyses, women with a history of cancer took fewer mean daily steps (4,572 (standard deviation 2557) vs 5,029 (2679) steps/day) and had lower mean moderate-to-vigorous PA (74.9 (45.0) vs. 81.6 (46.7) minutes/day) than cancer-free women. In adjusted analyses, for cancer and cancer-free women, age, diabetes, overweight, and obesity were inversely associated with all metrics of PA (average vector magnitude, time in moderate-to-vigorous PA, step volume, time at ≥40 steps/minutes, and peak 30-minute step cadence). In unadjusted analyses, mean SB was similar for those with and without cancer (529.7 (98.1) vs. 521.7 (101.2) minutes/day). In adjusted analyses, for cancer and cancer-free women, age, diabetes, cardiovascular disease, current smoking, overweight, and obesity were positive correlates of SB, while Black or Hispanic race/ethnicity, weekly/daily alcohol intake, and excellent/very good/good self-rated health were inverse correlates of SB.

CONCLUSION

Several sociodemographic, health, and chronic conditions were correlates of PA/SB for postmenopausal women with and without cancer. Future studies should examine longitudinal relationships to gain insight into potential determinants of PA/SB.

Outcomes and Costs in Patients with Immune Thrombotic Thrombocytopenic Purpura Receiving Front-Line Versus Delayed Caplacizumab: A US Hospital Database Study

European real-world data indicate that front-line treatment with caplacizumab is associated with improved clinical outcomes compared with delayed caplacizumab treatment. The objective of the study was to describe the characteristics, treatment patterns, and outcomes in hospitalized patients with an immune-mediated thrombotic thrombocytopenic purpura (iTTP) episode treated with front-line versus delayed caplacizumab in the US. This retrospective cohort analysis of a US hospital database included adult patients (≥18 years) with an acute iTTP episode (a diagnosis of thrombotic microangiopathy and ≥1 therapeutic plasma exchange [TPE] procedure) from January 21, 2019, to February 28, 2021. Unadjusted baseline characteristics, treatment patterns, healthcare resource utilization, and costs were compared between patients who received front-line versus delayed (<2 vs ≥2 days after TPE initiation) caplacizumab treatment. Out of 39 patients, 16 (41.0%) received front-line and 23 (59.0%) received delayed treatment with caplacizumab. Baseline characteristics and symptoms were similar between the two groups. Patients who received front-line caplacizumab treatment had significantly fewer TPE administrations (median: 5.0 vs 12.0); and a significantly shorter hospital stay (median: 9.0 days vs 16.0 days) than patients receiving delayed caplacizumab therapy. Both of these were significantly lower in comparison of means (t-test P < .01). Median inpatient costs (inclusive of caplacizumab costs) were 54% higher in the delayed treated patients than in the front-line treated patients (median: $112 711 vs $73 318). TPE-specific cost was lower in the front-line treated cohort (median: $6 989 vs $10 917). In conclusion, front-line treatment with caplacizumab had shorter hospitalizations, lower healthcare resource utilization, and lower costs than delayed caplacizumab treatment after TPE therapy.

The association of Step-based metrics and adiposity in the Hispanic community Health Study/Study of Latinos

OBJECTIVE

Examine cross-sectional and longitudinal associations of accelerometer measured step volume (steps/day) and cadence with adiposity and six-year changes in adiposity in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

METHODS

HCHS/SOL's target population was 60% female with a mean age of 41 years. Cross-sectional (n = 12,353) and longitudinal analyses (n = 9,077) leveraged adjusted complex survey regression models to examine associations between steps/day, and cadence with weight (kg), waist circumference (cm) and body mass index (kg/m2). Effect measure modification by covariates was examined.

RESULTS

Lower steps/day and intensity was associated with higher adiposity at baseline. Compared to those in the highest quartile of steps/day those in the lowest quartile have 1.42 95% CI (1.19, 1.70) times the odds of obesity. Compared to those in the highest categories of cadence step-based metrics, those in the lowest categories had a 1.62 95% CI (1.36, 1.93), 2.12 95% CI (1.63, 2.75) and 1.41 95% CI (1.16, 1.70) odds of obesity for peak 30-minute cadence, brisk walking and faster ambulation and bouts of purposeful steps and faster ambulation, respectively. Compared to those with the highest stepping cadences, those with the slowest peak 30-minute cadence and fewest minutes in bouts of purposeful steps and faster ambulation had 0.72 95% CI (0.57, 0.89) and 0.82 95% CI (0.60, 1.14) times the odds of gaining weight, respectively.

CONCLUSION

Inverse cross-sectional relationships were found for steps/day and cadence and adiposity. Over a six-year period, higher step intensity but not volume was associated with higher odds of gaining weight.

Trends in Medicare Payment Rates for Noninvasive Cardiac Tests and Association With Testing Location

IMPORTANCE

To control spending, the Centers for Medicare & Medicaid Services reduced Medicare fee-for-service (FFS) payments for noninvasive cardiac tests (NCTs) performed in provider-based office settings (ambulatory offices not administratively affiliated with hospitals) starting in 2005. Contemporaneously, payments for hospital-based outpatient testing increased. The association between differential payments by site and test location is unknown.

OBJECTIVES

To quantify trends in differential Medicare FFS payments for NCTs performed in hospital-based and provider-based settings, determine the association between the hospital-based outpatient testing to provider-based office testing payment ratio and the proportion of hospital-based NCTs, and to examine trends in test location between Medicare FFS and 3 Medicare Advantage health maintenance organizations for which Centers for Medicare & Medicaid Services payments do not depend on testing location.

DESIGN, SETTING, AND PARTICIPANTS

This observational claims-based study used Medicare FFS claims from 1999 to 2015 (5% random sample) and Medicare Advantage claims from 3 large health maintenance organizations (2005-2015) among Medicare FFS beneficiaries aged 65 years or older and a health maintenance organization control group. Statistical analysis was performed from May 1, 2017, to July 15, 2019.

EXPOSURES

The weighted mean payment ratio of Medicare FFS hospital-based outpatient testing to provider-based office testing for outpatient NCTs.

MAIN OUTCOMES AND MEASURES

Proportion of outpatient NCTs performed in the hospital-based setting and Medicare FFS costs.

RESULTS

The data included a mean of 1.72 million patient-years annually in Medicare FFS (mean age, 75.2 years; 57.3% female in 2015) and a mean of 142 230 patient-years annually in the managed care control group (mean age, 74.8 years; 56.2% female in 2015). The Medicare payment ratio of FFS hospital-based outpatient testing to provider-based office testing increased from 1.05 in 2005 to 2.32 in 2015. The FFS hospital-based outpatient testing proportion increased from 21.1% in 2008 to 43.2% in 2015 and was correlated with the payment ratio (correlation coefficient with a 1-year lag, 0.767; P < .001). In contrast, the hospital-based outpatient testing proportion for the control group declined from 16.6% in 2008 to 15.2% in 2015 (correlation coefficient, -0.024, P = .95). The estimated extra costs owing to tests shifting to the hospital-based outpatient setting in the Medicare FFS group was $661 million in 2015, including $161 million in patient out-of-pocket costs.

CONCLUSIONS AND RELEVANCE

In settings in which reimbursement depends on test location, increasing hospital-based payments correlated with greater proportions of outpatient NCTs performed in the hospital-based outpatient setting. Site-neutral payments may offer an incentive for testing to be performed in the more efficient location.

Association of Medical Liability Reform With Clinician Approach to Coronary Artery Disease Management

Importance

Physicians often report practicing defensive medicine to reduce malpractice risk, including performing expensive but marginally beneficial tests and procedures. Although there is little evidence that malpractice reform affects overall health care spending, it may influence physician behavior for specific conditions involving clinical uncertainty.

Objective

To examine whether reducing malpractice risk is associated with clinical decisions involving coronary artery disease testing and treatment.

Design, Setting, and Participants

Difference-in-differences design, comparing physician-specific changes in coronary artery disease testing and treatment in 9 new-cap states that adopted damage caps between 2003 and 2005 with 20 states without caps. We used the 5% national Medicare fee-for-service random sample between 1999 and 2013. Physicians (n = 75 801; 36 647 in new-cap states) who ordered or performed 2 or more coronary angiographies. Data were analyzed from June 2015 to January 2018.

Main Outcomes and Measures

Changes in ischemic evaluation rates for possible coronary artery disease, type of initial evaluation (stress testing or coronary angiography), progression from stress test to angiography, and progression from ischemic evaluation to revascularization (percutaneous coronary intervention or coronary artery bypass grafting).

Results

We studied 36 647 physicians in new-cap states and 39 154 physicians in no-cap states. New-cap states had younger populations, more minorities, lower per-capita incomes, fewer physicians per capita, and lower managed care penetration. Following cap adoption, new-cap physicians reduced invasive testing (angiography) as a first diagnostic test compared with control physicians (relative change, -24%; 95% CI, -40% to -7%; P = .005) with an offsetting increase in noninvasive stress testing (7.8%; 95% CI, -3.6% to 19.3%; P = .17), and referred fewer patients for angiography following stress testing (-21%; 95% CI, -40% to -2%; P = .03). New-cap physicians also reduced revascularization rates after ischemic evaluation (-23%; 95% CI, -40% to -4%; P = .02; driven by fewer percutaneous coronary interventions). Changes in overall ischemic evaluation rates were similar for new-cap and control physicians (-0.05%; 95% CI, -8.0% to 7.9%; P = .98).

Conclusions and Relevance

Physicians substantially altered their approach to coronary artery disease testing and follow-up after initial ischemic evaluations following adoption of damage caps. They performed a similar number of ischemic evaluations but conducted fewer initial left heart catheterizations, referred fewer stress-tested patients for left heart catheterizations, and referred fewer patients for revascularization. These findings suggest that physicians tolerate greater clinical uncertainty in coronary artery disease testing and treatment if they face lower malpractice risk.

The Association of Sport and Exercise Activities With Cardiovascular Disease Risk: The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

This study assessed the independent associations between participation in self-reported sport and exercise activities and incident cardiovascular disease (CVD).

METHODS

Data were from 13,204 participants in the Atherosclerosis Risk in Communities Study cohort (1987-2015). Baseline sport and exercise activities were assessed via the modified Baecke questionnaire. Incident CVD included coronary heart disease, heart failure, or stroke. Multivariable-adjusted Cox proportional hazard models assessed the association of participation in specific sport and exercise activities at enrollment with risk of CVD.

RESULTS

During a median follow-up time of 25.2 years, 30% of the analytic sample (n = 3966) was diagnosed with incident CVD. In fully adjusted models, participation in racquet sports (hazard ratio [HR] 0.75; 95% confidence interval [CI], 0.61-0.93), aerobics (HR 0.75; 95% CI, 0.63-0.88), running (HR 0.68; 95% CI, 0.54-0.85), and walking (HR 0.89; 95% CI, 0.83-0.95) was significantly associated with a lower risk of CVD. There were no significant associations for bicycling, softball/baseball, gymnastics, swimming, basketball, calisthenics exercises, golfing with cart, golfing with walking, bowling, or weight training.

CONCLUSIONS

Participation in specific sport and exercises may substantially reduce the risk for CVD.

The double burden of malnutrition among adolescents: analysis of data from the Global School-Based Student Health and Health Behavior in School-Aged Children surveys in 57 low- and middle-income countries

Background

Adults and young children in countries experiencing the nutrition transition are known to be affected simultaneously by undernutrition and overnutrition. Adolescence is a critical period for growth and development. Yet, it is unknown to what extent this double burden of malnutrition affects adolescents in low- and middle-income countries (LMICs) and the macrolevel contextual factors associated with the double burden of malnutrition.

Objective

The aim was to quantify the magnitude of the double burden of malnutrition among adolescents and to examine the potential sources of heterogeneity in prevalence estimates across LMICs.

Design

We used individual-participant data from the Global School-Based Student Health and Health Behavior in School-Aged Children surveys conducted in 57 LMICs between 2003 and 2013, comprising 129,276 adolescents aged 12-15 y. Pooled estimates of stunting, thinness, or both; overweight or obesity; and concurrent stunting and overweight or obesity were calculated overall, by regions, and stratified by sex, with random-effects meta-analysis. Guided by UNICEF's conceptual framework for child malnutrition, we used ecological linear regression models to examine the association between macrolevel contextual factors (internal conflict, lack of democracy, gross domestic product, food insecurity, urbanization, and survey year) and stunting, thinness, and overweight and obesity prevalence, respectively.

Results

The prevalence of stunting was 10.2% (95% CI: 8.3%, 12.2%) and of thinness was 5.5% (95% CI: 4.3%, 6.9%). The prevalence of overweight or obesity was 21.4% (95% CI: 18.6%, 24.2%). Between 38.4% and 58.7% of the variance in adolescent malnutrition was explained by macrolevel contextual factors. The prevalence of concurrent stunting and overweight or obesity was 2.0% (95% CI: 1.7%, 2.5%).

Conclusions

The double burden of malnutrition among adolescents in LMICs is common. Context-sensitive implementation and scale-up of interventions and policies for the double burden of malnutrition are needed to achieve the Sustainable Development Goal to end malnutrition in all of its forms by 2030. This trial was registered at clinicaltrials.gov as NCT03346473.