Population-average mediation analysis for zero-inflated count outcomes

Mediation analysis is an increasingly popular statistical method for explaining causal pathways to inform intervention. While methods have increased, there is still a dearth of robust mediation methods for count outcomes with excess zeroes. Current mediation methods addressing this issue are computationally intensive, biased, or challenging to interpret. To overcome these limitations, we propose a new mediation methodology for zero-inflated count outcomes using the marginalized zero-inflated Poisson (MZIP) model and the counterfactual approach to mediation. This novel work gives population-average mediation effects whose variance can be estimated rapidly via delta method. This methodology is extended to cases with exposure-mediator interactions. We apply this novel methodology to explore if diabetes diagnosis can explain BMI differences in healthcare utilization and test model performance via simulations comparing the proposed MZIP method to existing zero-inflated and Poisson methods. We find that our proposed method minimizes bias and computation time compared to alternative approaches while allowing for straight-forward interpretations.

Regional and rural-urban patterns in the prevalence of diagnosed hypertension among older U.S. adults with diabetes, 2005-2017

BACKGROUND

Hypertension prevalence among the overall US adult population has been relatively stable during the last two decades. However, whether this stabilization has occurred across rural-urban communities and across different geographic regions is unknown, particularly among older adults with diabetes who are likely to have concomitant cardiovascular risk factors.

METHODS

This serial cross-sectional analysis used the 5% national sample of Medicare administrative claims data (n = 3,516,541) to examine temporal trends (2005-2017) in diagnosed hypertension among older adults with diabetes, across urban-rural communities and US census regions (Northeast, Midwest, South, and West). Joinpoint regression was used to obtain annual percent change (APC) in hypertension prevalence across rural-urban communities and geographic regions, and multivariable adjusted regression was used to assess associations between rural-urban communities and hypertension prevalence.

RESULTS

The APC in the prevalence of hypertension was higher during 2005-2010, and there was a slowdown in the increase during 2011-2017 across all regions, with significant variations across rural-urban communities within each of the regions. In the regression analysis, in the adjusted model, older adults living in non-core (most rural) areas in the Midwest (PR = 0.988, 95% CI: 0.981-0.995) and West (PR = 0.935, 95% CI: 0.923-0.946) had lower hypertension prevalence than their regional counterparts living in large central metro areas.

CONCLUSIONS

Although the magnitudes of these associations are small, differences in hypertension prevalence across rural-urban areas and geographic regions may have implications for targeted interventions to improve chronic disease prevention and management.

Why location matters: Associations between county-level characteristics and availability of NCORP and NCI sites

BACKGROUND

The majority of patients with cancer seek care at community oncology sites; however, most clinical trials are available at National Cancer Institute (NCI)-designated sites. While the NCI National Cancer Oncology Research Program (NCORP) was designed to address this problem, little is known about the county-level characteristics of NCORP site locations.

METHODS

This cross-sectional analysis determined the association between availability of NCORP or NCI sites and county-level characteristic theme percentile scores from the CDC's Social Vulnerability Index themes. Health Resources and Services Administration's Area Health Resource Files were used to determine contiguous counties. We estimated risk ratios and 95% confidence intervals (CI) using modified Poisson regression models to evaluate the association between county-level characteristics and site availability within singular and singular & contiguous counties.

RESULTS

Of 3141 included counties, 14% had an NCORP, 2% had an NCI, and 1% had both sites. Among singular counties, for a standard deviation (SD) increase in the racial and ethnic theme score there was a 22% higher likelihood of NCORP site availability (95% CI 1.10-1.36); for a SD increase in the socioeconomic status theme score there was a 24% lower likelihood of NCORP site availability (95% CI 0.67-0.87). Associations were of smaller magnitude when including contiguous counties. NCI sites were located in more vulnerable counties.

CONCLUSION(S)

NCORP sites were more often in racially diverse counties, and less often in socioeconomically vulnerable counties. Research is needed to understand how clinical trial representation will increase if NCORP sites strategically increase their locations in more vulnerable counties.

Cardiovascular Burden of the V142I Transthyretin Variant

Importance

Individual cohort studies concur that the amyloidogenic V142I variant of the transthyretin (TTR) gene, present in 3% to 4% of US Black individuals, increases heart failure (HF) and mortality risk. Precisely defining carrier risk across relevant clinical outcomes and estimating population burden of disease are important given established and emerging targeted treatments.

Objectives

To better define the natural history of disease in carriers across mid to late life, assess variant modifiers, and estimate cardiovascular burden to the US population.

Design, Setting, and Participants

A total of 23 338 self-reported Black participants initially free from HF were included in 4 large observational studies across the US (mean [SD], 15.5 [8.2] years of follow-up). Data analysis was performed between May 2023 and February 2024.

Exposure

V142I carrier status (n = 754, 3.2%).

Main Outcomes and Measures

Hospitalizations for HF (including subtypes of reduced and preserved ejection fraction) and all-cause mortality. Outcomes were analyzed by generating 10-year hazard ratios for each age between 50 and 90 years. Using actuarial methods, mean survival by carrier status was estimated and applied to the 2022 US population using US Census data.

Results

Among the 23 338 participants, the mean (SD) age at baseline was 62 (9) years and 76.7% were women. Ten-year carrier risk increased for HF hospitalization by age 63 years, predominantly driven by HF with reduced ejection fraction, and 10-year all-cause mortality risk increased by age 72 years. Only age (but not sex or other select variables) modified risk with the variant, with estimated reductions in longevity ranging from 1.9 years (95% CI, 0.6-3.1) at age 50 to 2.8 years (95% CI, 2.0-3.6) at age 81. Based on these data, 435 851 estimated US Black carriers between ages 50 and 95 years are projected to cumulatively lose 957 505 years of life (95% CI, 534 475-1 380 535) due to the variant.

Conclusions and Relevance

Among self-reported Black individuals, male and female V142I carriers faced similar and substantial risk for HF hospitalization, predominantly with reduced ejection fraction, and death, with steep age-dependent penetrance. Delineating the individual contributions of, and complex interplay among, the V142I variant, ancestry, the social construct of race, and biological or social determinants of health to cardiovascular disease merits further investigation.

Development and validation of mortality prediction models based on the social determinants of health

BACKGROUND

There is no standardised approach to screening adults for social risk factors. The goal of this study was to develop mortality risk prediction models based on the social determinants of health (SDoH) for clinical risk stratification.

METHODS

Data were used from REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based, longitudinal cohort of black and white Americans aged ≥45 recruited between 2003 and 2007. Analysis was limited to participants with available SDoH and mortality data (n=20 843). All-cause mortality, available through 31 December 2018, was modelled using Cox proportional hazards with baseline individual, area-level and business-level SDoH as predictors. The area-level Social Vulnerability Index (SVI) was included for comparison. All models were adjusted for age, sex and sampling region and underwent internal split-sample validation.

RESULTS

The baseline prediction model including only age, sex and REGARDS sampling region had a c-statistic of 0.699. An individual-level SDoH model (Model 1) had a higher c-statistic than the SVI (0.723 vs 0.708, p<0.001) in the testing set. Sequentially adding area-level SDoH (c-statistic 0.723) and business-level SDoH (c-statistics 0.723) to Model 1 had minimal improvement in model discrimination. Structural racism variables were associated with all-cause mortality for black participants but did not improve model discrimination compared with Model 1 (p=0.175).

CONCLUSION

In conclusion, SDoH can improve mortality prediction over 10 years relative to a baseline model and have the potential to identify high-risk patients for further evaluation or intervention if validated externally.

Impact of Chronic HIV Infection on Acute Immune Responses to SARS-CoV-2

ABSTRACT

There is mounting evidence that HIV infection is a risk factor for severe presentations of COVID-19. We hypothesized that the persistent immune activation associated with chronic HIV infection contributes to worsened outcomes during acute COVID-19. The goals of this study were to provide an in-depth analysis of immune response to acute COVID-19 and investigate relationships between immune responses and clinical outcomes in an unvaccinated, sex- and race-matched cohort of people with HIV (PWH, n = 20) and people without HIV (PWOH, n = 41). We performed flow cytometric analyses on peripheral blood mononuclear cells from PWH and PWOH experiencing acute COVID-19 (≤21-day postsymptom onset). PWH were younger (median 52 vs 65 years) and had milder COVID-19 (40% vs 88% hospitalized) compared with PWOH. Flow cytometry panels included surface markers for immune cell populations, activation and exhaustion surface markers (with and without SARS-CoV-2-specific antigen stimulation), and intracellular cytokine staining. We observed that PWH had increased expression of activation (eg, CD137 and OX40) and exhaustion (eg, PD1 and TIGIT) markers as compared to PWOH during acute COVID-19. When analyzing the impact of COVID-19 severity, we found that hospitalized PWH had lower nonclassical (CD16 + ) monocyte frequencies, decreased expression of TIM3 on CD4 + T cells, and increased expression of PDL1 and CD69 on CD8 + T cells. Our findings demonstrate that PWH have increased immune activation and exhaustion as compared to a cohort of predominately older, hospitalized PWOH and raises questions on how chronic immune activation affects acute disease and the development of postacute sequelae.

Characteristics and determinants of pulmonary long COVID

BACKGROUNDPersistent cough and dyspnea are prominent features of postacute sequelae of SARS-CoV-2 (also termed "long COVID"); however, physiologic measures and clinical features associated with these pulmonary symptoms remain poorly defined. Using longitudinal pulmonary function testing (PFT) and CT imaging, this study aimed to identify the characteristics and determinants of pulmonary long COVID.METHODSThis single-center retrospective study included 1,097 patients with clinically defined long COVID characterized by persistent pulmonary symptoms (dyspnea, cough, and chest discomfort) lasting for 1 or more months after resolution of primary COVID infection.RESULTSAfter exclusion, a total of 929 patients with post-COVID pulmonary symptoms and PFTs were stratified as diffusion impairment and pulmonary restriction, as measured by percentage predicted diffusion capacity for carbon monoxide (DLCO) and total lung capacity (TLC). Longitudinal evaluation revealed diffusion impairment (DLCO ≤ 80%) and pulmonary restriction (TLC ≤ 80%) in 51% of the cohort overall (n = 479). In multivariable modeling regression analysis, invasive mechanical ventilation during primary infection conferred the greatest increased odds of developing pulmonary long COVID with diffusion impairment and restriction (adjusted odds ratio [aOR] = 9.89, 95% CI 3.62-26.9]). Finally, a subanalysis of CT imaging identified radiographic evidence of fibrosis in this patient population.CONCLUSIONLongitudinal PFTs revealed persistent diffusion-impaired restriction as a key feature of pulmonary long COVID. These results emphasize the importance of incorporating PFTs into routine clinical practice for evaluation of long COVID patients with prolonged pulmonary symptoms. Subsequent clinical trials should leverage combined symptomatic and quantitative PFT measurements for more targeted enrollment of pulmonary long COVID patients.FUNDINGNational Institute of Allergy and Infectious Diseases (AI156898, K08AI129705), National Heart, Lung, and Blood Institute (HL153113, OTA21-015E, HL149944), and the COVID-19 Urgent Research Response Fund at the University of Alabama at Birmingham.

Cardiometabolic Disease Staging and Major Adverse Cardiovascular Event Prediction in 2 Prospective Cohorts

BACKGROUND

Cardiometabolic risk prediction models that incorporate metabolic syndrome traits to predict cardiovascular outcomes may help identify high-risk populations early in the progression of cardiometabolic disease.

OBJECTIVES

The purpose of this study was to examine whether a modified cardiometabolic disease staging (CMDS) system, a validated diabetes prediction model, predicts major adverse cardiovascular events (MACE).

METHODS

We developed a predictive model using data accessible in clinical practice [fasting glucose, blood pressure, body mass index, cholesterol, triglycerides, smoking status, diabetes status, hypertension medication use] from the REGARDS (REasons for Geographic And Racial Differences in Stroke) study to predict MACE [cardiovascular death, nonfatal myocardial infarction, and/or nonfatal stroke]. Predictive performance was assessed using receiver operating characteristic curves, mean squared errors, misclassification, and area under the curve (AUC) statistics.

RESULTS

Among 20,234 REGARDS participants with no history of stroke or myocardial infarction (mean age 64 ± 9.3 years, 58% female, 41% non-Hispanic Black, and 18% diabetes), 2,695 developed incident MACE (13.3%) during a median 10-year follow-up. The CMDS development model in REGARDS for MACE had an AUC of 0.721. Our CMDS model performed similarly to both the ACC/AHA 10-year risk estimate (AUC 0.721 vs 0.716) and the Framingham risk score (AUC 0.673).

CONCLUSIONS

The CMDS predicted the onset of MACE with good predictive ability and performed similarly or better than 2 commonly known cardiovascular disease prediction risk tools. These data underscore the importance of insulin resistance as a cardiovascular disease risk factor and that CMDS can be used to identify individuals at high risk for progression to cardiovascular disease.

Comparative Discrimination of Life's Simple 7 and Life's Essential 8 to Stratify Cardiovascular Risk: Is the Added Complexity Worth It?

BACKGROUND

Life's Simple 7 (LS7) is an easily calculated and interpreted metric of cardiovascular health based on 7 domains: smoking, diet, physical activity, body mass index, blood pressure, cholesterol, and fasting glucose. The Life's Essential 8 (LE8) metric was subsequently introduced, adding sleep metrics and revisions of the previous 7 domains. Although calculating LE8 requires additional information, we hypothesized that it would be a more reliable index of cardiovascular health.

METHODS

Both the LS7 and LE8 metrics yield scores with higher values indicating lower risk. These were calculated among 11 609 Black and White participants free of baseline cardiovascular disease (CVD) in the Reasons for Geographic and Racial Differences in Stroke study, enrolled in 2003 to 2007, and followed for a median of 13 years. Differences in 10-year risk of incident CVD (coronary heart disease or stroke) were calculated as a function LS7, and LE8 scores were calculated using Kaplan-Meier and proportional hazards analyses. Differences in incident CVD discrimination were quantified by difference in the c-statistic.

RESULTS

For both LS7 and LE8, the 10-year risk was approximately 5% for participants around the 99th percentile of scores, and a 4× higher 20% risk for participants around the first percentile. Comparing LS7 to LE8, 10-year risk was nearly identical for individuals at the same relative position in score distribution. For example, the "cluster" of 2013 participants with an LS7 score of 7 was at the 35.8th percentile in distribution of LS7 scores, and had an estimated 10-year CVD risk of 8.4% (95% CI, 7.2%-9.8%). In a similar location in the LE8 distribution, the 1457 participants with an LE8 score of 60±2.5 at the 39.4th percentile of LE8 scores had a 10-year risk of CVD of 8.5% (95% CI, 7.1%-10.1%), similar to the cluster defined by LS7. The age-race-sex adjusted c-statistic of the LS7 model was 0.691 (95% CI, 0.667-0.705), and 0.695 for LE8 (95% CI, 0.681-0.709) (P for difference, 0.12).

CONCLUSIONS

Both LS7 and LE8 were associated with incident CVD, with discrimination of the 2 indices practically indistinguishable. As a simpler metric, LS7 may be favored for use by the general population and clinicians.

Association Between Pharmacy Proximity With Cardiovascular Medication Use and Risk Factor Control in the United States

BACKGROUND

Poor neighborhood-level access to health care, including community pharmacies, contributes to cardiovascular disparities in the United States. The authors quantified the association between pharmacy proximity, antihypertensive and statin use, and blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) among a large, diverse US cohort.

METHODS AND RESULTS

A cross-sectional analysis of Black and White participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study during 2013 to 2016 was conducted. The authors designated pharmacy proximity by census tract using road network analysis with population-weighted centroids within a 10-minute drive time, with 5- and 20-minute sensitivity analyses. Pill bottle review measured medication use, and BP and LDL-C were assessed using standard methods. Poisson regression was used to quantify the association between pharmacy proximity with medication use and BP control, and linear regression for LDL-C. Among 16 150 REGARDS participants between 2013 and 2016, 8319 (51.5%) and 8569 (53.1%) had an indication for antihypertensive and statin medication, respectively, and pharmacy proximity data. The authors did not find a consistent association between living in a census tract with higher pharmacy proximity and antihypertensive medication use, BP control, or statin medication use and LDL-C levels, regardless of whether the area was rural, suburban, or urban. Results were similar among the 5- and 20-minute drive-time analyses.

CONCLUSIONS

Living in a low pharmacy proximity census tract may be associated with antihypertensive and statin medication use, or with BP control and LDL-C levels. Although, in this US cohort, outcomes were similar for adults living in high or low pharmacy proximity census tracts.

Atherosclerotic cardiovascular disease events among adults with high predicted risk without established risk factors

Objective

Age is the strongest contributor to 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk. Some older adults have a predicted ASCVD risk ≥7.5 %, without established risk factors. We sought to compare ASCVD incidence among adults with predicted ASCVD risk ≥7.5 %, with and without established ASCVD risk factors, to adults with predicted risk <7.5 %.

Methods

We analyzed data from REasons for Geographic and Racial Differences in Stroke study participants, 45-79 years old, without ASCVD or diabetes, not taking statins and with low-density lipoprotein cholesterol 70-189 mg/dL. Participants were categorized into 3 groups based on their 10-year predicted ASCVD risk and presence of established risk factors: <7.5 %, ≥7.5 % with established risk factors and ≥7.5 % without established risk factors. Established risk factors included smoking, systolic blood pressure ≥130 mmHg or antihypertensive medication use, total cholesterol ≥200 mg/dL, or high-density lipoprotein cholesterol <50 mg/dL for women (<40 mg/dL for men). Participants were followed for ASCVD events.

Results

Among 11,115 participants, 911 incident ASCVD events occurred over a median of 11.1 years. ASCVD incidence rates were 3.6, 12.8, and 9.8 per 1,000 person-years for participants with predicted risk <7.5 %, predicted risk ≥7.5 % with established risk factors and predicted risk ≥7.5 % without established risk factors, respectively. Compared to adults with predicted risk <7.5 %, hazard ratios for incident ASCVD in participants with risk ≥7.5 % with and without established risk factors were 3.58 (95 %CI 3.03 - 4.21) and 2.72 (95 %CI 1.91-3.88), respectively.

Conclusions

Adults with a 10-year predicted ASCVD risk ≥7.5 % but without established risk factors had a high ASCVD incidence.

Neighborhood Disadvantage and Risk of Heart Failure: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

Heart failure (HF) affects >6 million US adults, with recent increases in HF hospitalizations. We aimed to investigate the association between neighborhood disadvantage and incident HF events and potential differences by diabetes status.

METHODS

We included 23 645 participants from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), a prospective cohort of Black and White adults aged ≥45 years living in the continental United States (baseline 2005-2007). Neighborhood disadvantage was assessed using a Z score of 6 census tract variables (2000 US Census) and categorized as quartiles. Incident HF hospitalizations or HF-related deaths through 2017 were adjudicated. Multivariable-adjusted Cox regression was used to examine the association between neighborhood disadvantage and incident HF. Heterogeneity by diabetes was assessed using an interaction term.

RESULTS

The mean age was 64.4 years, 39.5% were Black adults, 54.9% females, and 18.8% had diabetes. During a median follow-up of 10.7 years, there were 1125 incident HF events with an incidence rate of 3.3 (quartile 1), 4.7 (quartile 2), 5.2 (quartile 3), and 6.0 (quartile 4) per 1000 person-years. Compared to adults living in the most advantaged neighborhoods (quartile 1), those living in neighborhoods in quartiles 2, 3, and 4 (most disadvantaged) had 1.30 (95% CI, 1.06-1.60), 1.36 (95% CI, 1.11-1.66), and 1.45 (95% CI, 1.18-1.79) times greater hazard of incident HF even after accounting for known confounders. This association did not significantly differ by diabetes status (interaction P=0.59). For adults with diabetes, the adjusted incident HF hazards comparing those in quartile 4 versus quartile 1 was 1.34 (95% CI, 0.92-1.96), and it was 1.50 (95% CI, 1.16-1.94) for adults without diabetes.

CONCLUSIONS

In this large contemporaneous prospective cohort, neighborhood disadvantage was associated with an increased risk of incident HF events. This increase in HF risk did not differ by diabetes status. Addressing social, economic, and structural factors at the neighborhood level may impact HF prevention.

Characteristics and Determinants of Pulmonary Long COVID

RATIONALE

Persistent cough and dyspnea are prominent features of post-acute sequelae of SARS-CoV-2 (termed 'Long COVID'); however, physiologic measures and clinical features associated with these pulmonary symptoms remain poorly defined.

OBJECTIVES

Using longitudinal pulmonary function testing (PFTs) and CT imaging, this study aimed to identify the characteristics and determinants of pulmonary Long COVID.

METHODS

The University of Alabama at Birmingham Pulmonary Long COVID cohort was utilized to characterize lung defects in patients with persistent pulmonary symptoms after resolution primary COVID infection. Longitudinal PFTs including total lung capacity (TLC) and diffusion limitation of carbon monoxide (DLCO) were used to evaluate restriction and diffusion impairment over time in this cohort. Analysis of chest CT imaging was used to phenotype the pulmonary Long COVID pathology. Risk factors linked to development of pulmonary Long COVID were estimated using univariate and multivariate logistic regression models.

MEASUREMENTS AND MAIN RESULTS

Longitudinal evaluation 929 patients with post-COVID pulmonary symptoms revealed diffusion impairment (DLCO ≤80%) and restriction (TLC ≤80%) in 51% of the cohort (n=479). In multivariable logistic regression analysis (adjusted odds ratio; aOR, 95% confidence interval [CI]), invasive mechanical ventilation during primary infection conferred the greatest increased odds of developing pulmonary Long COVID with diffusion impaired restriction (aOR=10.9 [4.09-28.6]). Finally, a sub-analysis of CT imaging identified evidence of fibrosis in this population.

CONCLUSIONS

Persistent diffusion impaired restriction was identified as a key feature of pulmonary Long COVID. Subsequent clinical trials should leverage combined symptomatic and quantitative PFT measurements for more targeted enrollment of pulmonary Long COVID patients.

Application of marginalized zero-inflated models when mediators have excess zeroes

Mediation analysis has become increasingly popular over the last decade as researchers are interested in assessing mechanistic pathways for intervention. Although available methods have increased, there are still limited options for mediation analysis with zero-inflated count variables where the distribution of response has a "cluster" of data at the zero value (i.e. distribution of number of cigarettes smoked per day, where nonsmokers cluster at zero cigarettes). The currently available methods do not obtain unbiased population average effects of mediation effects. In this paper, we propose an extension of the counterfactual approach to mediation with direct and indirect effects to scenarios where the mediator is a count variable with excess zeroes by utilizing the Marginalized Zero-Inflated Poisson Model (MZIP) for the mediator model. We derive direct and indirect effects for continuous, binary, and count outcomes, as well as adapt to allow mediator-exposure interactions. Our proposed work allows straightforward calculation of direct and indirect effects for the overall population mean values of the mediator, for scenarios in which researchers are interested in generalizing direct and indirect effects to the population. We apply this novel methodology to an application observing how alcohol consumption may explain sex differences in cholesterol and assess model performance via a simulation study comparing the proposed MZIP mediator framework to existing methods for marginal mediator effects.

Treatment Location Variation for Chronic Limb-Threatening Ischemia in Patients With Kidney Failure

INTRODUCTION

End-stage kidney disease (ESKD) is an established risk factor for chronic limb-threatening ischemia (CLTI). Procedural location for ESKD patients has not been well described. This study aims to examine variation in index procedural location in ESKD versus non-ESKD patients undergoing peripheral vascular intervention for CLTI and identify preoperative risk factors for tibial interventions.

METHODS

Chronic limb-threatening ischemia (CLTI) patients were identified in the Vascular Quality Initiative (VQI) peripheral vascular intervention dataset. Patient demographics and comorbidities were compared between patients with and without ESKD and those undergoing index tibial versus nontibial interventions. A multivariable logistic regression evaluating risk factors for tibial intervention was conducted.

RESULTS

A total of 23,480 procedures were performed on CLTI patients with 13.6% (n = 3154) with ESKD. End-stage kidney disease (ESKD) patients were younger (66.56 ± 11.68 versus 71.66 ± 12.09 y old, P = 0.019), more often Black (40.6 versus 18.6%, P < 0.001), male (61.2 versus 56.5%, P < 0.001), and diabetic (81.8 versus 60.0%, P < 0.001) than non-ESKD patients. Patients undergoing index tibial interventions had higher rates of ESKD (19.4 versus 10.6%, P < 0.001) and diabetes (73.4 versus 57.5%, P < 0.001) and lower rates of smoking (49.9 versus 73.0%, P < 0.001) than patients with nontibial interventions. ESKD (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.52-1.86, P < 0.001), Black race (OR 1.19, 95% CI 1.09-1.30, P < 0.001), and diabetes (OR 1.82, 95% CI 1.71-2.00, P < 0.001) were risk factors for tibial intervention.

CONCLUSIONS

Patients with ESKD and CLTI have higher rates of diabetes and tibial disease and lower rates of smoking than non-ESKD patients. Tibial disease was associated with ESKD, diabetes, and Black race.

Disparities in Hypertension Prevalence, Awareness, Treatment, and Control Among Women Living With and Without HIV in the US South

Background

Hypertension-related diseases are major causes of morbidity among women living with HIV. We evaluated cross-sectional associations of race/ethnicity and HIV infection with hypertension prevalence, awareness, treatment, and control.

Methods

Among women recruited into Southern sites of the Women's Interagency HIV Study (2013-2015), hypertension was defined as (1) systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg according to clinical guidelines when data were collected, (2) self-report of hypertension, or (3) use of antihypertensive medication. Awareness was defined as self-report of hypertension, and treatment was self-report of any antihypertensive medication use. Blood pressure control was defined as <140/90 mm Hg at baseline. Prevalence ratios for each hypertension outcome were estimated through Poisson regression models with robust variance estimators adjusted for sociodemographic, behavioral, and clinical risk factors.

Results

Among 712 women, 56% had hypertension and 83% were aware of their diagnosis. Of those aware, 83% were using antihypertensive medication, and 63% of those treated had controlled hypertension. In adjusted analyses, non-Hispanic White and Hispanic women had 31% and 48% lower prevalence of hypertension than non-Hispanic Black women, respectively. Women living with HIV who had hypertension were 19% (P = .04) more likely to be taking antihypertension medication when compared with women living without HIV.

Conclusions

In this study population of women living with and without HIV in the US South, the prevalence of hypertension was lowest among Hispanic women and highest among non-Hispanic Black women. Despite similar hypertension prevalence, women living with HIV were more likely to be taking antihypertensive medication when compared with women living without HIV.

Patient-level factors associated with hemoglobin A1C testing in Alabama Medicaid beneficiaries with diabetes

AIM

We evaluated patient-level factors associated with receipt of hemoglobin A1c (HbA1c) testing among Alabama Medicaid beneficiaries with type 2 diabetes.

METHODS

We conducted a retrospective analysis of person-year observations from Medicaid claims data from 2011 to 2020. Adults aged 19-64 years with type 2 diabetes and continuous enrollment in Medicaid for study year and year prior were included. Primary outcomes were ≥ 1 and ≥ 2 HbA1c test(s) per year. We conducted multivariable Poisson regression stratified by Medicaid eligibility reason (disability, poverty) examining the association of study year, demographics, clinical factors, and healthcare utilization with HbA1c testing.

RESULTS

We analyzed 288,379 observations, 51% with disability-based, 49% poverty-based eligibility. Overall, 57% observations had ≥ 1 HbA1c, 35% had ≥ 2 HbA1c tests. More observations with disability-based than poverty-based eligibility had ≥ 1 (76% vs. 38%) and ≥ 2 HbA1c tests (49% vs. 20%). Patient-level factors were associated with a higher likelihood of having ≥ 1 HbA1c: Black race and older age (disability-based eligibility); year after 2011, female sex, and younger age (poverty-based eligibility); and rurality, insulin use, endocrinology care, diabetes complications, and ambulatory care visits (both groups).

CONCLUSIONS

Just over one-third of adult Alabama Medicaid beneficiaries with diabetes had ≥ 2 HbA1c tests per year; testing frequency differed by Medicaid eligibility.

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Importance

Involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF.

Objective

To determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF.

Design, Setting, and Participants

This retrospective cohort study used data from the Reasons for Geographic and Racial Difference in Stroke (REGARDS) cohort. Participants included adults who experienced an adjudicated hospitalization for HF between 2009 and 2017 in all 48 contiguous states in the US. Data analysis was performed from November 2022 to January 2023.

Exposures

A total of 9 candidate SDOH, aligned with the Healthy People 2030 conceptual model, were examined: Black race, social isolation, social network and/or caregiver availability, educational attainment less than high school, annual household income less than $35 000, living in rural area, living in a zip code with high poverty, living in a Health Professional Shortage Area, and living in a state with poor public health infrastructure.

Main Outcomes and Measures

The primary outcome was cardiologist involvement, defined as involvement of a cardiologist as the primary responsible clinician or as a consultant. Bivariate associations between each SDOH and cardiologist involvement were examined using Poisson regression with robust SEs.

Results

The study included 1000 participants (median [IQR] age, 77.8 [71.5-84.0] years; 479 women [47.9%]; 414 Black individuals [41.4%]; and 492 of 876 with low income [56.2%]) hospitalized at 549 unique US hospitals. Low annual household income (<$35 000) was the only SDOH with a statistically significant association with cardiologist involvement (relative risk, 0.88; 95% CI, 0.82-0.95). In a multivariable analysis adjusting for age, race, sex, HF characteristics, comorbidities, and hospital characteristics, low income remained inversely associated with cardiologist involvement (relative risk, 0.89; 95% CI, 0.82-0.97).

Conclusions and Relevance

This cohort study found that adults with low household income were 11% less likely than adults with higher incomes to have a cardiologist involved in their care during a hospitalization for HF. These findings suggest that socioeconomic status may bias the care provided to patients hospitalized for HF.

Myocardial infarction and physical function: the REasons for Geographic And Racial Differences in Stroke prospective cohort study

Objective

To examine associations between myocardial infarction (MI) and multiple physical function metrics.

Methods

Among participants aged ≥45 years in the REasons for Geographic And Racial Differences in Stroke prospective cohort study, instrumental activities of daily living (IADL), activities of daily living (ADL), gait speed, chair stands, and Short Form-12 physical component summary (PCS) were assessed after approximately 10 years of follow-up. We examined associations between MI and physical function (no MI [n = 9,472], adjudicated MI during follow-up [n = 288, median 4.7 years prior to function assessment], history of MI at baseline [n = 745], history of MI at baseline and adjudicated MI during follow-up [n = 70, median of 6.7 years prior to function assessment]). Models were adjusted for sociodemographic characteristics, health behaviours, depressive symptoms, cognitive impairment, body mass index, diabetes, hypertension, and urinary albumin to creatinine ratio. We examined subgroups defined by age, gender, and race.

Results

The average age at baseline was 62 years old, 56% were women, and 35% Black. MI was significantly associated with worse IADL and ADL scores, IADL dependency, chair stands, and PCS, but not ADL dependency or gait speed. For example, compared to participants without MI, IADL scores (possible range 0-14, higher score represents worse function) were greater for participants with MI during follow-up (difference: 0.37 [95% CI 0.16, 0.59]), MI at baseline (0.26 [95% CI 0.12, 0.41]), and MI at baseline and follow-up (0.71 [95% CI 0.15, 1.26]), p < 0.001. Associations tended to be greater in magnitude among participants who were women and particularly Black women.

Conclusion

MI was associated with various measures of physical function. These decrements in function associated with MI may be preventable or treatable.

Trends and Predictors of Glycemic Control Among Adults With Type 2 Diabetes Covered by Alabama Medicaid, 2011-2019

INTRODUCTION

Despite advances in diabetes management, only one-quarter of people with diabetes in the US achieve optimal targets for glycated hemoglobin A1c (HbA1c), blood pressure, and cholesterol. We sought to evaluate temporal trends and predictors of achieving glycemic control among adults with type 2 diabetes covered by Alabama Medicaid from 2011 through 2019.

METHODS

We completed a retrospective analysis of Medicaid claims and laboratory data, using person-years as the unit of analysis. Inclusion criteria were being aged 19 to 64 years, having a diabetes diagnosis, being continuously enrolled in Medicaid for a calendar year and preceding 12 months, and having at least 1 HbA1c result during the study year. Primary outcomes were HbA1c thresholds of <7% and <8%. Primary exposure was study year. We conducted separate multivariable-adjusted logistic regressions to evaluate relationships between study year and HbA1c thresholds.

RESULTS

We included 43,997 person-year observations. Mean (SD) age was 51.0 (9.9) years; 69.4% were women; 48.1% were Black, 42.9% White, and 0.4% Hispanic. Overall, 49.1% had an HbA1c level of <7% and 64.6% <8%. Later study years and poverty-based eligibility were associated with lower probability of reaching target HbA1c levels of <7% or <8%. Sex, race, ethnicity, and geography were not associated with likelihood of reaching HbA1c <7% or <8% in any model.

CONCLUSION

Later study years were associated with lower likelihood of meeting target HbA1c levels compared with 2011, after adjusting for covariates. With approximately 35% not meeting an HbA1c target of <8%, more work is needed to improve outcomes of low-income adults with type 2 diabetes.

Associations of dietary patterns with risk of incident atrial fibrillation in the REasons for Geographic And Racial Differences in Stroke (REGARDS)

BACKGROUND

We examined whether the risk of incident atrial fibrillation (AF) in a large, biracial, prospective cohort is lower in participants who adhere to heart-healthy dietary patterns and higher in participants who adhere to less heart-healthy diets.

METHODS

Between 2003 and 2007, the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study enrolled 30,239 Black and White Americans aged 45 years or older. Dietary patterns (convenience, plant-based, sweets, Southern, and alcohol and salads) and the Mediterranean diet score (MDS) were derived based on food frequency questionnaire data. The primary outcome was incident AF at the follow-up visit 2013-2016, defined by either electrocardiogram or self-reported medical history of a physician diagnosis.

RESULTS

This study included 8977 participants (mean age 63 ± 8.3 years; 56% women; 30% Black) free of AF at baseline who completed the follow-up exam an average of 9.4 years later. A total of 782 incident AF cases were detected. In multivariable logistic regression analyses, neither the MDS score (odds ratio (OR) per SD increment = 1.03; 95% confidence interval (CI) 0.95-1.11) or the plant-based dietary pattern (OR per SD increment = 1.03; 95% CI 0.94-1.12) were associated with AF risk. Additionally, an increased AF risk was not associated with any of the less-healthy dietary patterns.

CONCLUSIONS

While specific dietary patterns have been associated with AF risk factors, our findings fail to show an association between diet patterns and AF development.

Urinary Biomarkers of Kidney Tubule Health and Mortality in Persons with CKD and Diabetes Mellitus

Key Points

Among adults with diabetes and CKD, biomarkers of kidney tubule health were associated with a greater risk of death, independent of eGFR, albuminuria, and additional risk factors. Higher urine levels of YKL-40 and KIM-1 were associated with a greater risk of death. For cause-specific death, UMOD was independently and inversely associated with the risk of cardiovascular death.

Background

Kidney disease assessed by serum creatinine and albuminuria are strongly associated with mortality in diabetes. These markers primarily reflect glomerular function and injury. Urine biomarkers of kidney tubule health were recently associated with the risk of kidney failure in persons with CKD and diabetes. Associations of these biomarkers with risk of death are poorly understood.

Methods

In 560 persons with diabetes and eGFR ≤60 ml/min per 1.73 m2 from the Reasons for Geographic and Racial Differences in Stroke study (47% male, 53% Black), we measured urine biomarkers of kidney tubule health at baseline: monocyte chemoattractant protein-1 (MCP-1), alpha-1-microglobulin, kidney injury molecule-1 (KIM-1), EGF, chitinase-3-like protein 1 (YKL-40), and uromodulin (UMOD). Cox proportional hazards regression was used to examine the associations of urine biomarkers with all-cause and cause-specific mortality in nested models adjusted for urine creatinine, demographics, mortality risk factors, eGFR, and urine albumin.

Results

The mean (SD) age was 70 (9.6) years, and baseline eGFR was 40 (3) ml/min per 1.73 m2. There were 310 deaths over a mean follow-up of 6.5 (3.2) years. In fully adjusted models, each two-fold higher urine concentration of KIM-1 and YKL-40 were associated with all-cause mortality (hazard ratio [HR] 1.15, 95% confidence interval [CI], 1.01 to 1.31 and 1.13, 95% CI, 1.07 to 1.20, respectively). When examining cause-specific mortality, higher UMOD was associated with a lower risk of cardiovascular death (adjusted HR per two-fold higher concentration 0.87, 95% CI, 0.77 to 0.99), and higher MCP-1 was associated with higher risk of cancer death (HR per two-fold higher concentration 1.52, 95% CI, 1.05 to 2.18).

Conclusion

Among persons with diabetes and CKD, higher urine KIM-1 and YKL-40 were associated with a higher risk of all-cause mortality independently of established risk factors. Urine UMOD and MCP-1 were associated with cardiovascular and cancer-related death, respectively.

Partnership status and retention in care among cisgender heterosexual newly diagnosed people with HIV: a cohort study

This study examined the role of partnership status (married, unmarried-partnered, and unpartnered) on retention in care among newly diagnosed (2013-2017), cisgender heterosexual people with HIV in Birmingham, Alabama (n = 152). This study evaluated all scheduled HIV primary care provider visits for two years following diagnosis date. A kept-visit measure was calculated such that, if an individual attended ≥1 visit in each of the four 6-month intervals, they were considered to have high visit constancy. A missed-visit measure was categorized as ≥1 no-show vs. 0 no-show for first and second year after diagnosis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression models. Models were adjusted for confounding sociodemographic and clinical characteristics. The study population was 76% Black, 57% male, median age of 37 years. Overall, 65% had high visit consistency and 34.5% had ≥1 no-show in both years. Compared to unpartnered, married individuals had higher visit constancy [AOR (95% CI): 2.88 (1.02, 8.16)]; no differences were observed among unmarried-partnered individuals. No differences in having ≥1 no-show among partnership status groups were observed for either year. These findings suggest potential success of interventions involving a social confidant in optimizing retention in care among newly diagnosed, heterosexual PWH.

Measuring continuity of care for diabetes: which visits to include?

OBJECTIVES

Continuity of care measures are widely used to evaluate the quality of health care delivery, but which visits are included vary across studies. Our objective was to determine how the provider specialties included affect continuity values, year-to-year stability, and association with emergency department (ED) visits.

STUDY DESIGN

Retrospective study of Alabama Medicaid administrative data.

METHODS

We included beneficiaries with diabetes who had at least 3 outpatient visits in each of 2018 and 2019 (N = 9578). We defined 3 provider groupings: all providers, diabetes-broad (primary care, cardiology, neurology, endocrinology, ophthalmology, nephrology, and psychiatry), and diabetes-narrow (primary care and endocrinology). Continuity of care was calculated using the Continuity of Care Index (COCI) for each provider grouping. We compared correlation between measures and from year to year using Spearman correlations, and we used multivariable logistic regression to determine association with ED visits.

RESULTS

The mean COCI was 0.54 using visits with all providers, 0.64 with diabetes-broad providers, and 0.83 with diabetes-narrow providers. COCI with diabetes-narrow providers was moderately correlated with the broader sets of providers (Spearman ρ, 0.52-0.65). Comparing each participant's COCI in 2018 with that in 2019, the mean intraperson difference was similar (0.16-0.22), and correlation was moderate (Spearman ρ, 0.41-0.47) for each measure. COCI had similar weak association with ED visits using each provider grouping (odds ratio, 0.99; 95% CI, 0.98-0.99 for each 0.1-unit difference in COCI).

CONCLUSIONS

Continuity values differed substantially depending on which provider specialties were included. The importance of this variation is uncertain, as continuity was weakly associated with ED visits using each of the measures.

Differences in Long-Term Outcomes in End-Stage Kidney Disease Patients with Chronic Limb-Threatening Ischemia

BACKGROUND

End-stage kidney disease (ESKD) is a risk factor for peripheral arterial disease and major adverse limb events following infra-inguinal bypass. Despite comprising an important patient population, ESKD patients are rarely analyzed as a subgroup and are underrepresented in vascular surgery guidelines. This study aims to compare the long-term outcomes of patients with and without ESKD undergoing endovascular peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI).

METHODS

CLTI patients with and without ESKD from 2007-2020 were identified in the Vascular Quality Initiative PVI dataset. Patients with prior bilateral interventions were excluded. Patients undergoing femoral-popliteal and tibial interventions were included. Mortality, reintervention, amputation, and occlusion rates at 21 months following intervention were examined. Statistical analyses were completed with the t-test, chi-square, and Kaplan-Meier curves.

RESULTS

The ESKD cohort was younger (66.4 ± 11.8 vs. 71.6 ± 12.1 years, P < 0.001) with higher rates of diabetes (82.2 vs. 60.9%, P < 0.001) the non-ESKD cohort. Long-term follow-up was available for 58.4% (N = 2,128 procedures) of ESKD patients and 60.8% (N = 13,075 procedures) of non-ESKD patients. At 21 months, ESKD patients had a higher mortality (41.7 vs. 17.4%, P < 0.001) and a higher amputation rate (22.3 vs. 7.1%, P < 0.001); however, they had a lower reintervention rate (13.2 vs. 24.6%, P < 0.001).

CONCLUSIONS

CLTI patients with ESKD have worse long-term outcomes at 2 years following PVI than non-ESKD patients. Mortality and amputation are higher with ESKD, while the reintervention rate is lower. Development of guidelines within the ESKD population has the potential to improve limb salvage.

Estimated Population Health Benefits of Intensive Systolic Blood Pressure Treatment Among SPRINT-Eligible US Adults

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated an intensive (<120 mm Hg) vs. standard (<140 mm Hg) systolic blood pressure (SBP) goal lowered cardiovascular disease (CVD) risk. Estimating the effect of intensive SBP lowering among SPRINT-eligible adults most likely to benefit can guide implementation efforts.

METHODS

We studied SPRINT participants and SPRINT-eligible participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study and National Health and Nutrition Examination Surveys (NHANES). A published algorithm of predicted CVD benefit with intensive SBP treatment was used to categorize participants into low, medium, or high predicted benefit. CVD event rates were estimated with intensive and standard treatment.

RESULTS

Median age was 67.0, 72.0, and 64.0 years in SPRINT, SPRINT-eligible REGARDS, and SPRINT-eligible NHANES participants, respectively. The proportion with high predicted benefit was 33.0% in SPRINT, 39.0% in SPRINT-eligible REGARDS, and 23.5% in SPRINT-eligible NHANES. The estimated difference in CVD event rate (standard minus intensive) was 7.0 (95% confidence interval [CI] 3.4-10.7), 8.4 (95% CI 8.2-8.5), and 6.1 (95% CI 5.9-6.3) per 1,000 person-years in SPRINT, SPRINT-eligible REGARDS participants, and SPRINT-eligible NHANES participants, respectively (median 3.2-year follow-up). Intensive SBP treatment could prevent 84,300 (95% CI 80,800-87,920) CVD events per year in 14.1 million SPRINT-eligible US adults; 29,400 and 28,600 would be in 7.0 million individuals with medium or high predicted benefit, respectively.

CONCLUSIONS

Most of the population health benefit from intensive SBP goals could be achieved by treating those characterized by a previously published algorithm as having medium or high predicted benefit.

Prescribing patterns of fall risk-increasing drugs in older adults hospitalized for heart failure

BACKGROUND

Older adults hospitalized for heart failure (HF) are at risk for falls after discharge. One modifiable contributor to falls is fall risk-increasing drugs (FRIDs). However, the prevalence of FRIDs among older adults hospitalized for HF is unknown. We describe patterns of FRIDs use and examine predictors of a high FRID burden.

METHODS

We used the national biracial REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a prospective cohort recruited from 2003-2007. We included REGARDS participants aged ≥ 65 years discharged alive after a HF hospitalization from 2003-2017. We determined FRIDs -cardiovascular (CV) and non-cardiovascular (non-CV) medications - at admission and discharge from chart abstraction of HF hospitalizations. We examined the predictors of a high FRID burden at discharge via modified Poisson regression with robust standard errors.

RESULTS

Among 1147 participants (46.5% women, mean age 77.6 years) hospitalized at 676 hospitals, 94% were taking at least 1 FRID at admission and 99% were prescribed at least 1 FRID at discharge. The prevalence of CV FRIDs was 92% at admission and 98% at discharge, and the prevalence of non-CV FRIDs was 32% at admission and discharge. The most common CV FRID at admission (88%) and discharge (93%) were antihypertensives; the most common agents were beta blockers (61% at admission, 75% at discharge), angiotensin-converting enzyme inhibitors (36% vs. 42%), and calcium channel blockers (32% vs. 28%). Loop diuretics had the greatest change in prevalence (53% vs. 72%). More than half of the cohort (54%) had a high FRID burden (Agency for Healthcare Research and Quality (AHRQ) score ≥ 6), indicating high falls risk after discharge. In a multivariable Poisson regression analysis, the factors strongly associated with a high FRID burden at discharge included hypertension (PR: 1.41, 95% CI: 1.20, 1.65), mood disorder (PR: 1.24, 95% CI: 1.10, 1.38), and hyperpolypharmacy (PR: 1.88, 95% CI: 1.64, 2.14).

CONCLUSIONS

FRID use was nearly universal among older adults hospitalized for HF; more than half had a high FRID burden at discharge. Further work is needed to guide the management of a common clinical conundrum whereby guideline indications for treating HF may contribute to an increased risk for falls.

Allostatic load and incident heart failure in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

BACKGROUND

Allostatic load (AL) is the physiologic "wear and tear" on the body from stress. Yet, despite stress being implicated in the development heart failure (HF), it is unknown whether AL is associated with incident HF events.

METHODS

We examined 16,765 participants without HF at baseline from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The main exposure was AL score quartile. AL was determined according to 11 physiologic parameters, whereby each parameter was assigned points (0-3) based on quartiles within the sample, and points were summed to create a total AL score ranging from 0-33. The outcome was incident HF event. We examined the association between AL quartile (Q1-Q4) and incident HF events using Cox proportional hazards models, adjusted for demographics, socioeconomic factors, and lifestyle.

RESULTS

The mean age was 64 ± 9.6 years, 61.5% were women, and 38.7% were Black participants. Over a median follow up of 11.4 years, we observed 750 incident HF events (635 HF hospitalizations and 115 HF deaths). Compared to the lowest AL quartile (Q1), the fully adjusted hazards of an incident HF event increased in a graded fashion: Q2 HR 1.49 95% CI 1.12-1.98; Q3 HR 2.47 95% CI 1.89-3.23; Q4 HR 4.28 95% CI 3.28-5.59. The HRs for incident HF event in the fully adjusted model that also adjusted for CAD were attenuated, but remained significant and increased in a similar, graded fashion by AL quartile. There was a significant age interaction (p-for-interaction < 0.001), whereby the associations were observed across each age stratum, but the HRs were highest among those aged < 65 years.

CONCLUSION

AL was associated with incident HF events, suggesting that AL could be an important risk factor and potential target for future interventions to prevent HF.

Disparities in Postdischarge Ambulatory Care Follow-Up Among Medicaid Beneficiaries With Diabetes, Hospitalized for Heart Failure

Background Ambulatory follow-up for all patients with heart failure (HF) is recommended within 7 to 14 days after hospital discharge to improve HF outcomes. We examined postdischarge ambulatory follow-up of patients with comorbid diabetes and HF from a low-income population in primary and specialty care. Methods and Results Adults with diabetes and first hospitalizations for HF, covered by Alabama Medicaid in 2010 to 2019, were included and the claims analyzed for ambulatory care use (any, primary care, cardiology, or endocrinology) within 60 days after discharge using restricted mean survival time regression and negative binomial regression. Among 9859 Medicaid-covered adults with diabetes and first hospitalization for HF (mean age, 53.7 years; SD, 9.2 years; 47.3% Black; 41.8% non-Hispanic White; 10.9% Hispanic/Other [Other included non-White Hispanic, American Indian, Pacific Islander and Asian adults]; 65.4% women, 34.6% men), 26.7% had an ambulatory visit within 0 to 7 days, 15.2% within 8 to 14 days, 31.3% within 15 to 60 days, and 26.8% had no visit; 71% saw a primary care physician and 12% a cardiology physician. Black and Hispanic/Other adults were less likely to have any postdischarge ambulatory visit (P<0.0001) or the visit was delayed (by 1.8 days, P=0.0006 and by 2.8 days, P=0.0016, respectively) and were less likely to see a primary care physician than non-Hispanic White adults (adjusted incidence rate ratio, 0.96 [95% CI, 0.91-1.00] and 0.91 [95% CI, 0.89-0.98]; respectively). Conclusions More than half of Medicaid-covered adults with diabetes and HF in Alabama did not receive guideline-concordant postdischarge care. Black and Hispanic/Other adults were less likely to receive recommended postdischarge care for comorbid diabetes and HF.

Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection

Importance

SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals.

Objective

To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections.

Design, Setting, and Participants

Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling.

Exposure

SARS-CoV-2 infection.

Main Outcomes and Measures

PASC and 44 participant-reported symptoms (with severity thresholds).

Results

A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months.

Conclusions and Relevance

A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.

Development and implementation of a distributed data network between an academic institution and state health departments to investigate variation in time to HIV viral suppression in the Deep South

BACKGROUND

Achieving early and sustained viral suppression (VS) following diagnosis of HIV infection is critical to improving outcomes for persons with HIV (PWH). The Deep South of the United States (US) is a region that is disproportionately impacted by the domestic HIV epidemic. Time to VS, defined as time from diagnosis to initial VS, is substantially longer in the South than other regions of the US. We describe the development and implementation of a distributed data network between an academic institution and state health departments to investigate variation in time to VS in the Deep South.

METHODS

Representatives of state health departments, the Centers for Disease Control and Prevention (CDC), and the academic partner met to establish core objectives and procedures at the beginning of the project. Importantly, this project used the CDC-developed Enhanced HIV/AIDS Reporting System (eHARS) through a distributed data network model that maintained the confidentiality and integrity of the data. Software programs to build datasets and calculate time to VS were written by the academic partner and shared with each public health partner. To develop spatial elements of the eHARS data, health departments geocoded residential addresses of each newly diagnosed individual in eHARS between 2012-2019, supported by the academic partner. Health departments conducted all analyses within their own systems. Aggregate results were combined across states using meta-analysis techniques. Additionally, we created a synthetic eHARS data set for code development and testing.

RESULTS

The collaborative structure and distributed data network have allowed us to refine the study questions and analytic plans to conduct investigations into variation in time to VS for both research and public health practice. Additionally, a synthetic eHARS data set has been created and is publicly available for researchers and public health practitioners.

CONCLUSIONS

These efforts have leveraged the practice expertise and surveillance data within state health departments and the analytic and methodologic expertise of the academic partner. This study could serve as an illustrative example of effective collaboration between academic institutions and public health agencies and provides resources to facilitate future use of the US HIV surveillance system for research and public health practice.

Recurrent Atherosclerotic Cardiovascular Disease Events Potentially Prevented with Guideline-Recommended Cholesterol-Lowering Therapy following Myocardial Infarction

PURPOSE

Many adults with atherosclerotic cardiovascular disease (ASCVD) who are recommended to take a statin, ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) by the 2018 American Heart Association/American College of Cardiology cholesterol guideline do not receive these medications. We estimated the percentage of recurrent ASCVD events potentially prevented with guideline-recommended cholesterol-lowering therapy following a myocardial infarction (MI) hospitalization.

METHODS

We conducted simulations using data from US adults with government health insurance through Medicare or commercial health insurance in the MarketScan database. We used data from patients with an MI hospitalization in 2018-2019 to estimate the percentage receiving guideline-recommended therapy. We used data from patients with an MI hospitalization in 2013-2016 to estimate the 3-year cumulative incidence of recurrent ASCVD events (i.e., MI, coronary revascularization or ischemic stroke). The low-density lipoprotein cholesterol (LDL-C) reduction with guideline-recommended therapy was derived from trials of statins, ezetimibe and PCSK9i, and the associated ASCVD risk reduction was estimated from a meta-analysis by the Cholesterol-Lowering Treatment Trialists Collaboration.

RESULTS

Among 279,395 patients with an MI hospitalization in 2018-2019 (mean age 75 years, mean LDL-C 92 mg/dL), 27.3% were receiving guideline-recommended cholesterol-lowering therapy. With current cholesterol-lowering therapy use, 25.3% (95%CI: 25.2%-25.4%) of patients had an ASCVD event over 3 years. If all patients were to receive guideline-recommended therapy, 19.8% (95%CI: 19.5%-19.9%) were estimated to have an ASCVD event over 3 years, representing a 21.6% (95%CI: 20.5%-23.6%) relative risk reduction.

CONCLUSION

Implementation of guideline-recommended cholesterol-lowering therapy could prevent a substantial percentage of recurrent ASCVD events.

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Introduction

The involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Since reasons for this are not entirely clear, we sought to determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. We hypothesized that SDOH would be inversely associated with cardiologist involvement in the care of adults hospitalized for HF.

Methods

We included adult participants from the national REasons for Geographic And Racial Difference in Stroke (REGARDS) cohort, who experienced an adjudicated hospitalization for HF between 2009 and 2017. We excluded participants who were hospitalized at institutions that lacked cardiology services (n=246). We examined nine candidate SDOH, which align with the Healthy People 2030 conceptual model: Black race, social isolation (0-1 visits from a family or friend in the past month), social network/caregiver availability (having someone to care for them if ill), educational attainment < high school, annual household income < $35,000, living in rural areas, living in a zip code with high poverty, living in a Health Professional Shortage Area, and residing in a state with poor public health infrastructure. The primary outcome was cardiologist involvement, a binary variable which was defined as involvement of a cardiologist as the primary responsible clinician or as a consultant, collected via chart review. We examined associations between each SDOH and cardiologist involvement using Poisson regression with robust standard errors. Candidate SDOH with statistically significant associations (p<0.10) were retained for multivariable analysis. Potential confounders/covariates for the multivariable analysis included age, race, sex, HF characteristics, comorbidities, and hospital characteristics.

Results

We examined 876 participants hospitalized at 549 unique US hospitals. The median age was 77.5 years (IQR 71.0-83.7), 45.9% were female, 41.4% were Black, and 56.2% had low income. Low household income (<$35,000/year) was the only SDOH that had a statistically significant association with cardiologist involvement in a bivariate analysis (RR: 0.88 [95% CI: 0.82-0.95]). After adjusting for potential confounders, low income remained inversely associated (RR: 0.89 [95% CI: 0.82-0.97]).

Conclusions

Adults with low household income were 11% less likely to have a cardiologist involved in their care during a hospitalization for HF. This suggests that socioeconomic status may implicitly bias the care provided to patients hospitalized for HF.

Geospatial analysis of time to HIV diagnosis and adult HIV testing coverage highlights areas for intervention in the U.S. Southeast

Background

In the U.S., 44% of people with HIV (PWH) live in the Southeastern census region; many PWH remain undiagnosed. Novel strategies to inform testing outreach in rural states with dispersed HIV-epidemics are needed.

Methods

Alabama state public health HIV testing surveillance data from 2013-2017 were used to estimate time from infection to HIV diagnosis using CD4 T-cell depletion modeling, mapped to county. Diagnostic HIV tests performed 2013-2021 by commercial testing entities were used to estimate HIV tests per 100,000 adults (15-65-year-old), mapped to client ZIP code tabulation area (ZCTA). We then defined testing “cold spots”: those with &lt;10% adults tested plus either (a) within or bordering one of the 13 counties with HIV prevalence greater than 400 cases per 100,000 population or (b) within a county with average time to diagnosis greater than the state average to inform testing outreach.

Results

Time to HIV diagnosis is a median of 3.7 (IQR 0-9.2) years across Alabama, with a range from 0.06-12.25 years. Approximately 63% of counties (N=42) have a longer time-to-diagnosis compared to national U.S. estimates. 643 ZCTAs tested 17.3% (IQR: 10.3%,25.0%) of the adult population from 2013-2017. To prioritize areas for testing outreach, we generated maps to describe 47 areas of HIV-testing cold spots at the ZCTA level.

Conclusions

Combining public health surveillance with commercial testing data provides a more nuanced understanding of HIV testing gaps in a state with a rural HIV epidemic and identifies areas to prioritize for testing outreach.

Implications of Under-Reporting Medication Side Effects: Beta-Blockers in Heart Failure as a Case Example

INTRODUCTION

Perceiving medication side effects but not reporting them to a clinician is common. Patterns of "under-reporting" and their implications are not well described. We aimed to address this gap by examining patterns of under-reporting perceived side effects of beta-blockers among patients with heart failure.

METHODS

In 2016, a survey that evaluated medication-taking behavior was administered to 1114 participants (46.5% response rate) from The Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort with prior adjudicated heart failure hospitalization or a heart failure Medicare claim. We examined the results of survey respondents who reported taking a beta-blocker to understand patterns of under-reporting perceived beta-blocker side effects. We defined an under-reporter as a participant who perceived experiencing a side effect from their beta-blocker but did not share it with their clinician (according to survey responses). We conducted a multivariable logistic regression analysis to identify determinants of being an under-reporter. Co-variates included age, sex, race, income, level of education, geographical location, and pill burden. We also examined whether under-reporters differed in self-reported medication adherence and willingness to take additional medication to prevent a future healthcare encounter compared to participants who reported perceived side effects to their clinicians and those who did not experience side effects.

RESULTS

Among 310 respondents, 28% (n = 87) were under-reporters. Black race (odds ratio 2.11, confidence interval 1.21-3.67) and education less than college (odds ratio 2.00, confidence interval 1.09-3.67) were associated with being an under-reporter. Self-reported medication adherence was similar between groups (under-reporters: 46.3%; those who reported perceived side effects: 49.4%; those who did not experience side effects: 45.0%); under-reporters were more frequently unwilling to take additional medication to prevent a doctor's visit (18.9% vs 12.1% vs 10.8%), emergency room visit (21.6% vs 13.3% vs 9.9%), and hospitalization (17.6% vs 10.8% vs 9.0%) compared with the other groups.

CONCLUSION

We conclude that under-reporting perceived side effects of beta-blockers among adults with heart failure is common, is associated with Black race and low education, and may contribute to patient willingness to take additional medication to prevent future medical encounters.

Abstract P582: Race, Social Determinants of Health, and Comorbidity Patterns Among Participants With Heart Failure in the Reasons for Geographic and Racial Differences in Stroke Study

Introduction: Heart failure (HF) is often accompanied by comorbid conditions that impact outcomes. We examined racial differences in comorbidities among patients with HF and the mediating role of social determinants of health (SDOH).

Hypothesis: Comorbidities among people hospitalized with HF with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) will differ by race, and SDOH will partly explain the disparities.

Methods: Black and White US community-dwelling participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study aged ≥ 45 years with an adjudicated HF hospitalization between 2003 and 2017 (n = 506 HFpEF and 742 HFrEF, 4.1% of the REGARDS cohort) were included in this cross-sectional analysis. Comorbidities were abstracted from HF hospitalization records. We estimated age- and sex-adjusted prevalence ratios (PR) for comorbidities comparing Black to White participants. Guided by the Healthy People’s 2030 framework, SDOH including income, education, marital status, rural residence, ZIP code-level poverty, healthcare provider shortage area and poor public infrastructure were considered as potential mediators using the inverse odds weighting method.

Results: Among participants with a HF hospitalization, the median age was 79 (IQR: 73 – 85) years and 74 (67 – 80) years for White and Black adults, respectively. There were racial differences in the prevalence of some comorbidities between Black and White participants (Table). In HFpEF, low income and education explained 27% of the excess diabetes experienced by Black adults compared to White adults (P < 0.05). There was no significant mediation of other associations by SDOH.

Conclusions: There were racial differences in the patterns of comorbidities among REGARDS participants with HF, with low income and education partly explaining the higher prevalence of diabetes among Black adults with HFpEF.

Abstract P182: Post-Discharge Ambulatory Care Follow-Up Among Medicaid Beneficiaries With Diabetes, Hospitalized for Heart Failure

Background: Ambulatory follow-up for all patients with heart failure (HF) is recommended within 7-14 days after hospital discharge to improve HF outcomes. This study objective was to examine post-discharge ambulatory follow-up of patients with comorbid diabetes and HF from a low-income population in primary and specialty care.

Methods: Adults with diabetes and first hospitalizations for HF, covered by Alabama Medicaid in 2010-2019, were included and the claims analyzed for ambulatory care utilization (any, primary care, cardiology or endocrinology) within 60 days after hospital discharge. Restricted mean survival time regression, adjusted for socio-demographics and clinical factors, examined the time to first ambulatory visit. Multivariable-adjusted Poisson regression estimated prevalence ratios (PR) of primary and specialty care post-discharge visits.

Results: Among 9,867 Medicaid-covered adults with diabetes and first hospitalization for HF, [mean age 53.7, SD 9.2 years, 47.4% African American, 10.9% Hispanic/other, 65.4% women], 26.5% had an ambulatory visit within 0-7 days, 15.1% - 8-14 days, 31.0% - 15-60 days and 26.8% - no visit; 71% saw primary care, 12% - cardiology and 1.6% - endocrinology. Compared to Non-Hispanic white adults, African American and Hispanic/other ethnicity adults were less likely to see primary care (adjusted PR 95% Confidence Interval [CI] 0.96 [0.91-1.00], and 0.91 [0.89-0.98], respectively), and their visits occurred later (by 1.8 day, p=0.0006 and by 2.8 days, p=0.0016, respectively). Having 4 or more additional comorbidities was associated with both primary care and cardiology visits (aPR [95% CI] 1.59 [1.35-1.87], and 1.45 [1.01-2.09], respectively).

Conclusion: More than a half of Medicaid-covered adults with diabetes and HF in Alabama did not receive post-discharge ambulatory care follow-up as recommended by guidelines. African American and Hispanic/other ethnicity adults were less likely to receive recommended post-discharge ambulatory care for comorbid diabetes and HF.

Real-world safety of neurohormonal antagonist initiation among older adults following a heart failure hospitalization

AIMS

To optimize guideline-directed medical therapy for heart failure, patients may require the initiation of multiple neurohormonal antagonists (NHAs) during and following hospitalization. The safety of this approach for older adults is not well established.

METHODS AND RESULTS

We conducted an observational cohort study of 207 223 Medicare beneficiaries discharged home following a hospitalization for heart failure with reduced ejection fraction (HFrEF) (2008-2015). We performed Cox proportional hazards regression to examine the association between the count of NHAs initiated within 90 days of hospital discharge (as a time-varying exposure) and all-cause mortality, all-cause rehospitalization, and fall-related adverse events over the 90 day period following hospitalization. We calculated inverse probability-weighted hazard ratios (IPW-HRs) with 95% confidence intervals (CIs) comparing initiation of 1, 2, or 3 NHAs vs. 0. The IPW-HRs for mortality were 0.80 [95% CI (0.78-0.83)] for 1 NHA, 0.70 [95% CI (0.66-0.75)] for 2, and 0.94 [95% CI (0.83-1.06)] for 3. The IPW-HRs for readmission were 0.95 [95% CI (0.93-0.96)] for 1 NHA, 0.89 [95% CI (0.86-0.91)] for 2, and 0.96 [95% CI (0.90-1.02)] for 3. The IPW-HRs for fall-related adverse events were 1.13 [95% CI (1.10-1.15)] for 1 NHA, 1.25 [95% CI (1.21-1.30)] for 2, and 1.64 [95% CI (1.54-1.76)] for 3.

CONCLUSIONS

Initiating 1-2 NHAs among older adults within 90 days of HFrEF hospitalization was associated with lower mortality and lower readmission. However, initiating 3 NHAs was not associated with reduced mortality or readmission and was associated with a significant risk for fall-related adverse events.

Using publicly available data to identify priority communities for a SARS-CoV-2 testing intervention in a southern U.S. state

Background

The U.S. Southeast has a high burden of SARS-CoV-2 infections and COVID-19 disease. We used public data sources and community engagement to prioritize county selections for a precision population health intervention to promote a SARS-CoV-2 testing intervention in rural Alabama during October 2020 and March 2021.

Methods

We modeled factors associated with county-level SARS-CoV-2 percent positivity using covariates thought to associate with SARS-CoV-2 acquisition risk, disease severity, and risk mitigation practices. Descriptive epidemiologic data were presented to scientific and community advisory boards to prioritize counties for a testing intervention.

Results

In October 2020, SARS-CoV-2 percent positivity was not associated with any modeled factors. In March 2021, premature death rate (aRR 1.16, 95% CI 1.07, 1.25), percent Black residents (aRR 1.00, 95% CI 1.00, 1.01), preventable hospitalizations (aRR 1.03, 95% CI 1.00, 1.06), and proportion of smokers (aRR 0.231, 95% CI 0.10, 0.55) were associated with average SARS-CoV-2 percent positivity. We then ranked counties based on percent positivity, case fatality, case rates, and number of testing sites using individual variables and factor scores. Top ranking counties identified through factor analysis and univariate associations were provided to community partners who considered ongoing efforts and strength of community partnerships to promote testing to inform intervention.

Conclusions

The dynamic nature of SARS-CoV-2 proved challenging for a modelling approach to inform a precision population health intervention at the county level. Epidemiological data allowed for engagement of community stakeholders implementing testing. As data sources and analytic capacities expand, engaging communities in data interpretation is vital to address diseases locally.

The Projected Impact of Population-Wide Achievement of LDL Cholesterol <70 mg/dL on the Number of Recurrent Events Among US Adults with ASCVD

PURPOSE

Adults with atherosclerotic cardiovascular disease (ASCVD) are recommended high-intensity statins, with those at very high risk for recurrent events recommended adding ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor if their low-density lipoprotein cholesterol (LDL-C) is ≥70 mg/dL. We estimated the number of recurrent ASCVD events potentially averted if all adults in the United States (US) ≥45 years of age with ASCVD achieved an LDL-C <70 mg/dL.

METHODS

The number of US adults with ASCVD and LDL-C ≥70 mg/dL was estimated from the National Health and Nutrition Examination Survey 2009-2016 (n = 596). The 10-year cumulative incidence of recurrent ASCVD events was estimated from the REasons for Geographic And Racial Differences in Stroke study (n = 5390), weighted to the US population by age, race, and sex. The ASCVD risk reduction by achieving an LDL-C <70 mg/dL was estimated from meta-analyses of lipid-lowering treatment trials.

RESULTS

Overall, 14.7 (95% CI, 13.7-15.8) million US adults had ASCVD, of whom 11.6 (95% CI, 10.6-12.5) million had LDL-C ≥70 mg/dL. The 10-year cumulative incidence of ASCVD events was 24.3% (95% CI, 23.2-25.6%). We projected that 2.823 (95% CI, 2.543-3.091) million ASCVD events would occur over 10 years among US adults with ASCVD and LDL-C ≥70 mg/dL. Overall, 0.634 (95% CI, 0.542-0.737) million ASCVD events could potentially be averted if all US adults with ASCVD achieved and maintained LDL-C <70 mg/dL.

CONCLUSION

A substantial number of recurrent ASCVD events could be averted over 10 years if all US adults with ASCVD achieved, and maintained, an LDL-C <70 mg/dL.

Role of Visit Modality in the HIV-Related No-Shows During the COVID-19 Pandemic: A Multisite Retrospective Cohort Study

The emergence of the COVID-19 pandemic necessitated rapid expansion of telehealth as part of healthcare delivery. This study compared HIV-related no-shows by visit type (in-person; video; telephone) during the COVID-19 pandemic (April 2020-September 2021) from the Data for Care Alabama project. Using all primary care provider visits, each visit's outcome was categorized as no-show or arrived. A logistic regression model using generalized estimating equations accounting for repeat measures in individuals and within sites calculated odds ratios (OR) and their accompanying 95% confidence interval (CI) for no-shows by visit modality. The multivariable models adjusted for sociodemographic factors. In-person versus telephone visits [OR (95% CI) 1.64 (1.48-1.82)] and in-person versus video visits [OR (95% CI) 1.53 (1.25-1.85)] had higher odds of being a no-show. In-person versus telephone and video no-shows were significantly higher. This may suggest success of telehealth visits as a method for HIV care delivery even beyond COVID-19.

Assessing the Impact of COVID-19 on Retention in HIV Primary Care: A Longitudinal Multisite Analysis

We compared retention in care outcomes between a pre-COVID-19 (Apr19-Mar20) and an early-COVID-19 (Apr20-Mar21) period to determine whether the pandemic had a significant impact on these outcomes and assessed the role of patient sociodemographics in both periods in individuals enrolled in the Data for Care Alabama project (n = 6461). Using scheduled HIV primary care provider visits, we calculated a kept-visit measure and a missed-visit measure and compared them among the pre-COVID-19 and early-COVID-19 periods. We used logistic regression models to calculated odds ratios (OR) and accompanying 95% confidence intervals (CI). Overall, individuals had lowers odds of high visit constancy [OR (95% CI): 0.85 (0.79, 0.92)] and higher odds of no-shows [OR (95% CI): 1.27 (1.19, 1.35)] during the early-COVID-19 period. Compared to white patients, Black patients were more likely to miss an appointment and transgender people versus cisgender women had lower visit constancy in the early-COVID-19 period.

Recurrent atherosclerotic cardiovascular disease events preventable with guideline recommended lipid-lowering treatment following myocardial infarction

Background

The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol guideline provides recommendations for lipid-lowering therapy (LLT) including statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) to prevent recurrent atherosclerotic cardiovascular disease (ASCVD) events in adults with established ASCVD. Many adults with ASCVD who are recommended to take statins, ezetimibe and/or PCSK9i do not receive these medications.

Purpose

To estimate the number of recurrent ASCVD events potentially prevented by population-wide use of guideline recommended LLT following a myocardial infarction (MI).

Methods

We simulated the population-wide impact of receipt of 2018 AHA/ACC cholesterol guideline recommended LLT over 3 and 5 years among US adults with government health insurance through Medicare or commercial health insurance following hospital discharge for MI. We used data from patients with an MI hospitalization in 2018–2019 to estimate the percentage receiving guideline recommended LLT defined by having the medications available to take in the 30 days after their discharge date. We used data from patients with an MI hospitalization in 2013–2016 to estimate the 3 and 5-year cumulative incidence of recurrent ASCVD events (i.e., MI, coronary revascularization or ischemic stroke). The reduction in ASCVD events associated with guideline recommended LLT was estimated from a meta-analysis by the Cholesterol-Lowering Treatment Trialists Collaboration. We conducted a sensitivity analysis estimating the number and percentage of ASCVD events prevented if LLT recommendations from the 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) cholesterol guideline were followed. We repeated all analyses with recurrent coronary heart disease (i.e., MI or coronary revascularization) and ischemic stroke events as separate outcomes.

Results

Among 279,395 adults with an MI hospitalization in 2018–2019 (mean age 75 years, 54% men, mean low-density lipoprotein cholesterol 92 mg/dL), 27% were receiving guideline recommended LLT. With current lipid-lowering medication use, we estimated that 70,698 (95% CI: 70,311–71,077) and 89,255 (95% CI: 88,841–89,730) ASCVD events would occur in 3 and 5 years, respectively, after MI hospital discharge (Table, top panel). If all patients were to receive 2018 AHA/ACC guideline recommended LLT, the number of ASCVD events was estimated to be reduced by 21.6%, representing 15,264 (95% CI: 14,451–16,679) events prevented over 3 years and 19,271 (95% CI: 18,245–21,055) events prevented over 5 years. A higher number of recurrent ASCVD events were estimated to be averted following the LLT recommendations of the 2019 ESC/EAS cholesterol guideline (Table, bottom panel).

Conclusions

Population-wide implementation of guideline recommended LLT in adults with an MI hospitalization could prevent a substantial number of recurrent ASCVD events.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen Inc.

COVID Community-Engaged Testing in Alabama: Reaching Underserved Rural Populations Through Collaboration

Rural communities are often underserved by public health testing initiatives in Alabama. As part of the National Institutes of Health's Rapid Acceleration of Diagnostics‒Underserved Populations initiative, the University of Alabama at Birmingham, along with community partners, sought to address this inequity in COVID-19 testing. We describe the participatory assessment, selection, and implementation phases of this project, which administered more than 23 000 COVID-19 tests throughout the state, including nearly 4000 tests among incarcerated populations. (Am J Public Health. 2022;112(10):1399-1403. https://doi.org/10.2105/AJPH.2022.306985).

Estimated number and percentage of US adults with atherosclerotic cardiovascular disease recommended add-on lipid-lowering therapy by the 2018 AHA/ACC multi-society cholesterol guideline

Study objective

The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol guideline recommends a maximally-tolerated statin with add-on lipid-lowering therapy, ezetimibe and/or proprotein convertase subtilisin/kexin type 9 (PCSK9) for adults with very-high atherosclerotic cardiovascular disease (ASCVD) risk to achieve a low-density lipoprotein cholesterol (LDL-C) <70 mg/dL. We estimated the percentage of US adults with ASCVD recommended, by the 2018 AHA/ACC cholesterol guideline, and receiving add-on lipid-lowering therapy.

Design setting and participants

Cross-sectional study including 805 participants from the US National Health and Nutrition Examination Survey (NHANES) 2013-2020 data. NHANES sampling weights were used to obtain estimates for the US adult population.

Main measures

Very-high ASCVD risk was defined as either: ≥2 ASCVD events, or one ASCVD event with ≥2 high-risk conditions. Being recommended add-on lipid-lowering therapy was defined as having very-high ASCVD risk and LDL-C ≥ 70 mg/dL, or LDL-C < 70 mg/dL while taking ezetimibe or a PCSK9 inhibitor.

Results

An estimated 18.7 (95%CI, 16.0-21.4) million US adults had ASCVD, of whom 81.6 % (95%CI, 76.7 %-86.4 %) had very-high ASCVD risk, and 60.1 % (95%CI, 54.5 %-65.7 %) had very-high ASCVD risk and LDL-C ≥ 70 mg/dL. Overall, 61.4 % (95%CI, 55.8 %-66.9 %) were recommended add-on lipid-lowering therapy and 3.2 % (95 % CI, 1.2 %-5.3 %) were taking it. Smokers, adults with diabetes, hypertension and chronic kidney disease were more likely, while those taking atorvastatin or rosuvastatin were less likely, to be recommended add-on lipid-lowering therapy.

Conclusion

The majority of US adults with ASCVD are recommended add-on lipid-lowering therapy by the 2018 AHA/ACC cholesterol guideline but few are receiving it.

Association of Perceived Stress With Incident Heart Failure

BACKGROUND

The relationship between psychological stress and heart failure (HF) has not been well studied. We sought to assess the relationship between perceived stress and incident HF.

METHODS

We used data from the national REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a large prospective biracial cohort study that enrolled community-dwellers aged 45 years and older between 2003 and 2007, with follow-up. We included participants free of suspected prevalent HF who completed the Cohen 4-item Perceived Stress Scale (PSS-4). Our outcome variables were incident HF event, HF with reduced ejection fraction events, and HF with preserved ejection fraction events. We estimated Cox proportional hazard models to determine if PSS-4 quartiles were independently associated with incident HF events, adjusting for sociodemographics, social support, unhealthy behaviors, comorbid conditions, and physiologic parameters. We also tested interactions by baseline statin use, given its anti-inflammatory properties.

RESULTS

Among 25,785 participants with a mean age of 64 ± 9.3 years, 55% were female and 40% were Black. Over a median follow-up of 10.1 years, 1109 ± 4.3% experienced an incident HF event. In fully adjusted models, the PSS-4 was not associated with HF or HF with reduced ejection fraction. However, PSS-4 quartiles 2-4 (compared with the lowest quartile) were associated with incident HF with preserved ejection fraction (Q2 hazard ratio 1.37, 95% confidence interval 1.00-1.88; Q3 hazard ratio 1.42, 95% confidence interval 1.03-1.95; Q4 hazard ratio 1.41, 95% confidence interval 1.04-1.92). Notably, this association was attenuated among participants who took a statin at baseline (P for interaction = .07).

CONCLUSIONS

Elevated perceived stress was associated with incident HF with preserved ejection fraction but not HF with reduced ejection fraction.

Depressive symptoms, cognitive impairment, and all-cause mortality among REGARDS participants with heart failure

Aims

To ascertain whether depressive symptoms and cognitive impairment (CI) are associated with mortality among patients with heart failure (HF), adjusting for sociodemographic, comorbidities, and biomarkers.

Methods and results

We utilized Medicare-linked data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a biracial prospective ongoing cohort of 30 239 US community-dwelling adults, recruited in 2003-07. HF diagnosis was ascertained in claims analysis. Depressive symptoms were defined as a score ≥4 on the four-item Center for Epidemiological Studies-Depression scale. Cognitive impairment was defined as a score of ≤4 on the six-item screener that assessed three-item recall and orientation to year, month, and day of the week. Sequentially adjusted Cox proportional hazard models were used to estimate the risk of death. We analyzed 1059 REGARDS participants (mean age 73, 48%-African American) with HF; of those 146 (14%) reported depressive symptoms, 136 (13%) had CI and 31 (3%) had both. Over the median follow-up of 6.8 years (interquartile range, 3.4-10.3), 785 (74%) died. In the socio-demographics-adjusted model, CI was significantly associated with increased mortality, hazard ratio 1.24 (95% confidence interval 1.01-1.52), compared with persons with neither depressive symptoms nor CI, but this association was attenuated after further adjustment. Neither depressive symptoms alone nor their comorbidity with CI was associated with mortality. Risk factors of all-cause mortality included: low income, comorbidities, smoking, physical inactivity, and severity of HF.

Conclusion

Depressive symptoms, CI, or their comorbidity was not associated with mortality in HF in this study. Treatment of HF in elderly needs to be tailored to cognitive status and includes focus on medical comorbidities.