Neighborhood Environment Characteristics and Control of Hypertension and Diabetes in a Primary Care Patient Sample

BACKGROUND

Hypertension control and diabetes control are important for reducing cardiovascular disease burden. A growing body of research suggests an association between neighborhood environment and hypertension or diabetes control among patients engaged in clinical care.

OBJECTIVE

To investigate whether neighborhood conditions (i.e., healthy food availability, socioeconomic status (SES), and crime) were associated with hypertension and diabetes control.

DESIGN

Cross-sectional analyses using electronic medical record (EMR) data, U.S. Census data, and secondary data characterizing neighborhood food environments. Multivariate logistic regression analyses adjusted for potential confounders. Analyses were conducted in 2017.

PARTICIPANTS

Five thousand nine hundred seventy adults receiving primary care at three Baltimore City clinics in 2010-2011.

MAIN MEASURES

Census tract-level neighborhood healthy food availability, neighborhood SES, and neighborhood crime. Hypertension control defined as systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg. Diabetes control defined as HgbA1c < 7.

KEY RESULTS

Among patients with hypertension, neighborhood conditions were not associated with lower odds of blood pressure control after accounting for patient and physician characteristics. However, among patients with diabetes, in fully adjusted models accounting for patient and physician characteristics, we found that patients residing in neighborhoods with low and moderate SES had reduced odds of diabetes control (OR = 0.74 (95% CI = 0.57-0.97) and OR = 0.75 (95% CI = 0.57-0.98), respectively) compared to those living in high-SES neighborhoods.

CONCLUSIONS

Neighborhood disadvantage may contribute to poor diabetes control among patients in clinical care. Community-based chronic disease care management strategies to improve diabetes control may be optimally effective if they also address neighborhood SES among patients engaged in care.

Comparison of Cardiovascular Disease Risk Factors Among African Immigrants and African Americans: An Analysis of the 2010 to 2016 National Health Interview Surveys

Background Racial/ethnic minorities, especially non-Hispanic blacks, in the United States are at higher risk of developing cardiovascular disease. However, less is known about the prevalence of cardiovascular disease risk factors among ethnic sub-populations of blacks such as African immigrants residing in the United States. This study's objective was to compare the prevalence of cardiovascular disease risk factors among African immigrants and African Americans in the United States. Methods and Results We performed a cross-sectional analysis of the 2010 to 2016 National Health Interview Surveys and included adults who were black and African-born (African immigrants) and black and US-born (African Americans). We compared the age-standardized prevalence of hypertension, diabetes mellitus, overweight/obesity, hypercholesterolemia, physical inactivity, and current smoking by sex between African immigrants and African Americans using the 2010 census data as the standard. We included 29 094 participants (1345 African immigrants and 27 749 African Americans). In comparison with African Americans, African immigrants were more likely to be younger, educated, and employed but were less likely to be insured (P<0.05). African immigrants, regardless of sex, had lower age-standardized hypertension (22% versus 32%), diabetes mellitus (7% versus 10%), overweight/obesity (61% versus 70%), high cholesterol (4% versus 5%), and current smoking (4% versus 19%) prevalence than African Americans. Conclusions The age-standardized prevalence of cardiovascular disease risk factors was generally lower in African immigrants than African Americans, although both populations are highly heterogeneous. Data on blacks in the United States. should be disaggregated by ethnicity and country of origin to inform public health strategies to reduce health disparities.

Back to the Future: Achieving Health Equity Through Health Informatics and Digital Health

The rapid proliferation of health informatics and digital health innovations has revolutionized clinical and research practices. There is no doubt that these fields will continue to have accelerated growth and a substantial impact on population health. However, there are legitimate concerns about how these promising technological advances can lead to unintended consequences such as perpetuating health and health care disparities for underresourced populations. To mitigate this potential pitfall, it is imperative for the health informatics and digital health scientific communities to understand the challenges faced by disadvantaged groups, including racial and ethnic minorities, which hinder their achievement of ideal health. This paper presents illustrative exemplars as case studies of contextually tailored, sociotechnical mobile health interventions designed with community members to address health inequities using community-engaged research approaches. We strongly encourage researchers and innovators to integrate community engagement into the development of data-driven, modernized solutions for every sector of society to truly achieve health equity for all.

Hypertension Self-management in Socially Disadvantaged African Americans: the Achieving Blood Pressure Control Together (ACT) Randomized Comparative Effectiveness Trial

BACKGROUND

Effective hypertension self-management interventions are needed for socially disadvantaged African Americans, who have poorer blood pressure (BP) control compared to others.

OBJECTIVE

We studied the incremental effectiveness of contextually adapted hypertension self-management interventions among socially disadvantaged African Americans.

DESIGN

Randomized comparative effectiveness trial.

PARTICIPANTS

One hundred fifty-nine African Americans at an urban primary care clinic.

INTERVENTIONS

Participants were randomly assigned to receive (1) a community health worker ("CHW") intervention, including the provision of a home BP monitor; (2) the CHW plus additional training in shared decision-making skills ("DoMyPART"); or (3) the CHW plus additional training in self-management problem-solving ("Problem Solving").

MAIN MEASURES

We assessed group differences in BP control (systolic BP (SBP) < 140 mm Hg and diastolic BP (DBP) < 90 mmHg), over 12 months using generalized linear mixed models. We also assessed changes in SBP and DBP and participants' BP self-monitoring frequency, clinic visit patient-centeredness (i.e., extent of patient-physician discussions focused on patient emotional and psychosocial concerns), hypertension self-management behaviors, and self-efficacy.

KEY RESULTS

BP control improved in all groups from baseline (36%) to 12 months (52%) with significant declines in SBP (estimated mean [95% CI] - 9.1 [- 15.1, - 3.1], - 7.4 [- 13.4, - 1.4], and - 11.3 [- 17.2, - 5.3] mmHg) and DBP (- 4.8 [- 8.3, - 1.3], - 4.0 [- 7.5, - 0.5], and - 5.4 [- 8.8, - 1.9] mmHg) for CHW, DoMyPART, and Problem Solving, respectively). There were no group differences in BP outcomes, BP self-monitor use, or clinic visit patient-centeredness. The Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 18.7 [4.0, 87.3]) and self-efficacy scores (OR [95% CI] 4.7 [1.5, 14.9]) at 12 months compared to baseline, while other groups did not. Compared to DoMyPART, the Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 5.7 [1.3, 25.5]) at 12 months.

CONCLUSION

A context-adapted CHW intervention was correlated with improvements in BP control among socially disadvantaged African Americans. However, it is not clear whether improvements were the result of this intervention. Neither the addition of shared decision-making nor problem-solving self-management training to the CHW intervention further improved BP control.

TRIAL REGISTRY

ClinicalTrials.gov Identifier: NCT01902719.

Awareness and Discussions About Chronic Kidney Disease Among African-Americans with Chronic Kidney Disease and Hypertension: a Mixed Methods Study

BACKGROUND

Routine primary care visits provide an educational opportunity for African-Americans with chronic kidney disease (CKD) and CKD risk factors such as hypertension. The nature of patient-physician discussions about CKD and their impact on CKD awareness in this population have not been well explored.

OBJECTIVE

To characterize patient CKD awareness and discussions about CKD between patients and primary care physicians (PCPs).

DESIGN

Mixed methods study.

PATIENTS

African-American patients with uncontrolled hypertension (≥ 140/90 mmHg) and CKD (albuminuria or eGFR < 60 ml/min/1.73 m2) recruited from an urban primary care clinic.

MAIN MEASURES

We assessed patient CKD awareness with questionnaires and audio-recorded patients-PCP discussions during a routine visit. We characterized discussions and used multivariate regression analysis to identify independent patient and visit predictors of CKD awareness or CKD discussions.

RESULTS

Among 48 African-American patients with uncontrolled hypertension and CKD, 29% were aware of their CKD. After adjustment, CKD awareness was associated with moderate-severe CKD (stages 3-4) (vs. mild CKD [stages 1-2]) (prevalence ratio [PR] 2.82; 95% CI 1.18-6.78) and inversely associated with diabetes (vs. without diabetes) (PR 0.28; 95% CI 0.10-0.75). CKD discussions occurred in 30 (63%) visits; most focused on laboratory assessment (n = 23, 77%) or risk factor management to delay CKD progression (n = 19, 63%). CKD discussions were associated with moderate-severe CKD (vs. mild CKD) (PR 1.57; 95% CI 1.04-2.36) and diabetes (vs. without diabetes) (PR 1.42; 95% CI 1.09-1.85), and inversely associated with uncontrolled hypertension (vs. controlled) (PR 0.58; 95% CI 0.92-0.89). In subgroup analysis, follow-up CKD awareness did not change by presence or absence of CKD discussion (10.5% vs. 7.7%, p = 0.8).

CONCLUSIONS

In patients at risk of CKD progression, few were aware of CKD, and CKD discussions were not associated with CKD awareness. More resources may be needed to enhance the clarity of clinical messages regarding CKD and its significance for patients' health.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01902719.

Addressing Cardiovascular Health Disparities in Minnesota: Establishment of a Community Steering Committee by FAITH! (Fostering African-American Improvement in Total Health)

Despite its rank as the fourth healthiest state in the United States, Minnesota has clear cardiovascular disease disparities between African-Americans and whites. Culturally-tailored interventions implemented using community-based participatory research (CBPR) principles have been vital to improving health and wellness among African-Americans. This paper delineates the establishment, impact, and lessons learned from the formation of a community steering committee (CSC) to guide the Fostering African-American Improvement in Total Health (FAITH!) Program, a CBPR cardiovascular health promotion initiative among African-Americans in Minnesota. The theory-informed CSC implementation process included three phases: (1) Membership Formation and Recruitment, (2) Engagement, and (3) Covenant Development and Empowerment. The CSC is comprised of ten diverse community members guided by mutually agreed upon bylaws in their commitment to FAITH!. Overall, members considered the CSC implementation process effective and productive. A CBPR conceptual model provided an outline of proximal and distal goals for the CSC and FAITH!. The CSC implementation process yielded four lessons learned: (1) Have clarity of purpose and vision, (2) cultivate group cohesion, (3) employ consistent review of CBPR tenets, and (4) expect the unexpected. A robust CSC was established and was instrumental to the success and impact of FAITH! within African-American communities in Minnesota.

Commentary: Engaging African Immigrants in Research Experiences and Lessons from the Field

Global migration from Africa to more economically developed regions such as the United States, Europe, the Middle East, and Australia has reached unprecedented rates in the past five decades. The size of the African immigrant population in the United States has roughly doubled every decade since 1970. However, research has not kept up with the growing size of this vulnerable population. Data from African immigrants have not traditionally been reported separately from Blacks/African Americans. There is growing interest in increasing the participation of African immigrants in research to understand their unique health needs and the full spectrum of factors impacting their health, ranging from racial, social, environmental, and behavioral factors, to individual biological and genetic factors which may also inform health challenges. This line of inquiry may also inform our understanding of health disparities among their African American counterparts. However, little is known about effective community engagement and recruitment strategies that may increase the participation of this population in research studies. The purpose of this commentary is to: 1) describe lessons learned from our experiences engaging African immigrants in research in the Baltimore, Washington, DC, and Atlanta metropolitan areas; 2) discuss strategies for successful recruitment; and 3) consider future directions of research and opportunities to translate research findings into health policy for this population.

Leveraging Delivery of Blood Pressure Control Interventions among Low-income African American Adults: Opportunities to Increase Social Support and Produce Family-level Behavior Change

Purpose

Few family-oriented cardiovascular risk reduction interventions exist that leverage the home environment to produce health behavior change among multiple family members. We identified opportunities to adapt disease self-management interventions included in a blood pressure control comparative effectiveness trial for hypertensive African American adults to address family-level factors.

Methods

We conducted and analyzed semi-structured interviews with five intervention study staff (all study interventionists and the study coordinator) between December 2016 and January 2017 and with 11 study participants between September and November 2015.1 All study staff involved with intervention delivery and coordination were interviewed. We sampled adult participants from the parent study, and we analyzed interviews that were originally obtained as part of a previous study based on their status as a caregiver of an adolescent family member.

Results

Thematic analysis identified family influences on disease management and the importance of relationships between index patients and family members, between index patients and study peers, and between index patients and study staff through study participation to understand social effects on healthy behaviors. We identified four themes: 1) the role of family in health behavior change; 2) the impact of family dynamics on health behaviors; 3) building peer relationships through intervention participation; and 4) study staff role conflict.

Conclusions

These findings inform development of family-oriented interventions to improve health behaviors among African American index patients at high risk for cardiovascular disease and their family members.

Neighborhood Poverty and Sex Differences in Live Donor Kidney Transplant Outcomes in the United States

BACKGROUND

Neighborhood poverty has been associated with worse outcomes after live donor kidney transplantation (LDKT), and prior work suggests that women with kidney disease may be more susceptible to the negative influence of poverty than men. As such, our goal was to examine whether poverty differentially affects women in influencing LDKT outcomes.

METHODS

Using data from the Scientific Registry of Transplant Recipients and US Census, we performed multivariable Cox regression to compare outcomes among 18 955 women and 30 887 men who received a first LDKT in 2005-2014 with follow-up through December 31, 2016.

RESULTS

Women living in poor (adjusted hazard ratio [aHR], 1.30; 95% confidence interval [CI], 1.13-1.50) and middle-income (aHR, 1.26; 95% CI, 1.14-1.40) neighborhoods had higher risk of graft loss than men, but there were no differences in wealthy areas (aHR, 1.07; 95% CI, 0.88-1.29). Women living in wealthy (aHR, 0.71; 95% CI, 0.59-0.87) and middle-income (aHR, 0.82; 95% CI, 0.74-0.92) neighborhoods incurred a survival advantage over men, but there were no statistically significant differences in mortality in poor areas (aHR, 0.85; 95% CI, 0.72-1.01).

CONCLUSIONS

Given our findings that poverty is more strongly associated with graft loss in women, targeted efforts are needed to specifically address mechanisms driving these disparities in LDKT outcomes.

Promoting cardiovascular health and wellness among African-Americans: Community participatory approach to design an innovative mobile-health intervention

Background

Despite improvements in mortality rates over the past several decades, cardiovascular (CV) disease remains the leading cause of death for African-Americans (AAs). Innovative approaches through mobile health (mHealth) interventions have the potential to support lifestyle change for CV disease prevention among AAs. We aimed to translate a behavioral theory–informed, evidence-based, face-to-face health education program into an mHealth lifestyle intervention for AAs. We describe the design and development of a culturally relevant, CV health and wellness digital application (app) and pilot testing using a community-based participatory research (CBPR) approach with AA churches.

Methods

This mixed methods study used a 4-phase iterative development process for intervention design with the AA community. Phase 1 included focus groups with AA community members and church partners (n = 23) to gain insight regarding potential app end user preferences. In Phase 2, the interdisciplinary research team synthesized Phase 1 input for preliminary app design and content development. Phase 3 consisted of a sequential 3-meeting series with church partners (n = 13) for iterative app prototyping (assessment, cultural tailoring, final review). Phase 4, a single group pilot study among AA church congregants (n = 50), assessed app acceptability, usability, and satisfaction.

Results

Phase 1 focus groups indicated general and health-related apps preferences: multifunctional, high-quality graphics/visuals, evidence-based, yet simple health information and social networking capability. Phase 2 integrated these preferences into the preliminary app prototype. Phase 3 feedback was used to refine the app prototype for pilot testing. Phase 4 pilot testing indicated high app acceptability, usability, and satisfaction.

Conclusions

This study illustrates integration of formative and CBPR approaches to design a culturally relevant, mHealth lifestyle intervention to address CV health disparities among AAs. Given the positive app perceptions, our study supports the use of an iterative development process by others interested in implementing an mHealth lifestyle intervention for racial/ethnic minority communities.

Trial registration

Clinicaltrials.gov NCT03084822.

Overcoming Barriers to Sustaining Health Equity Interventions: Insights from the National Institutes of Health Centers for Population Health and Health Disparities

We conducted qualitative semi-structured telephone interviews with the directors of the 10 National Institutes of Health Centers for Population Health and Health Disparities (NIH/CPHHD) to identify factors that were associated with the sustainability of 19 interventions developed to address cancer disparities and 17 interventions developed to address cardiovascular disease disparities in the United States. Interview transcripts were analyzed using the constant comparative method of analysis to identify key themes and synthesize findings. Directors at NIH/CPHHD reported that barriers to sustainability included uncertainty about future funding and insufficient resources to build and maintain diverse stakeholder partnerships. Strategies that helped to overcome these barriers included developing and engaging community partnerships with health care systems; early pursuit of multiple funding sources; and investments in infrastructure to address the social determinants of health. Sustainability planning should be incorporated during the early stages of intervention development to facilitate maintenance of successful programs that address health disparities.

Lower carotid revascularization rates after stroke in racial/ethnic minority-serving US hospitals

OBJECTIVE

We sought to determine whether the use of carotid revascularization procedures after stroke due to carotid stenosis differs between minority-serving hospitals and hospitals serving predominantly white patients.

METHODS

We identified ischemic stroke cases due to carotid disease, identified by ICD-9-CM codes, from 2007 to 2011 in the Nationwide Inpatient Sample. The use of carotid endarterectomy (CEA) and carotid artery stenting (CAS) was recorded. Hospitals with ≥40% racial/ethnic minority patients (minority-serving hospitals) were compared to hospitals with <40% minority patients (predominantly white hospitals [hereafter, abbreviated to white]). Logistic regression was used to evaluate the use of CEA/CAS among minority-serving and white hospitals.

RESULTS

Of the 26,189 ischemic stroke cases meeting inclusion criteria, 20,870 (79.7%) were treated at 1,113 white hospitals and 5,319 (20.3%) received care at 325 minority-serving hospitals. Compared to patients in white hospitals, patients in minority-serving hospitals were less likely to undergo CEA/CAS (17.6%, 95% confidence interval [CI] 16.6%-18.6%, in minority-serving vs 21.2%, 95% CI 20.7%-21.8%, in white hospitals; p < 0.001). In fully adjusted logistic regression models, the odds of CEA/CAS were lower in minority-serving compared to white hospitals (odds ratio 0.81, 95% CI 0.70-0.93), independent of individual patient race/ethnicity and other measured hospital characteristics. White and Hispanic individuals had significantly lower odds of CEA/CAS in minority-serving compared to white hospitals. Patient-level racial/ethnic differences in the use of carotid revascularization procedures remained within each hospital stratum.

CONCLUSION

The odds of carotid revascularization after stroke is lower in minority- compared to white-serving hospitals, suggesting system-level factors as a major contributor to explain race disparities in the use of carotid revascularization.

Patient-level Predictors of Extent of Exposure to a Community Health Worker Intervention in a Randomized Controlled Trial

Objective

Community health worker (CHW) interventions have been cited as a best practice for reducing health disparities, but patient-level attributes may contribute to differential uptake. We examined patient characteristics associated with the extent of exposure to a CHW coaching intervention among a predominantly low-income, African American population participating in a randomized controlled trial of hypertension interventions.

Design

We conducted a within-group longitudinal analysis of those receiving a CHW intervention from a study conducted between September 2003 and August 2005. We employed mixed effects models to ascertain relationships between patients' characteristics, length of time spent with the CHW, and the number of topics discussed during the intervention.

Setting

Baltimore, MD.

Participants

140 patients with a diagnosis of hypertension in the CHW intervention arm.

Results

Marital status, stress, depression symptomology, and having multiple comorbid conditions were each independently and positively related to the length of time patients spent with CHWs. An indirect relationship between higher perceived physical health and time spent with the CHW was observed. Patients with multiple comorbid conditions discussed more intervention-related topics, while patients who perceived themselves as being healthier discussed fewer topics. Marital status and extreme poverty were the strongest predictors of the length of time spent with the CHW, while having multiple comorbid conditions was the strongest predictor of the number of coaching topics discussed.

Conclusions

Differential exposure to a CHW intervention is influenced by patients' physical, psychosocial, and sociodemographic characteristics.

Abstract P5-07-01: Computational scoring of tumor infiltrating lymphocytes in triple-negative breast cancer

Background: Stromal Tumor Infiltrating Lymphocytes (sTIL) are an established prognostic feature in triple-negative breast cancer, yet manual assessment or visual estimation of sTILs with conventional light microscopy may be subject to inter-pathologist variability. Recently published guidelines by the International TIL Working Group help address inter-pathologist variability, yet there remains a need for more objective and quantitative computational sTIL scoring.

Methods: Our study used 120 triple-negative breast cancer slides (one slide per patient). A deep-learning based image analysis workflow is used to perform segmentation and classification of tissue regions and cells on the digital whole slide image. We used 14 annotated slides to train and validate the deep learning model, and to obtain image segmentation and classification accuracy statistics. Non-training slides were used to evaluate the concordance of manual (m-sTIL) and computationally derived (c-sTIL) scores. To generate data to create the model we manually annotated tissue regions in FFPE H&E stained digital slides, including: tumor, stroma, and necrosis. Initial classification of cell nuclei was performed using a semi-automated image analysis method, and then manually corrected to generate ground truth for tumor, stroma (fibroblasts), and lymphocytes. All annotations were performed by a trained research fellow and reviewed by a board-certified pathologist. Corresponding region and nucleus-level annotations were combined to train and validate a fully-convolutional neural network that jointly classifies tissue regions and cell nuclei. Tissue region segmentation accuracy was assessed by the Dice coefficient to measure degree of overlap between predicted tissue regions and ground truth annotations. Cell classification accuracy was assessed using area under curve (AUC). Two board-certified pathologists independently generated an m-sTIL score for all slides according to clinical guidelines, and discrepancies between pathologists were resolved by consensus. c-sTIL scores were calculated as the percentage of classified stromal areas occupied by nuclei classified as lymphocytic infiltrates.

Results: Tissue region segmentation was accurate for both stroma (0.77 Dice) and tumor (0.83 Dice) regions, and accurate overall (0.78 Dice). Cell classification was highly accurate for lymphocytes (0.89 AUC), tumor cells (0.90 AUC), stromal cells (0.78 AUC), and overall (0.89 AUC, micro average). Inter observer spearman correlation between the m-sTIL scores of our two pathologists was 0.66 (p &lt; 0.001). By comparison, the correlation between c-sTIL and consensus m-sTIL was higher at 0.73 (p &lt; 0.001). Dichotomizing at a threshold sTIL score of 10%, c-sTIL scoring identifies low-sTIL patients with an accuracy of 85%. High- and Low- sTIL score patient groups show clear separation on a Kaplan-Meier curve for both c-sTIL and m-sTIL scoring approaches.

Conclusions: Our pipeline quantifies stromal TILs with high concordance with manual pathologist scores, and sheds light on the ability of computational approaches in standardizing diagnostic pathology workflows. Future work will investigate how other computationally driven histology biomarkers can predict outcomes and help prognosticate breast cancer patients.

Citation Format: Amgad M, Sarkar A, Srinivas C, Redman R, Ratra S, Bechert CJ, Calhoun BC, Mrazeck K, Kurkure U, Cooper LA, Barnes M. Computational scoring of tumor infiltrating lymphocytes in triple-negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-07-01.

Sociodemographic and Kidney Disease Correlates of Nutrient Intakes Among Urban African Americans With Uncontrolled Hypertension

OBJECTIVE

The objective of this study was to determine the association between sociodemographic factors and intakes of 4 nutrients and associations between intakes and markers of kidney disease to identify opportunities to improve outcomes among clinically high-risk African Americans.

DESIGN AND METHODS

We conducted a cross-sectional study of baseline data from the Achieving Blood Pressure Control Together study, a randomized controlled trial of 159 African Americans (117 females) with uncontrolled hypertension in Baltimore MD. To determine the association between sociodemographic factors and nutrient intakes, we constructed linear and logistic regression models. Using logistic regression, we determined the association between below-median nutrient intakes and kidney disease. Our outcomes of interest were daily intakes of vitamin C, magnesium, dietary fiber, and potassium as estimated by the Block Fruit-Vegetable-Fiber Screener and kidney disease defined as estimated glomerular filtration rate <60 mL/min per 1.73 m2 or urinary albumin-to-creatinine ratio >=30 mg/g.

SETTING AND SUBJECTS

Baseline data from the Achieving Blood Pressure Control Together study, a randomized controlled trial of 159 African Americans (117 females) with uncontrolled hypertension, were obtained.

METHODS

To determine the association between sociodemographic factors and nutrient intakes, we constructed linear and logistic regression models. Using logistic regression, we determined the association between below-median nutrient intakes and kidney disease.

MAIN OUTCOME MEASURES

Our outcomes of interest were daily intakes of vitamin C, magnesium, dietary fiber, and potassium as estimated by the Block Fruit-Vegetable-Fiber Screener and kidney disease defined as estimated glomerular filtration rate <60 mL/min per 1.73 m² or urinary albumin-to-creatinine ratio ≥30 mg/g.

RESULTS

Overall, compared to Institute of Medicine recommendations, participants had lower intakes of magnesium, fiber, and potassium but higher vitamin C intakes. For females, sociodemographic factors that significantly associated with lower intake of the 4 nutrients were older age, obesity, lower health numeracy, and lesser educational attainment. For males, none of the sociodemographic factors were significantly associated with nutrient intakes. Below-median intake was significantly associated with albumin-to-creatinine ratio ≥30 (adjusted odds ratio [95% confidence interval]: 3.4 [1.5, 7.8] for vitamin C; 3.6 [1.6, 8.4] for magnesium; 2.9 [1.3, 6.5] for fiber; 3.6 [1.6, 8.4] for potassium), but not with estimated glomerular filtration rate <60.

CONCLUSION

African Americans with uncontrolled hypertension may have low intakes of important nutrients, which could increase their risk of chronic kidney disease. Tailored dietary interventions for African Americans at high risk for chronic kidney disease may be warranted.

Abstract WP364: Lower Revascularization Rates for Stroke Due to Carotid Stenosis at Ethnic Minority Serving US Hospitals

Background: Revascularization with either carotid endarterectomy (CEA) or carotid artery stenting (CAS) has been shown to decrease future stroke risk in eligible patients with ischemic stroke due to carotid artery stenosis. We sought to determine whether the use of carotid revascularization procedures after ischemic stroke due to carotid stenosis differs between minority-serving hospitals and hospitals serving predominantly white patients.

Methods: We identified ischemic stroke cases due to carotid artery disease, identified by ICD9-CM codes, from 2007-2011 in the Nationwide Inpatient Sample. The use of carotid revascularization procedures, i.e. CEA and CAS, was recorded. Hospitals with ≥40% ethnic minority patients (minority-serving hospitals) were compared to hospitals with <40% minority patients (white hospitals). Logistic regression was used to evaluate the use of CEA/CAS among minority-serving and white hospitals.

Results: Of the 21,135 ischemic stroke cases meeting inclusion criteria, 16,256 (76.9%) were treated at 827 white hospitals, and 4,879 (23.1%) received care at 284 minority-serving hospitals. Compared to patients in white hospitals, patients in minority hospitals were less likely to undergo CEA or CAS (18.3%, 95% CI 16.7%-19.9%, in minority vs. 21.6%, 95% CI 20.5%-22.8%, in white hospitals, p<0.001). In fully adjusted logistic regression models, the odds of CEA/CAS were lower in minority compared to white hospitals (OR 0.82, 95% CI 0.71-0.95), independent of individual patient race and other measured hospital characteristics. Patient-level racial differences in the use of carotid revascularization procedures remained within each hospital stratum.

Conclusions: The odds of receiving carotid revascularization after stroke is lower in minority-serving compared to white hospitals, suggesting system-level factors as a major contributor to explain race disparities in the use of carotid revascularization.

Comparison of automated clinical and research blood pressure measurements: Implications for clinical practice and trial design

Discrepancies between clinic and research blood pressure (BP) measurements lead to uncertainties in translating hypertension management guidelines into practice. We assessed the concordance between standardized automated clinic BP, from a primary care clinic, and research BP, from a randomized trial conducted at the same site. Mean single-visit clinic BP was higher by 4.4/3.8 mm Hg (P = 0.007/<0.001). Concordance in systolic BP (SBP) improved with closer proximity of measurements (difference = 2.5 mm Hg, P = 0.21 for visits within 7 days), but not averaging across multiple visits (difference =5.1(9.2) mm Hg; P < 0.001). This discrepancy was greater among female participants. Clinic-based difference in SBP between two visits was more variable than research-based change (SD = 19.6 vs 14.0; P = 0.002); a 2-arm trial using clinic measurements would need 95% more participants to achieve comparable power. Implementation of a bundled standardization intervention decreased discrepancies between clinic and research BP, compared to prior reports. However, clinic measurements remained higher and more variable, suggesting treatment to research-based targets may lead to overtreatment and using clinic BP approximately halves power in trials.

Stakeholder Perspectives on the Use of Community Health Workers To Improve Palliative Care Use by African Americans with Cancer

BACKGROUND

African Americans in the United States have worse end-of-life care and cancer outcomes than whites. Palliative care may improve this disparity. Community Health Workers may provide a means to improve palliative care disparities.

METHODS

Semistructured in-depth interviews (five) and stakeholder focus groups (four) were conducted with cancer patients, caregivers, health care administrators, oncologists, and community health workers (CHWs). Patients were recruited through snowball sampling. Three raters coded interviews independently. Data were analyzed using interpretative phenomenological analysis.

RESULTS

Seventy-one individuals were contacted to participate with 24 stakeholders (34%) participating in individual interviews or across 4 stakeholder engagements. Eleven constructs were identified and grouped in three broader themes: "hub of the wheel," understanding palliative care, and patient-provider relationships. Participants felt that the role of a CHW should be central, bridging patients with their providers, information, and resources, including psychosocial support and advance care planning documents. They also placed an emphasis on the background of CHWs, saying individuals selected should be familiar with the history, culture, and norms of the communities from which they operate. Stakeholders reported that a CHW could activate a patient to contact their primary care physician or oncologist who may refer to or provide palliative care. Stakeholders reported that given the barriers to palliative care, a CHW could contribute to patient-centered multidisciplinary care while addressing palliative care domains with patients and families in a culturally sensitive manner.

CONCLUSION

Based on feedback from patients, caregivers, and providers, a culturally adapted CHW intervention may improve palliative care use for African American patients with advanced malignancies.