Disparities in cholesterol screening: falling short of a national health objective

Racial, ethnic, and language differences in screening measures for statin therapy following a major guideline change

Atherosclerotic cardiovascular disease (ASCVD) disproportionally affects racial and ethnic minority populations. Statin prescribing guidelines changed in 2013 to improve ASCVD prevention. It is unknown whether risk screening for statin eligibility differed across race and ethnicity over this guideline change. We examine racial/ethnic/language differences in screening measure prevalence for period-specific statin consideration using a retrospective cohort design and linked electronic health records from 635 community health centers in 24 U.S. states. Adults 50+ years, without known ASCVD, and ≥ 1 visit in 2009-2013 and/or 2014-2018 were included, grouped as: Asian, Latino, Black, or White further distinguished by language preference. Outcomes included screening measure prevalence for statin consideration, 2009-2013: low-density lipoprotein (LDL), 2014-2018: pooled cohort equation (PCE) components age, sex, race, systolic blood pressure, total cholesterol, high-density lipoprotein, smoking status. Among patients seen both periods, change in period-specific measure prevalence was assessed. Adjusting for sociodemographic and clinical factors, compared to English-preferring White patients, all other groups were more likely to have LDL documented (2009-2013, n = 195,061) and all PCE components documented (2014-2018, n = 344,504). Among patients seen in both periods (n = 128,621), all groups had lower odds of PCE components versus LDL documented in the measures' respective period; English-preferring Black adults experienced a greater decline compared to English-preferring White adults (OR 0.81; 95% CI: 0.72-0.91). Racial/ethnic/language disparities in documented screening measures that guide statin therapy for ASCVD prevention were unaffected by a major guideline change advising this practice. It is important to understand whether the newer guidelines have altered disparate prescribing and morbidity/mortality for this disease.

Social Determinants of Health Associated with the Use of Screenings for Hypertension, Hypercholesterolemia, and Hyperglycemia among American Adults

National and international health guidelines have recommended measurements of blood pressure, blood cholesterol, and blood glucose as the first step in detecting hypertension, hypercholesterolemia, and hyperglycemia, respectively. These chronic conditions are modifiable risk factors for chronic diseases such as obesity, diabetes, and cardiovascular disease. Social determinants of health (SDoHs) have contributed to persistent chronic condition disparities in the United States. This study identified SDoHs associated with the use of screening services for hypertension, hypercholesterolemia, and hyperglycemia by analyzing data from the 2019 United States National Health Interview Survey. Examined SDoHs consisted of demographic characteristics, socioeconomic status, and health care utilization. Age, gender, education, annual income, health coverage, and usual care source were positively associated with the odds of receiving secondary preventive services. There was a marginal significance among race/ethnicity and employment status in association with the odds of receiving secondary preventive services. This study's findings inform health educators and providers, public health professionals, and policymakers to fund, plan, and coordinate services and interventions accordingly to improve the population's quality of life and lengthen lifespan by promptly diagnosing and treating these diseases.

Racial/Ethnic Disparities in Screening for and Awareness of High Cholesterol Among Pregnant Women Receiving Prenatal Care

Background Atherosclerotic cardiovascular disease remains a leading cause of morbidity and mortality among women, with younger women being disproportionately affected by traditional cardiovascular risk factors such as dyslipidemia. Despite recommendations for lipid screening in early adulthood and the risks associated with maternal dyslipidemia during pregnancy, many younger women lack access to and utilization of early screening. Accordingly, our objective was to assess the prevalence of and disparities in lipid screening and awareness of high cholesterol as an atherosclerotic cardiovascular disease risk factor among pregnant women receiving prenatal care. Methods and Results We invited 234 pregnant women receiving prenatal care at 1 of 3 clinics affiliated with the University of Pennsylvania Health System to complete our survey. A total of 200 pregnant women (86% response rate) completed the survey. Overall, 59% of pregnant women (mean age 32.2 [±5.7] years) self-reported a previous lipid screening and 79% of women were aware of high cholesterol as an atherosclerotic cardiovascular disease risk factor. Stratified by racial/ethnic subgroups, non-Hispanic Black women were less likely to report a prior screening (43% versus 67%, P=0.022) and had lower levels of awareness (66% versus 92%, P<0.001) compared with non-Hispanic White women. Non-Hispanic Black women were more likely to see an obstetrician/gynecologist for their usual source of non-pregnancy care compared with non-Hispanic White women (18% versus 5%, P=0.043). Those seeing an obstetrician/gynecologist for usual care were less likely to report a prior lipid screening compared with those seeing a primary care physician (29% versus 63%, P=0.007). Conclusions Significant racial/ethnic disparities persist in lipid screening and risk factor awareness among pregnant women. Prenatal care may represent an opportunity to enhance access to and uptake of screening among younger women and reduce variations in accessing preventive care services.

Health Benefits and Cost-Effectiveness of Asymptomatic Screening for Hypertension and High Cholesterol and Aspirin Counseling for Primary Prevention

PURPOSE

Our aim was to update estimates of the health and economic impact of clinical services recommended for the primary prevention of cardiovascular disease (CVD) for the comparative rankings of the National Commission on Prevention Priorities, and to explore differences in outcomes by sex and race/ethnicity.

METHODS

We used a single, integrated, microsimulation model to generate comparable results for 3 services recommended by the US Preventive Services Task Force: aspirin counseling for the primary prevention of CVD and colorectal cancer, screening and treatment for lipid disorders (usually high cholesterol), and screening and treatment for hypertension. Analyses compare lifetime outcomes from the societal perspective for a US-representative birth cohort of 100,000 persons with and without access to each clinical preventive service. Primary outcomes are health impact, measured by the net difference in lifetime quality-adjusted life years (QALYs), and cost-effectiveness, measured in incremental cost per QALY or cost savings per person in 2012 dollars. Results are also presented for population subgroups defined by sex and race/ethnicity.

RESULTS

Health impact is highest for hypertension screening and treatment (15,600 QALYs), but is closely followed by cholesterol screening and treatment (14,300 QALYs). Aspirin counseling has a lower health impact (2,200 QALYs) but is found to be cost saving ($31 saved per person). Cost-effectiveness for cholesterol and hypertension screening and treatment is $33,800 per QALY and $48,500 per QALY, respectively. Findings favor hypertension over cholesterol screening and treatment for women, and opportunities to reduce disease burden across all services are greatest for the non-Hispanic black population.

CONCLUSIONS

All 3 CVD preventive services continue to rank highly among other recommended preventive services for US adults, but individual priorities can be tailored in practice by taking a patient's demographic characteristics and clinical objectives into account.

Primary prevention of cardiovascular disease: More patient gender-based differences in risk evaluation among male general practitioners

OBJECTIVE

Our objective was to analyse general practitioner (GP) cardiovascular risk assessment of patients for primary prevention while considering the gender of both the GP and the patient.

METHODS

This study consisted of an observational survey of GPs who were internship supervisors in the Paris metropolitan area. Each of 52 volunteer GPs completed a self-administered questionnaire regarding their own characteristics and randomly selected 70 patients from their patient list. Dependent variables from the patient files included the presence of information about risk factors necessary to assess the patient's cardiovascular risk according to the French scale and the Systematic COronary Risk Evaluation (SCORE) scale. Analyses used mixed logistic models with a random intercept and adjusted for patient and physician characteristics.

RESULTS

Both cardiovascular risk scales could be assessed less frequently in women than in men (odds ratio (OR) = 0.64 (95% confidence interval (CI): 0.5-0.8) for the French scale and OR = 0.63 (95% CI: 0.5-0.8) for the SCORE scale). These gender differences were less substantial when the patients were seen by female (for the SCORE scale OR = 0.72 (95% CI: 0.5-1.01)) compared with male physicians (OR = 0.56 (95% CI: 0.4-0.7)). The patients who were least well assessed for cardiovascular risk were women seen by male physicians.

CONCLUSION

Even before the onset of cardiovascular disease, women patients receive less satisfactory preventative management than men do, and these differences are even more marked when the physician is a man. More attention to the influence of gender stereotypes is needed in medical training in order to combat the inequalities that they cause.

Income Disparities in the Use of Health Screening Services Among University Students in Korea: A Cross-Sectional Study of 2479 Participants in a University

Public health insurance coverage for preventive care in young adults is incomplete in Korea. Few studies have focused on young adults' socioeconomic disparities in preventive care utilization. We aimed to explore household income disparities in the use of different types of health screening services among university students in Korea.This cross-sectional study used a web-based self-administered survey of students at a university in Korea from January to February 2013. To examine the associations between household income levels and health screening service use within the past 2 years, odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression with adjustment for various covariables.Of 2479 participants, 45.5% reported using health screening services within 2 years (university-provided screening 32.9%, private sector screening 16.7%, and both 4.1%). Household income levels were not significantly associated with overall rates of health screening service use with a multivariable-adjusted OR (95% CI) in the lowest versus highest income group of 1.12 (0.87-1.45, Ptrend = 0.35). However, we found significantly different associations in specific types of utilized screening services by household income levels. The multivariable-adjusted OR (95% CI) of university-provided health screening service use in the lowest versus highest income level was 1.74 (1.30-2.34; Ptrend < 0.001), whereas the multivariable-adjusted OR (95% CI) of private sector service use in the lowest versus highest income level was 0.45 (0.31-0.66; Ptrend < 0.001).This study demonstrated significant disparities in the types of utilized health screening services by income groups among university students in Korea, although overall rates of health screening service use were similar across income levels. Low-income students were more likely to use university-provided health screening services, and less likely to use private sector screening services. To ensure appropriate preventive care delivery for young adults and to address disparities in disadvantaged groups, the expansion of medical insurance coverage for preventive health care, establishment of a usual source of care, focusing on vulnerable groups, and the development of evidence-based standardized health screening guidelines for young adults are needed.

Explaining racial and ethnic disparities in cholesterol screening

OBJECTIVE

To determine whether racial and ethnic disparities in cholesterol screening persist after controlling for socioeconomic status, access to care and language.

METHODS

Data were obtained from the 2011 Behavioral Risk Factor Surveillance System for men aged 35 and older and women aged 45 and older in accordance with the United States Preventive Services Task Force guidelines. Self-reported cholesterol screening data are presented for 389,039 respondents reflecting over 141million people. Sequential logistic regression models of the likelihood of never having been screened are presented adjusted for demographic characteristics, health status, behavioral risk factors, socioeconomic status, health care access, and questionnaire language.

RESULTS

A total of 9.1% of respondents, reflecting almost 13million individuals, reported never having been screened. After adjustment for socioeconomic status, health care access and Spanish language, disparities between whites and Blacks and Hispanics, but not Asians and Pacific Islanders, were eliminated.

CONCLUSIONS

Lower socioeconomic status, lack of healthcare access and language barriers explained most of the racial and ethnic disparities in cholesterol screening. Expanding insurance coverage, simplifying cardiac risk assessment and improving access to culturally and linguistically appropriate care hold the greatest promise for improving cardiovascular disease screening and treatment for vulnerable populations.

Impact of performance improvement continuing medical education on cardiometabolic risk factor control: the COSEHC initiative

INTRODUCTION

The Consortium for Southeastern Hypertension Control (COSEHC) implemented a study to assess benefits of a performance improvement continuing medical education (PI CME) activity focused on cardiometabolic risk factor management in primary care patients.

METHODS

Using the plan-do-study-act (PDSA) model as the foundation, this PI CME activity aimed at improving practice gaps by integrating evidence-based clinical interventions, physician-patient education, processes of care, performance metrics, and patient outcomes. The PI CME intervention was implemented in a group of South Carolina physician practices, while a comparable physician practice group served as a control. Performance outcomes at 6 months included changes in patients' cardiometabolic risk factor values and control rates from baseline. We also compared changes in diabetic, African American, the elderly (> 65 years), and female patient subpopulations and in patients with uncontrolled risk factors at baseline.

RESULTS

Only women receiving health care by intervention physicians showed a statistical improvement in their cardiometabolic risk factors as evidenced by a -3.0 mg/dL and a -3.5 mg/dL decrease in mean LDL cholesterol and non-HDL cholesterol, respectively, and a -7.0 mg/dL decrease in LDL cholesterol among females with uncontrolled baseline LDL cholesterol values. No other statistical differences were found.

DISCUSSION

These data demonstrate that our PI CME activity is a useful strategy in assisting physicians to improve their management of cardiometabolic control rates in female patients with abnormal cholesterol control. Other studies that extend across longer PI CME PDSA periods may be needed to demonstrate statistical improvements in overall cardiometabolic treatment goals in men, women, and various subpopulations.

We can do better than last place: improving the health of us women

Life expectancy for US women lags behind that for women in other countries. Factors contributing to inequitable health for women are complex and include policy, community, healthcare access, and the interaction between the patient and her healthcare provider working within the healthcare system. We propose a societal pyramid of health accounting for the effects of these different factors and their impact on prevention, screening, diagnosis, and management of disease using the examples of smoking and obesity, two of the most important yet modifiable risk factors for chronic disease and death among US women.

Receipt of preventive health services in young adults

PURPOSE

To examine self-reported rates and disparities in delivery of preventive services to young adults.

METHODS

A population-based cross-sectional analysis, of 3,670 and 3,621 young adults aged 18-26 years who responded to California Health Interview Survey (CHIS) in 2005 and CHIS 2007, respectively. The main outcome measures were self-reported receipt of flu vaccination, sexually transmitted disease (STD) screening, cholesterol screening, diet counseling, exercise counseling, and emotional health screening. Multivariate logistic regression was used to examine how age, gender, race/ethnicity, income, insurance, and usual source of care influence the receipt of preventive services.

RESULTS

Delivery rates ranged from 16.7% (flu vaccine) to 50.6% (cholesterol screening). Being female and having a usual source of care significantly increased receipt of services, with female participants more likely to receive STD screening (p < .001), cholesterol screening (p < .01), emotional health screening (p < .001), diet counseling (p < .01), and exercise counseling (p < .05) than male participants after controlling for age, race/ethnicity, income, insurance, and usual source of care. Young adults with a usual source of care were more likely to receive a flu vaccine (p < .05), STD screening (p < .01), cholesterol screening (p < .001), diet counseling (p < .05), and exercise counseling (p < .05) than those without a usual source of care after adjusting for age, race/ethnicity, income, and insurance.

CONCLUSIONS

Rates of preventive services delivery are generally low. Greater efforts are needed to develop guidelines for young adults to increase the delivery of preventive care to this age-group, and to address the gender and ethnic/racial disparities in preventive services delivery.

Screening for cardiovascular disease risk factors in an urban low-income setting at baseline and post intervention: a prospective intervention study

BACKGROUND

Not all segments of society might have equal access to screening. We determined predictors for regular cardiovascular health screening at baseline amongst those of low socioeconomic status (SES) and evaluated the effectiveness of a 6-month intervention on screening in this group compared to a high-SES group.

METHODS

The study population involved all residents aged ≥ 40 years in two housing estates comprising owner-occupied housing (high SES) and rental flats (low SES) in Singapore. From 2009 to 2011, residents not being screened regularly at baseline for hypertension, diabetes, and dyslipidaemia were offered free and convenient blood pressure, fasting blood glucose, and lipid testing over 6 months. Chi-squared and multi-level logistic regression identified predictors of regular screening at baseline; likelihood ratio and Cox regression analysis identified predictors of screening participation post intervention.

RESULTS

Participation was 78.2% (1081/1383). At baseline, in the low-SES group, 41.7% (150/360), 38.8% (177/456), and 30.8% (128/416) had gone for regular hypertension, diabetes, and dyslipidaemia screening, respectively; compared with higher numbers in the high-SES group. Sociodemographic factors predicting regular screening in the low-SES community included being married and not smoking. Post intervention, screening rates rose significantly (p < 0.001) by similar proportions in both communities. Staying in a lower-SES community (adjusted relative risk (aRR) 0.61, 95% CI 0.37-0.99, p = 0.048) and having hypertension (aRR 0.45, 95% CI 0.18-0.98, p = 0.049) was associated with lower take-up; Chinese ethnicity (aRR 1.84, 95% CI 1.00-3.43, p = 0.050) and employment associated with higher take-up (aRR 1.57, 95% CI 1.03-2.60, p = 0.040).

CONCLUSION

Participation in cardiovascular health screening was poor amongst those of low SES; a 6-month intervention programme improved participation in this population.

Touch screen computer health assessment in Australian general practice patients: a cross-sectional study protocol

INTRODUCTION

Cardiovascular disease (CVD) and cancer are leading causes of death globally. Early detection of cancer and risk factors for CVD may improve health outcomes and reduce mortality. General practitioners (GPs) are accessed by the majority of the population and play a key role in the prevention and early detection of chronic disease risk factors. This cross-sectional study aims to assess the acceptability of an electronic method of data collection in general practice patients. The study will describe the proportion screened in line with guidelines for CVD risk factors and cancer as well as report the prevalence of depression, lifestyle risk factors, level of provision of preconception care, cervical cancer vaccination and bone density testing. Lastly, the study will assess the level of agreement between GPs and patients perception regarding presence of risk factors and screening.

METHODS AND ANALYSIS

The study has been designed to maximise recruitment of GPs by including practitioners in the research team, minimising participation burden on GPs and offering remuneration for participation. Patient recruitment will be carried out by a research assistant located in general practice waiting rooms. Participants will be asked regarding the acceptability of the touch screen computer and to report on a range of health risk and preventive behaviours using the touch screen computer. GPs will complete a one-page survey indicating their perception of the presence of risk behaviours in their patients. Descriptive statistics will be generated to describe the acceptability of the touch screen and prevalence of health risk behaviours. Cohen's κ will be used to assess agreement between GP and patient perception of presence of health risk behaviours.

ETHICS AND DISSEMINATION

This study has been approved by the human research committees in participating universities. Findings will be disseminated via peer-reviewed publications, conference presentations as well as practice summaries provided to participating practices.

Blood pressure and cholesterol screening prevalence among U.S. women of reproductive age opportunities to improve screening

BACKGROUND

Blood pressure and cholesterol screening among women of reproductive age are important for early disease detection and intervention, and because hypertension and dyslipidemia are associated with adverse pregnancy outcomes.

PURPOSE

The objective of this study was to examine associations of sociodemographic characteristics, cardiovascular disease risk factors, and healthcare access indicators with blood pressure and cholesterol screening among women of reproductive age.

METHODS

In 2011, prevalence estimates for self-reported blood pressure screening within 2 years and cholesterol screening within 5 years and AORs for screenings were calculated for 4837 women aged 20-44 years, using weighted 2008 National Health Interview Survey data.

RESULTS

Overall, recommended blood pressure and cholesterol screening was received by 89.6% and 63.3% women, respectively. Those who were underinsured or uninsured had the lowest screening percentage at 76.6% for blood pressure (95% CI=73.4, 79.6) and 47.6% for cholesterol (95% CI=43.8, 51.5) screening. Suboptimal cholesterol screening prevalence was also found for women who smoke (54.5%, 95% CI=50.8, 58.2); obese women (69.8%, 95% CI=66.3, 73.0); and those with cardiovascular disease (70.3%, 95% CI=63.7, 76.1), prediabetes (73.3%, 95% CI= 64.1, 80.8), or hypertension (81.4%, 95% CI=76.6, 85.4).

CONCLUSIONS

Most women received blood pressure screening, but many did not receive cholesterol screening. Universal healthcare access may improve screening prevalence.

Prediabetes and blood pressure effects on heart rate variability, QT-interval duration, and left ventricular hypertrophy in overweight-obese adolescents

This ancillary, descriptive correlational study examined the effect of glucose regulation, blood pressure (BP), and their combined effects on cardiac autonomic function in 128 overweight-obese 11-18-year-olds. Measures included body mass index, resting BP, fasting glucose, glucose tolerance, and cardiac autonomic function (heart rate variability, QT, and Cornell voltage). After adjusting for age and gender, multivariate analysis of covariance revealed no differences in cardiac autonomic measures based on glucose regulation (p = .319), BP (p = .286), or the interaction between glucose regulation and BP (p = .132). The additive effect of prediabetes and elevated BP did not impact cardiac autonomic function in overweight-obese youth.

Having a primary care provider and receipt of recommended preventive care among men in New York City

To assess the role of having a primary care provider (PCP) in men's up-to-date receipt of recommended preventive services (colonoscopy, pneumococcal and seasonal influenza vaccination, cholesterol and blood pressure screenings), data from the 2005 and 2006 New York City Community Health Surveys (N = 3,728 [2006], 2,810 [2005]) were analyzed. PCP prevalence and men's uptake of each service, overall and by age, race/ethnicity, education, income, insurance status, marital status, and nativity, were evaluated. After controlling for insurance status and other factors, having a PCP significantly predicted receipt of each service (adjusted prevalence ratio from 1.12 [1.08, 1.16] to 1.72 [1.35, 2.22]) and total services. Colonoscopy and seasonal influenza and pneumococcal vaccination receipt were below 70% with or without a PCP. Efforts to increase the proportion of men having a PCP are needed to improve receipt of recommended services. Maximizing awareness and provision of low-use preventive services may be useful.

Pre-existing cardiovascular conditions and pharmacological treatment of adult ADHD

BACKGROUND

Stimulants and atomoxetine should generally not be used or used only with caution in adults with pre-existing cardiovascular conditions. The extent to which pre-existing cardiovascular conditions influence initiation of these ADHD medications in adults is not known.

METHODS

We performed a retrospective cohort study of privately insured adults with new ADHD treatment episodes. Pre-existing cardiovascular conditions were assessed by the presence of ICD-9-CM codes for congenital abnormalities, atherosclerosis, cardiac disease, and cerebrovascular disease in the 12 months before the index ADHD diagnosis. The primary outcome was new initiation of a stimulant or atomoxetine in the 3 months after the index date. Multivariate logistic regression was used to predict the likelihood of treatment initiation with stimulants or atomoxetine based on pre-existing cardiovascular conditions, patient demographic characteristics, clinical mental disorder comorbidities, other psychotropic drug use, and provider type.

RESULTS

Of 8752 patients with a new ADHD treatment episode, 917 (10.5%) had evidence of >or=1 pre-existing cardiovascular condition. Stimulants were started by 40.8% of patients with and 53.0% of patients without pre-existing cardiovascular conditions (Adjusted Odds Ratio, AOR 0.71; 95%CI 0.61-0.82). Pre-existing cardiovascular conditions reduced the likelihood of initiating stimulant treatment in younger but not in older patients (p-value for age x cardiovascular condition interaction = 0.0002). Initiation of atomoxetine treatment was not affected by pre-existing cardiovascular conditions (AOR 1.19, 95%CI 0.94-1.50).

CONCLUSIONS

Pre-existing cardiovascular conditions reduce the likelihood of stimulant therapy but not atomoxetine treatment in adult ADHD patients. However, many adult ADHD patients with pre-existing cardiovascular conditions initiate stimulant therapy.

Influence of number of children on cancer screening among adults in the United States

OBJECTIVE

To investigate the influence of children in the household on the likelihood of reporting cancer screening among adult men and women living in the United States.

METHODS

2004-2006 Medical Expenditure Panel Surveys (MEPS) were used to calculate the probability of self-reported cancer screening by number of children for adult men and women with adjustment for age, sex, marital status, race, education, current smoking status, obesity status, health insurance and having a usual health-care provider.

RESULTS

The largest percentage of persons who had cancer screening was among respondents with no children in the household. In multivariate results, the probability of endoscopy was lower for persons with one child (24%) and two or more children (21%) in comparison with persons with no children living in the household (30%). Prostate-specific antigen (PSA) testing was lower among men with one child (17%) and two or more children (14%) in comparison with no children (22%). Pap smears were lower for women with two or more children (50%) but not different for women with one child (55%) in comparison with no children (56%). Mammograms were lower for women with one child (48%) and two or more children (42%) in comparison with no children in the household (55%).

CONCLUSION

Across several different cancer screening modalities, the probability of screening is lower as the number of children in the household increases. Children may be an additional barrier to screening beyond factors such as socioeconomic status and access to care.

Factors affecting use of preventive tests for cardiovascular risk among Greeks

Data from a Greek national representative sample was used to investigate socio-demographic, self-perceived health, and health risk factors that determine the use of cardiovascular preventive tests (blood pressure, cholesterol and blood glucose). Chi-square and logistic regression analyses were used (p < 0.05). Older age, marriage, regular family doctor and chronic diseases increased the likelihood of receiving preventive tests, whereas low education and alcohol consumption reduced the likelihood of having these tests. The effect of obesity varied. Interventions which improve the knowledge of the poorly educated and empower the preventive role of the physicians may redress the inequalities and improve the effectiveness of preventive services utilization.

Real men do...real men don't: Young Latino and African American men's discourses regarding sexual health care utilization

There is growing recognition that men as well as women need sexual health care (SHC) services. Despite this, male friendly sexual health services are not readily available in the United States, and men are underutilizing the services that are available. This situation needs to be rectified to improve sexual health outcomes for men and women. In this study we conducted 10 focus groups with young adult Latino and African American men to examine their perceptions of the factors influencing SHC utilization among the men they know, with an emphasis on how notions of what it means to be a man affects health care seeking. The findings both amplify and complicate the relationship between masculinity and SHC seeking. They suggest new directions for public health efforts to enhance men's SHC utilization.

Preventive care in Appalachia: use of the theory of planned behavior to identify barriers to participation in cholesterol screenings among West Virginians

CONTEXT

West Virginians are at increased risk for heart disease. Given that the process of atherosclerosis begins in childhood, the Coronary Artery Risk Detection in Appalachian Communities Project was developed to reduce this risk by implementing a cholesterol screening program in the schools. However, participation rates have been less than desired.

PURPOSE

This study examined the barriers to participation in preventive health screenings, specifically cholesterol screenings, in adults and children of West Virginia using the theory of planned behavior to guide conceptualization.

METHODS

A total of 14 community leaders, 36 parents, and 92 fifth-grade children from 6 West Virginia counties with predominately rural populations participated in individual and focus group interviews. Qualitative analysis was used to examine interview transcripts.

FINDINGS

Adult and child attitudes about preventive care were the largest barrier to cholesterol screenings. Adult attitudinal barriers included concerns with outcomes of testing, lack of knowledge about cholesterol and heart disease, concerns about needles, and traditional Appalachian cultural beliefs (resistance to change, denial, and fatalism). Children cited concerns about needles, outcomes of testing, privacy, and lack of concern about health and cholesterol. Adults also acknowledged environmental barriers to screenings. Finally, children reported a lack of social pressure to participate in prevention activities.

CONCLUSIONS

Attitudinal, social normative, and environmental barriers to health screenings may be characteristic of impoverished rural Appalachians. Interventions are being designed to target these belief barriers to improve participation in cholesterol screenings for fifth graders.

Gender Disparities in the Quality of Cardiovascular Disease Care in Private Managed Care Plans

BACKGROUND

Studies have shown that women with cardiovascular disease (CVD) are screened and treated less aggressively than men and are less likely to undergo cardiac procedures. Research in this area has primarily focused on the acute setting, and there are limited data on the ambulatory care setting, particularly among the commercially insured. To that end, the objective of this study is to determine if gender disparities in the quality of CVD care exist in commercial managed care populations.

METHODS

Using a national sample of commercial health plans, we analyzed member-level data for 7 CVD quality indicators from the Healthcare Effectiveness Data and Information Set (HEDIS) collected in 2005. We used hierarchical generalized linear models to estimate these HEDIS measures as a function of gender, controlling for race/ethnicity, socioeconomic status, age, and plans' clustering effects.

RESULTS

Results showed that women were less likely than men to have low-density lipoprotein (LDL) cholesterol controlled at <100 mg/dL in those who have diabetes (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.76-0.86) or a history of CVD (OR, 0.72; CI 95%, 0.64-0.82). The difference between men and women in meeting the LDL control measures was 5.74% among those with diabetes (44.3% vs. 38.5%) and 8.53% among those with a history of CVD (55.1% vs. 46.6%). However, women achieved higher performance than men in controlling blood pressure (OR, 1.12; 95% CI, 1.02-1.21), where the rate of women meeting this quality indicator exceeded that of men by 1.94% (70.8% for women vs. 68.9% for men).

CONCLUSIONS

Gender disparities in the management and outcomes of CVD exist among patients in commercial managed care plans despite similar access to care. Poor performance in LDL control was seen in both men and women, with a lower rate of control in women suggesting the possibility of less intensive cholesterol treatment in women. The differences in patterns of care demonstrate the need for interventions tailored to address gender disparities.

Disability and receipt of clinical preventive services among women

BACKGROUND

More individuals are surviving catastrophic injuries and living longer with persistent disability; however, their receipt of clinical preventive services is not well understood as compared with those without disabilities given the dual focus of care on both primary prevention and the prevention of secondary complications related to their disabilities.

METHODS

Longitudinal analyses of 1999-2002 Medical Expenditure Survey (MEPS). Study sample consisted of 3,183 community-dwelling women aged 51-64 years and followed for 2 full years. Women with disabilities were defined as having reported any limitation in any area of activity of daily living in 2 years. Recommended clinical preventive services were defined as receiving the following at the recommended intervals: colorectal, cervical, and breast cancer; cholesterol screening; and influenza immunization. chi(2) tests and multiple logistic regressions were used to examine variations in use of clinical preventive services.

RESULTS

Overall, 23% of the women in the study (n = 835) were disabled. Disabled women, however, were less likely to receive mammography and Pap smears within the recommended intervals. However, disabled women were more likely to receive influenza immunization, cholesterol screening, and colorectal screening within the recommended intervals. Among the disabled, usual source of care and health insurance remained significant predictors of receipt of clinical preventive services across all types,

CONCLUSIONS

Disabled women were less likely to receive some of the cancer screening services, suggesting a need for targeted interventions to promote breast cancer and cervical cancer screening. Increased access to health care insurance and health care providers may also help.

Health disparities and direct-to-consumer prescription drug advertising: a content analysis of targeted magazine genres, 1992-2002

Health disparities exist in the United States based on race, gender, and socioeconomic status. One way to alleviate some of the disparities regarding certain diseases or conditions is to increase awareness among populations most affected. Physicians have suggested that direct-to-consumer advertising (DTCA) of prescription drugs could play a role in awareness. Social identity theory suggests that individuals are likely to attend messages if they can identify, often based on race or gender, with people portrayed in the messages. This study analyzed DTCA in 11 years of Black, women's, news, and entertainment magazines to determine whether models in the ads targeted specific populations. Black magazines were more likely to contain ads featuring Black models only than were other genres, which had more DTCA picturing White models only. Health conditions the drugs were intended for varied by genre and over time, with STD drugs appearing primarily in Black magazines, and DTCA for heart disease not published in Black magazines, despite cardiovascular diseases being the No. 1 cause of death for Blacks (and Whites). Women's magazines featured DTCA for a wide variety of drugs, reinforcing their roles as caretakers, with proportionally few ads for women's health. Implications for targeted use of magazine genres as a means of providing health information to specific populations are discussed.

Comparison of rosuvastatin versus atorvastatin in Hispanic-Americans with hypercholesterolemia (from the STARSHIP trial)

In a multicenter, open-label trial, 696 Hispanic patients with low-density lipoprotein (LDL) cholesterol levels > or =130 and < or =300 mg/dl and triglyceride levels <400 mg/dl at medium or high risk of coronary heart disease were randomized to receive 10 or 20 mg of rosuvastatin or 10 or 20 mg of atorvastatin for 6 weeks. At week 6, LDL cholesterol was decreased more by 10 mg of rosuvastatin than by 10 mg of atorvastatin (45% vs 36%, p <0.0001) and more by 20 mg of rosuvastatin than by 20 mg of atorvastatin (50% vs 42%, p <0.0001). Significantly greater decreases were also observed with rosuvastatin for total cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein-B, and lipid ratios compared with milligram-equivalent doses of atorvastatin. Overall, National Cholesterol Education Program Adult Treatment Program III LDL cholesterol goals were achieved by 78% and 88% of patients who received 10 and 20 mg of rosuvastatin and by 60% and 73% of patients who received 10 and 20 mg of atorvastatin, respectively. Among high-risk patients, the LDL cholesterol goal of <100 mg/dl was achieved by 74% and 91% of patients who received 10 and 20 mg of rosuvastatin and by 52% and 62% who received 10 and 20 mg of atorvastatin, respectively. All treatments were well tolerated, and adverse events were similar in frequency across treatment groups. No cases of myopathy or rhabdomyolysis were observed. In conclusion, treatment with rosuvastatin and atorvastatin produced beneficial lipid changes in this group of Hispanic patients that appear comparable in magnitude to those observed in primarily non-Hispanic white study populations. These benefits were accompanied by a favorable safety profile that suggests no concerns particular to this population.

An evaluation of the Nashville REACH 2010 community health screening strategy

Community-based screening is 1 of 4 strategies selected by the Nashville REACH 2010 project for reducing disparities in heart disease and diabetes among African Americans in North Nashville, Tenn. We evaluated our screening efforts by asking 4 questions: (1) Are the screening participants representative of the target population? (2) How often were screening participants with possible undiagnosed hypertension, high cholesterol, and diabetes identified? (3) How often were screening participants with an elevated risk for developing hypertension, high cholesterol, and diabetes identified? and (4) How often did we identify screening participants with known hypertension, high cholesterol, and diabetes whose disease management was suboptimal? Results from 1757 persons screened were compared to telephone surveys from 16,199 Nashville residents. Those screened were younger and healthier than the target population. Rates of potentially undiagnosed cases among African Americans were 0.8% for diabetes, 17.4% for hypertension, and 32.7% for high cholesterol. High-risk individuals were identified 13.1% of the time for diabetes, 45.3% of the time for hypertension, and 21.3% of the time for total cholesterol. Rates of poorly controlled known disease were 23.5% for diabetes, 39.0% for hypertension, and 58.2% for total cholesterol. Although we reached a younger and healthier group than the community population, community-based screenings identified many people with potential health risks. We present a model of how to organize and implement successful community-based screening.

Effects of sex, age, and visits on receipt of preventive healthcare services: a secondary analysis of national data

BACKGROUND

Sex and age may exert a combined influence on receipt of preventive services with differences due to number of ambulatory care visits.

METHODS

We used nationally representative data to determine weighted percentages and adjusted odds ratios of men and women stratified by age group who received selected preventive services. The presence of interaction between sex and age group was tested using adjusted models and retested after adding number of visits.

RESULTS

Men were less likely than women to have received blood pressure screening (aOR 0.44;0.40-0.50), cholesterol screening (aOR 0.72;0.65-0.79), tobacco cessation counseling (aOR 0.66;0.55-0.78), and checkups (aOR 0.53;0.49-0.57). In younger age groups, men were particularly less likely than women to have received these services. In adjusted models, this observed interaction between sex and age group persisted only for blood pressure measurement (p = .016) and routine checkups (p < .001). When adjusting for number of visits, the interaction of age on receipt of blood pressure checks was mitigated but men were still overall less likely to receive the service.

CONCLUSION

Men are significantly less likely than women to receive certain preventive services, and younger men even more so. Some of this discrepancy is secondary to a difference in number of ambulatory care visits.

Using behavioral risk factor surveillance data for heart disease and stroke prevention programs

An effective state heart disease and stroke prevention program must be able to monitor changes in heart disease and stroke risk factors of the state population. The Behavioral Risk Factor Surveillance System (BRFSS), a state-based telephone survey, has been an important source for monitoring health-related factors and evaluating the success of programs. The BRFSS currently includes modules on hypertension and cholesterol screening and awareness, cardiovascular disease preventive practices, and recognition of the signs and symptoms of heart attack and stroke as well as relevant modules on fruit and vegetable intake, physical activity, tobacco use, and diabetes. Publication topics included monitoring risk factors and clinical services, assessing progress toward national goals, assessing health disparities, and health status and health-related quality of life issues. States have used the BRFSS data for monitoring health risks in the state, assessing state and national health objectives, determining and providing data for public health campaigns, providing information for legislative proposals, and providing information that helps to initiate collaboration. Major methodologic issues involve validating self-reported data against direct measurement and assessing the effects of changes in telecommunications. As Centers for Disease Control's (CDC) national heart disease and stroke prevention program and each state health department program develop, state and even local level data will become more important to measure the burden of disease and program impact. State heart disease and stroke prevention programs are encouraged to work closely with state BRFSS coordinators to obtain vital information to measure the burden of heart disease and stroke in their state and to be able to measure program impact on addressing the first and third leading causes of death in the U.S.

Disparities in lipid management for African Americans and Caucasians with coronary artery disease: a national cross-sectional study

Background

Individuals with coronary artery disease are at high risk for adverse health outcomes. This risk can be diminished by aggressive lipid management, but adherence to lipid management guidelines is far from ideal and substantial racial disparities in care have been reported. Lipid treatment and goal attainment information is not readily available for large patient populations seen in the fee-for-service setting. As a result, national programs to improve lipid management in this setting may focus on lipid testing as an indicator of lipid management. We describe the detection, treatment, and control of dyslipdemia for African Americans and Caucasians with coronary artery disease to evaluate whether public health programs focusing on lipid testing can eliminate racial disparities in lipid management.

Methods

Physicians and medical practices with high numbers of prescriptions for coronary artery disease medications were invited to participate in the Quality Assurance Program. Medical records were reviewed from a random sample of patients with coronary artery disease seen from 1995 through 1998. Data related to the detection, treatment, and control of dyslipidemia were abstracted from the medical record and evaluated in cross-sectional stratified and logistic regression analyses using generalized estimation equations.

Results

Data from the medical records of 1,046 African Americans and 22,077 Caucasians seen in outpatient medical practices in 23 states were analyzed. African-American patients were younger, more likely to be women and to have diabetes, heart failure, and hypertension. The low density lipoprotein cholesterol (LDL-C) testing rate for Caucasian men was over 1.4 times higher than that for African-American women and about 1.3 times higher than that for African-American men. Almost 60% of tested Caucasian men and less than half of tested African Americans were prescribed lipid-lowering drugs. Tested and treated Caucasian men had the highest LDL-C goal attainment (35%) and African-American men the lowest (21%).

Conclusions

Although increased lipid testing is clearly needed for African Americans, improvements in treatment and control are also necessary to eliminate racial disparities in lipid management. Disparities in treatment and goal attainment must be better understood and reflected in policy to improve the health of underserved populations.

Understanding the factors underlying disparities in cancer screening rates using the Peters-Belson approach: results from the 1998 National Health Interview Survey

BACKGROUND

Cancer screening rates vary substantially by race and ethnicity. We applied the Peters-Belson approach, often used in wage discrimination studies, to analyze disparities in cancer screening rates between different groups using the 1998 National Health Interview Survey.

METHODS

A regression model predicting the probability of getting screened is fit to the majority group and then used to estimate the expected values for minority group members had they been members of the majority group. The average difference between the observed and expected values for a minority group is the part of the disparity that is not explained by the covariates.

RESULTS

The observed disparities in colorectal cancer screening (5.88%) and digital rectal screening (8.54%) between white and black men were explained fully by the difference in their covariate distributions. Only half of the disparity in the observed screening rates (13.54% for colorectal and 17.47% for digital rectal) between white and Hispanic men was explained by the difference in covariates between the groups. The entire disparity observed in mammography screening rates for black and Hispanic women (2.71% and 6.53%, respectively) compared with white women was explained by the difference in covariate distributions.

CONCLUSIONS

We found that the covariates that explain the disparity in screening rates between the white and the black population do not explain the disparity between the white and the Hispanic population. Knowing how much of a health disparity is explained by measured covariates can be used to develop more effective interventions and policies to eliminate disparity.

Cardiovascular disease risk reduction in the Behavioral Risk Factor Surveillance System

BACKGROUND

Cardiovascular disease (CVD) risk-reduction practices are suboptimal in populations at high risk for CVD, and this problem may be worse in women than in men.

METHODS

In 2003, CVD risk-reduction practices were compared between men and women after stratification by CVD risk status (high, intermediate, low) in a cross-sectional analysis of the 1999 Behavioral Risk Factor Surveillance System (BRFSS), a random-digit telephone survey of state population-based samples of the civilian non-institutionalized population of adults. This analysis included persons aged >40 years who answered questions regarding lipid and blood pressure screening, recommendations for lifestyle modification, that is, exercise and reduced fat intake, and aspirin use. Risk status was defined according to Adult Treatment Panel III definitions.

RESULTS

In the 97,387 adults included in this analysis, high CVD risk was associated with lipid and blood pressure screening, lifestyle modification, and aspirin use in both men and women compared to intermediate-risk and low-risk (p <0.001). Among high-risk adults, men and women reported similar frequency of blood pressure and cholesterol measurement and physician advice on lifestyle modification; among intermediate- and low-risk adults, women reported slightly more frequent screening and lifestyle modification than men (p <0.001). In all CVD risk categories, women reported significantly less aspirin use than in men (p <0.001).

CONCLUSIONS

Among people at high risk for CVD, women report lifestyle modification more often than men, while men report use of aspirin more often than women. These findings may assist with targeting interventions to reduce CVD risk to the unique needs of men and women.

Cardiovascular Disease Risk Reduction: The Massachusetts WISEWOMAN Project

BACKGROUND

This report presents the effectiveness of the Massachusetts Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Project (MWWP) in reducing the cardiovascular disease (CVD) risk of uninsured and underinsured women aged > or =50.

METHODS

Healthcare sites were randomly assigned to an enhanced intervention (EI) or minimum intervention (MI). Women enrolled at all sites received CVD risk factor screening, onsite counseling, education, referral, and follow-up as needed. Women enrolled at EI sites received additional services and specially designed interventions, including one-on-one nutritional and physical activity counseling and group activities, such as walking groups, nutrition classes, and cultural festivals. We report results for 1443 women who attended the initial screening in 10 study sites. Blood pressure, total cholesterol, number of servings of fruits and vegetables, and level of moderate or vigorous physical activity were assessed at baseline and 12-month follow-up screenings. Baseline data were collected between March and June 1996; follow-up data were collected 12 months later.

RESULTS

The comprehensive screenings significantly lowered the overall prevalence of hypertension, resulting in a 7% reduction in high blood pressure among women at the EI sites (p = 0.02) and a 9% reduction at MI sites (p = 0.009). A significantly greater percentage of women became physically active at the EI sites (18%) than at the MI sites (6%) (p = 0.04).

CONCLUSIONS

MWWP is a promising model for providing comprehensive preventive healthcare to uninsured and underinsured women.

Review of evidence and explanations for suboptimal screening and treatment of dyslipidemia in women. A conceptual model

Screening and treatment rates for dyslipidemia in populations at high risk for cardiovascular disease (CVD) are inappropriately low and rates among women may be lower than among men. We conducted a review of the literature for possible explanations of these observed gender differences and categorized the evidence in terms of a conceptual model that we describe. Factors related to physicians' attitudes and knowledge, the patient's priorities and characteristics, and the health care systems in which they interact are all likely to play important roles in determining screening rates, but are not well understood. Research and interventions that simultaneously consider the influence of patient, clinician, and health system factors, and particularly research that focuses on modifiable mechanisms, will help us understand the causes of the observed gender differences and lead to improvements in cholesterol screening and management in high-risk women. For example, patient and physician preferences for lipid and other CVD risk factor management have not been well studied, particularly in relation to other gender-specific screening issues, costs of therapy, and by degree of CVD risk; better understanding of how available health plan benefits interact with these preferences could lead to structural changes in benefits that might improve screening and treatment.

Sicker and poorer--the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income

Health services research conducted over the past 25 years makes a compelling case that having health insurance or using more medical care would improve the health of the uninsured. The literature's broad range of conditions, populations, and methods makes it difficult to derive a precise quantitative estimate of the effect of having health insurance on the uninsured's health. Some mortality studies imply that a 4% to 5% reduction in the uninsured's mortality is a lower bound; other studies suggest that the reductions could be as high as 20% to 25%. Although all of the studies reviewed suffer from methodological flaws of varying degrees, there is substantial qualitative consistency across studies of different medical conditions conducted at different times and using different data sets and statistical methods. Corroborating process studies find that the uninsured receive fewer preventive and diagnostic services, tend to be more severely ill when diagnosed, and receive less therapeutic care. Other literature suggests that improving health status from fair or poor to very good or excellent would increase both work effort and annual earnings by approximately 15% to 20%.