Lifecourse Educational Trajectories and Hypertension in Midlife: An Application of Sequence Analysis

Association of socioeconomic status with prognosis in hypertensive patients over age 65: a cohort study in the community setting

OBJECTIVE

To examine whether socioeconomic status is associated with prognosis after the diagnosis of hypertension (HTN), in a population older than 65 years, in the community setting.

DESIGN

Retrospective cohort study.

SETTING

All the primary care centres of the Community of Madrid (n=392).

PARTICIPANTS

All patients (>65 years) with a new diagnosis of HTN in 2007-08, without previous kidney or cardiovascular (K/CV) events (n=21 754).Patient records from primary care electronic health records and Spanish mortality database were analysed from January 2007 through December 2018. Sociodemographic data such as age, gender, Area Deprivation Index (MEDEA-Mortalidad en áreas pequeñas Españolas y Desigualdades Socioeconómicas y Ambientales-Index in quintiles), and characteristics, such as smoking, type 2 diabetes mellitus and hypercholesterolaemia, were collected at the time of enrolment.

PRIMARY AND SECONDARY OUTCOME MEASURES

The occurrence of K/CV events (including mortality from these causes) and total mortality were evaluated using Cox regression.

RESULTS

Patients had a mean age of 73.5 (SD 6.5) years, and 63.5% were women. The median follow-up was 128.7 months (IQR: 110.6-136.7 months). There were 10 648 first K/CV events, including 1508 deaths from these causes and 4273 deaths from other causes. Adjusted for age, gender, smoking, diabetes and hypercholesterolaemia, when comparing the third, fourth and last quintiles (less affluent) of the Deprivation Index with respect to the first quintile, the hazard of K/CV events increased by 14.8% (95% CI: 3.3 to 27.6%), 16.0% (95% CI: 6.4 to 26.4%) and 19.1% (95% CI: 8.9 to 30.2%), respectively. The MEDEA Index was not associated with differences in adjusted total mortality.

CONCLUSION

Living in a low socioeconomic status area is associated with an increase in kidney or cardiovascular events in hypertensive patients diagnosed after age 65 years, which will result in a significant increase in disease burden even if not related to an increase in total mortality.

Education mediates the relationship of parental socioeconomic status with subjective adult oral health

BACKGROUND

Evidence shows that both socioeconomic status (SES) during childhood and education are associated with adult oral health. However, whether the range of opportunities families have regarding their children's education mediate the effect of childhood disadvantage on oral health later in life remains unknown. The aim of this study was to evaluate the mediating role of education in the association between parental SES and subjective oral health status in middle adulthood.

METHODS

Data from 6703 members of the British Cohort Study 1970 were analyzed. Parental SES was measured using the 7-class National Statistics Socio-Economic Classification (NS-SEC) at age 10 years. Five measures of education (type of high school, highest qualification, age left full-time education, status of institution and field of study) were obtained from ages 16 and 42 years. Subjective oral health was measured with a single global item at age 46 years. Causal mediation analysis was performed, using a weighting-based approach, to evaluate how much of the effect of parental SES on subjective oral health was mediated by the measures of education separately and jointly.

RESULTS

Overall, 23.6% of individuals reported poor oral health. Parental SES was associated with every measure of education, and they were also associated with subjective oral health in regression models adjusted for confounders. The effect of parental SES on subjective oral health was partially mediated by each measure of education, with a proportion mediated of 53.2% for the institution status, 46.5% for the field of study, 42.8% for the school type, 38.9% for the highest qualification earned and 38.4% for the age when full-time education was discontinued. The proportion of the effect of parental SES on subjective oral health jointly mediated by all measures of education was 81.1%.

CONCLUSION

This study found a substantial mediating role of education in the association between parental SES and subjective oral health in middle adulthood.

Development and validation of prediction models for hypertension risks: A cross-sectional study based on 4,287,407 participants

Objective

To develop an optimal screening model to identify the individuals with a high risk of hypertension in China by comparing tree-based machine learning models, such as classification and regression tree, random forest, adaboost with a decision tree, extreme gradient boosting decision tree, and other machine learning models like an artificial neural network, naive Bayes, and traditional logistic regression models.

Methods

A total of 4,287,407 adults participating in the national physical examination were included in the study. Features were selected using the least absolute shrinkage and selection operator regression. The Borderline synthetic minority over-sampling technique was used for data balance. Non-laboratory and semi-laboratory analyses were carried out in combination with the selected features. The tree-based machine learning models, other machine learning models, and traditional logistic regression models were constructed to identify individuals with hypertension, respectively. Top features selected using the best algorithm and the corresponding variable importance score were visualized.

Results

A total of 24 variables were finally included for analyses after the least absolute shrinkage and selection operator regression model. The sample size of hypertensive patients in the training set was expanded from 689,025 to 2,312,160 using the borderline synthetic minority over-sampling technique algorithm. The extreme gradient boosting decision tree algorithm showed the best results (area under the receiver operating characteristic curve of non-laboratory: 0.893 and area under the receiver operating characteristic curve of semi-laboratory: 0.894). This study found that age, systolic blood pressure, waist circumference, diastolic blood pressure, albumin, drinking frequency, electrocardiogram, ethnicity (uyghur, hui, and other), body mass index, sex (female), exercise frequency, diabetes mellitus, and total bilirubin are important factors reflecting hypertension. Besides, some algorithms included in the semi-laboratory analyses showed less improvement in the predictive performance compared to the non-laboratory analyses.

Conclusion

Using multiple methods, a more significant prediction model can be built, which discovers risk factors and provides new insights into the prediction and prevention of hypertension.