Occupation, education, and coronary heart disease. Risk is influenced more by education and background than by occupational experiences, in the Bell System

Patient perspectives on barriers to obtaining surgery for primary hyperparathyroidism: A qualitative review

BACKGROUND

The purpose of this study was to qualitatively explore patient-reported barriers to surgery for primary hyperparathyroidism (PHPT) and identify actionable interventions to improve access to surgical care.

METHODS

We recruited forty-nine patients in an endocrine surgery clinic at a large, academic medical to participate in an 11- question phone interview. All interviewees underwent parathyroidectomy for primary hyperparathyroidism. Responses were recorded and a codebook of qualitative themes, blinded to patient race and sex, was created by 3 independent reviewers. Comments were subsequently sorted into the codebook with patient demographic information.

RESULTS

Patients that experienced delays in parathyroidectomy most commonly cited "issues with the referral process" and "missed diagnosis" as the cause. Patients were asked to identify the most challenging part about the surgery process. Commonly evoked themes among patients of both races and sexes included "transportation" and "financial" with subthemes of "no ride," "distance from surgeon," "insurance," and "difficulty taking time off work." Patients were asked to name actionable interventions to improve access to surgical care. The most commonly evoked theme involved "support systems," with subthemes of "transportation assistance," "financial," and "patient advocacy." Physician factors were also commonly evoked among patients of both races with subthemes of "knowledge", "communication," and "listening."

CONCLUSION

PHPT patients cited multiple barriers to undergoing surgery. Future work can focus on examining these questions with a larger patient cohort and examining delays at the referral and diagnosis stage, which was most commonly cited by our respondents.

Cost, Gain, and Health: Theoretical Clarification and Psychometric Validation of a Work Stress Model With Data From Two National Studies

OBJECTIVE

The aim of this study was to test nonsymmetric effects of cost/gain imbalance at work on depression, based on the effort-reward imbalance (ERI) model.

METHODS

Study participants were derived from two large national studies from Germany and Sweden. Associations between the ERI scales, including the effort-reward (E-R) ratio in 2016 and depression (in 2016 for German sample, and in 2018 for Swedish sample) were examined by multivariable logistic regression.

RESULTS

In both samples, high cost/low gain, but not low cost/high gain, is associated with depression, with a 3- to 5-fold elevated risk in the highest decile of the E-R ratio.

CONCLUSIONS

The short version of the ERI questionnaire is a psychometrically useful tool for epidemiological research. The finding demonstrating nonsymmetric effects of cost/gain imbalance contributes to a theoretical clarification of this stress-theoretical model.

Defining the Human Envirome: An Omics Approach for Assessing the Environmental Risk of Cardiovascular Disease

Both genetic and environmental factors contribute to the development of cardiovascular disease, but in comparison with genetics, environmental factors have received less attention. Evaluation of environmental determinants of cardiovascular disease is limited by the lack of comprehensive omics approaches for integrating multiple environmental exposures. Hence, to understand the effects of the environment as a whole (envirome), it is important to delineate specific domains of the environment and to assess how, individually and collectively; these domains affect cardiovascular health. In this review, we present a hierarchical model of the envirome; defined by 3 consecutively nested domains, consisting of natural, social, and personal environments. Extensive evidence suggests that features of the natural environment such as sunlight, altitude, diurnal rhythms, vegetation, and biodiversity affect cardiovascular health. However, the effects of the natural environment are moderated by the social environment comprised of built environments, agricultural and industrial activities, pollutants and contaminants, as well as culture, economic activities, and social networks that affect health by influencing access to healthcare, social cohesion, and socioeconomic status. From resources available within society, individuals create personal environments, characterized by private income, wealth and education, and populated by behavioral and lifestyle choices relating to nutrition, physical activity, sleep, the use of recreational drugs, and smoking. An understanding of the interactions between different domains of the envirome and their integrated effects on cardiovascular health could lead to the development of new prevention strategies and deeper insights into etiologic processes that contribute to cardiovascular disease risk and susceptibility.

Socioeconomic factors in coronary artery disease - Results from the SPIRR-CAD study

Low socio-economic status (SES) has been associated with an increased coronary risk in Western countries. All stress experiences are more pronounced in low SES patients with stress emanating from problems with family, job, or money. The SPIRR-CAD study offered an excellent opportunity to examine these risk factors in German speaking mildly and medium depressed patients. In the SPIRR CAD study, a German multi centre randomized clinical trial of 450 male and 120 female coronary patients, we examined the standard and psychosocial risk factor profiles in relation to SES, as assessed by educational level. All differences in risk factors between low and high SES were in the inverse direction. Of standard risk factors, only smoking was socially graded and more common in low SES. Of psychosocial factors and emotions, exhaustion showed the strongest and most consistent inverse social gradient, but also anger, anxiety and depression were socially graded. The findings suggest that in German patients, as in other national groups, social gradients in CHD risk are considerable. They can be ascribed to both psychosocial and to standard risk factors. In the present two years follow-up, the prospective significance of psychological and social risk factors was analyzed showing that emotional factors played an important role, in that low and high SES patients differed in the expected direction. However, the differences were not statistically significant and therefore firm conclusions from follow up were not possible.

TRIAL REGISTRATION

ISRCTN 76240576; NCT00705965.

Epidemiology of Stroke in Costa Rica: A 7-Year Hospital-Based Acute Stroke Registry of 1319 Consecutive Patients

BACKGROUND

Limited data on stroke exist for Costa Rica. Therefore, we created a stroke registry out of patients with stroke seen in the Acute Stroke Unit of the Hospital Calderon Guardia.

METHODS

We analyzed 1319 patients enrolled over a 7-year period, which incorporated demographic, clinical, laboratory, and neuroimaging data.

RESULTS

The mean age of patients with stroke was 68.0 ± 15.5 years. Seven hundred twenty-five were men and the age range was 13-104 years. The most prevalent risk factors were hypertension (78.8%), dyslipidemia (36.3%), and diabetes (31.9%). Fifteen percent had atrial fibrillation and 24.7% had a previous stroke or transient ischemic attack. Prevalence of hypertension and atrial fibrillation increased with age; however, younger patients were more associated with thrombophilia. We documented 962 (72.9%) ischemic and 270 (20.5%) hemorrhagic strokes. Of the ischemic strokes, 174 (18.1%) were considered secondary to large-artery atherothrombosis, 175 (18.2%) were due to cardiac embolism, 19 (2.0%) were due to lacunar infarcts, and 25 (2.6%) were due to other determined causes. Five hundred sixty-nine (59.1%) remained undetermined. Atherothrombotic strokes were mostly associated with dyslipidemia, diabetes, metabolic syndrome, and obesity, whereas lacunar infarcts were associated with hypertension, smoking, sedentary lifestyle, and previous stroke or transient ischemic attack. Of our patients, 69.9% scored between 0 and 9 in the initial National Institutes of Health Stroke Scale (NIHSS).

CONCLUSIONS

We found differences in sociodemographic features, risk factors, and stroke severity among stroke subtypes. Risk factor prevalence was similar to other registries involving Hispanic populations.

Education and coronary heart disease: mendelian randomisation study

Objective To determine whether educational attainment is a causal risk factor in the development of coronary heart disease.Design Mendelian randomisation study, using genetic data as proxies for education to minimise confounding.Setting The main analysis used genetic data from two large consortia (CARDIoGRAMplusC4D and SSGAC), comprising 112 studies from predominantly high income countries. Findings from mendelian randomisation analyses were then compared against results from traditional observational studies (164 170 participants). Finally, genetic data from six additional consortia were analysed to investigate whether longer education can causally alter the common cardiovascular risk factors.Participants The main analysis was of 543 733 men and women (from CARDIoGRAMplusC4D and SSGAC), predominantly of European origin.Exposure A one standard deviation increase in the genetic predisposition towards higher education (3.6 years of additional schooling), measured by 162 genetic variants that have been previously associated with education.Main outcome measure Combined fatal and non-fatal coronary heart disease (63 746 events in CARDIoGRAMplusC4D).Results Genetic predisposition towards 3.6 years of additional education was associated with a one third lower risk of coronary heart disease (odds ratio 0.67, 95% confidence interval 0.59 to 0.77; P=3×10^-8). This was comparable to findings from traditional observational studies (prevalence odds ratio 0.73, 0.68 to 0.78; incidence odds ratio 0.80, 0.76 to 0.83). Sensitivity analyses were consistent with a causal interpretation in which major bias from genetic pleiotropy was unlikely, although this remains an untestable possibility. Genetic predisposition towards longer education was additionally associated with less smoking, lower body mass index, and a favourable blood lipid profile.Conclusions This mendelian randomisation study found support for the hypothesis that low education is a causal risk factor in the development of coronary heart disease. Potential mechanisms could include smoking, body mass index, and blood lipids. In conjunction with the results from studies with other designs, these findings suggest that increasing education may result in substantial health benefits.

Environmental Determinants of Cardiovascular Disease

Many features of the environment have been found to exert an important influence on cardiovascular disease (CVD) risk, progression, and severity. Changes in the environment because of migration to different geographic locations, modifications in lifestyle choices, and shifts in social policies and cultural practices alter CVD risk, even in the absence of genetic changes. Nevertheless, the cumulative impact of the environment on CVD risk has been difficult to assess and the mechanisms by which some environment factors influence CVD remain obscure. Human environments are complex, and their natural, social, and personal domains are highly variable because of diversity in human ecosystems, evolutionary histories, social structures, and individual choices. Accumulating evidence supports the notion that ecological features such as the diurnal cycles of light and day, sunlight exposure, seasons, and geographic characteristics of the natural environment such as altitude, latitude, and greenspaces are important determinants of cardiovascular health and CVD risk. In highly developed societies, the influence of the natural environment is moderated by the physical characteristics of the social environments such as the built environment and pollution, as well as by socioeconomic status and social networks. These attributes of the social environment shape lifestyle choices that significantly modify CVD risk. An understanding of how different domains of the environment, individually and collectively, affect CVD risk could lead to a better appraisal of CVD and aid in the development of new preventive and therapeutic strategies to limit the increasingly high global burden of heart disease and stroke.

Measuring the effects of CVD interventions and studies across socioeconomic groups: A brief review

There is a known socioeconomic skew in prevalence and outcomes of cardiovascular disease (CVD). To document the proportion of clinical trials and observational studies related to CVD recently published in peer-reviewed journals that report the socio-economic distributional differences in their outcomes. We undertook a review of peer-reviewed clinical trials and observational studies relating to CVD published between 01/06/2015-31/12/2015 in PubMed; and identified the proportion that included measures of socioeconomic status and the proportion that stratified results by, or controlled for, socioeconomic status when reporting outcomes. 414 peer reviewed publications reporting the outcomes of clinical trials or observational studies that related to CVD were identified. 32 of these reported on the socioeconomic status of participants. Of these, 20 stratified the results by socioeconomic status or adjusted the results for socioeconomic status. 18 studies measured education attainment, 5 measured income, 1 measured rurality and 1 measured occupation. Of the 414 articles reporting the outcomes of clinical trials or observational studies related to cardiovascular disease in 2015, the effectiveness of the intervention, or the differences in outcomes, between socioeconomic groups was assessed in 5% of studies. This lack of consideration of the effectiveness of trial outcomes or the differences in outcomes across socioeconomic groups impairs the ability of readers, healthcare professionals and policy makers to assess the impact of new treatments or interventions in closing the inequality gap associated with CVD.

Comparing teaching versus nonteaching hospitals: the association of patient characteristics with teaching intensity for three common medical conditions

PURPOSE

To quantify the role of teaching hospitals in direct patient care, the authors compared characteristics of patients served by hospitals of varying teaching intensity.

METHOD

The authors studied Medicare beneficiaries ≥ 66 years old, hospitalized in 2009-2010 for acute myocardial infarction, heart failure, or pneumonia. They categorized hospitals as nonteaching, teaching, or Council of Teaching Hospitals and Health Systems (COTH) members and performed secondary analyses using intern and resident-to-bed ratios. The authors used descriptive statistics, adjusted odds ratios, and linear propensity scores to compare patient characteristics among teaching intensity levels. They supplemented Medicare mortality model variables with race, transfer status, and distance traveled.

RESULTS

Adjusted for comorbidities, black patients had 2.44 (95% confidence interval [CI] 2.36-2.52), 2.56 (95% CI 2.51-2.60), and 2.58 (95% CI 2.51-2.65) times the odds of COTH hospital admission compared with white patients for acute myocardial infarction, heart failure, and pneumonia, respectively. For patients transferred from another hospital's inpatient setting, the corresponding adjusted odds ratios of COTH hospital admission were 3.99 (95% CI 3.85-4.13), 4.60 (95% CI 4.34-4.88), and 4.62 (95% CI 4.16-5.12). Using national data, distributions of propensity scores (probability of admission to a COTH hospital) varied markedly among teaching intensity levels. Data from Massachusetts and California illustrated between-state heterogeneity in COTH utilization.

CONCLUSIONS

Major teaching hospitals are significantly more likely to provide care for minorities and patients requiring transfer from other institutions for advanced care.Both are essential to an equitable and high-quality regional health care system.

Strategies to reduce diabetes disparities: an update

Racial and ethnic minorities in the US have a higher prevalence, as well as suffer from more complications, lower quality care, and poorer outcomes for diabetes than their counterparts. Given the US health care system is in the midst of drastic transformation, with the passage of health care reform, and efforts in payment reform, and value-based purchasing, there is now support to provide more intensive, team-based care for those conditions that are complex, costly, and highly prevalent. Addressing and improving diabetes disparities, given they are prevalent and costly, will be an important area of focus in the years to come. The latest research demonstrates that community-based efforts, multifactorial approaches, and the deployment of health information technology can be successful in addressing diabetes disparities, and require support, attention, resources, and continued evaluation. Ultimately, these efforts should improve the quality of care for all persons with diabetes, especially those who are most vulnerable.

The influence of social determinants on the use of prevention and health promotion services: Results of a systematic literature review

BACKGROUND

The following analysis aims to determine whether differences in the use of prevention and health promotion services in Germany can be attributed to health inequality between different social status groups measured by education, occupation and income and where certain improvements can be made in health promotion and prevention efforts and research to reduce those differences.

METHODS

A systematic literature search was conducted using MedPilot to identify relevant articles published between 1998 and 2010 in the Medline, Medizinische Gesundheit, CC Med, Deutsches Ärzteblatt and Sozialmedizin (SOMED) databases, the Hogrefe, Karger, Krause and Pachermegg and Thieme publisher databases, the Cochrane Database of Systematic Reviews (CDSR), the Cochrane Database of Abstracts of Reviews of Effectiveness (DARE), and the Cochrane Central Register of Controlled Trials.

RESULTS

A total of 23 empirical studies on the topic of "prevention, health prevention and social inequality" met the criteria for inclusion in the review. 20 of the 23 reviewed studies provided relatively clear evidence of a significant association between higher social status and greater use of prevention and health promotion services. According to the reviewed studies, gender tends to have a greater effect on the use of prevention and health promotion services than characteristics of vertical social inequality. No studies were found dealing with tertiary prevention or using qualitative methods to explore their research questions.

CONCLUSIONS

Overall, the review shows that there is sufficient evidence for the relationship between social status and the use of prevention and health promotion services and that this association is both significant and relevant. There are, however, a few "blind spots" in research on this topic, such as a lack of studies on tertiary prevention, especially with regards to prevention and health promotion services use among men, as well as general studies on health promotion among men and women. There is also a lack of published intervention studies demonstrating how to better reach the socially disadvantaged.

Immigrant status and increased risk of heart failure: the role of hypertension and life-style risk factors

Background

Studies from Sweden have reported association between immigrant status and incidence of cardiovascular diseases. The nature of this relationship is unclear. We investigated the relationship between immigrant status and risk of heart failure (HF) hospitalization in a population-based cohort, and to what extent this is mediated by hypertension and life-style risk factors. We also explored whether immigrant status was related to case-fatality after HF.

Methods

26,559 subjects without history of myocardial infarction (MI), stroke or HF from the community-based Malmö Diet and Cancer (MDC) cohort underwent a baseline examination during 1991-1996. Incidence of HF hospitalizations was monitored during a mean follow-up of 15 years.

Results

3,129 (11.8%) subjects were born outside Sweden. During follow-up, 764 subjects were hospitalized with HF as primary diagnosis, of whom 166 had an MI before or concurrent with the HF. After adjustment for potential confounding factors, the hazard ratios (HR) for foreign-born were 1.37 (95% CI: 1.08-1.73, p = 0.009) compared to native Swedes, for HF without previous MI. The results were similar in a secondary analysis without censoring at incident MI. There was a significant interaction (p < 0.001) between immigrant status and waist circumference (WC), and the increased HF risk was limited to immigrants with high WC. Although not significant foreign-born tended to have lower one-month and one-year mortality after HF.

Conclusions

Immigrant status was associated with long-term risk of HF hospitalization, independently of hypertension and several life-style risk factors. A significant interaction between WC and immigrant status on incident HF was observed.

Unequal treatment in the US: lessons and recommendations for cancer care internationally

Despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities have benefited less from these advances. Research has shown that multiple factors contribute to racial and ethnic disparities in health, health care, and cancer care. The Institute of Medicine Report, "Unequal Treatment" provides a detailed examination of racial/ethnic disparities in health care in the U.S., highlighting three clinical contributors--poor provider-patient communication, stereotyping in clinical decisionmaking, and patient mistrust. Although the findings and recommendations in "Unequal Treatment" are broad in scope, they provide a blueprint for how to address disparities in health care in general-as well as cancer care-and have direct implications for clinical practice, both nationally and internationally. We propose a patient-based approach to cross-cultural care as a model to improve communication with racial and ethnic minorities, and cross-cultural populations in general. We also highlight the importance of community based interventions, such as those that use health care navigators to promote cancer screening. If we hope to provide effective cancer care around the world, we must be attentive to the factors that impact minorities and vulnerable populations, and be prepared to address them.

Evidence base for pre-employment medical screening

This paper examines the evidence base for the use of pre-employment/pre-placement medical examinations. The use of pre-employment examinations is often driven more by cultural practices than evidence. There is a lack of evidence on their effectiveness in preventing health-related occupational risks. Hypertension screening is highlighted as a common pre-employment practice for which there is no standardized criteria to use to determine fitness for work. There are inherent problems in screening for psychiatric disorders and substance abuse as well as potential for racial bias and other unintended negative effects. This paper questions the economic case for this practice and also expresses concerns about paternalism related to identified risk factors. Health assessments should only be included when appropriate to the task environment and the general use of pre-employment exams and drug screening should be eliminated. Generally, a health assessment by questionnaire should suffice. Occupational health providers should advise against the application of physical or mental standards that are not relevant to fulfilment of the essential job functions. Consensus development regarding best practice, as well as consideration for acquiring outcome data related to pre-employment practice, is recommended.

Psychosocial risk factors for coronary heart disease

Four clusters of psychosocial risk factors for coronary heart disease (CHD) are reviewed. Socio-economic disadvantage acts through a number of influences to increase CHD risk. In advanced industrialized nations those in the lower social strata now have much higher CHD risk than persons in middle and upper social classes. Sustained disturbing emotions represent a second cluster. Anxiety, depression and other indices of neuroticism have frequently been found in association with angina pectoris and cardiac death, though not with myocardial infarction (MI). However, sleep disturbances are associated with angina, cardiac death and MI. The Type A behaviour pattern results from an interaction between a self-activating individual and an environment which rewards hurried and competitive activity. Despite a small number of negative findings, the Type A pattern has been shown in cross-sectional, retrospective and prospective studies by many research teams to be associated with a variety of manifestations of CHD. A fourth, and more recently recognized cluster of psychosocial risk factors, may be grouped together under the general heading of "overload". Many investigations have now shown, for example, that excessive workload is a powerful predictor of CHD risk. It is suggested that all four clusters share the common property of exposing the individual, either chronically, or in frequently recurring episodes, to excessive psychological demands. They appear to exert their pathogenic influence through long-term mechanisms such as atherosclerosis or plaque formation, rather than by precipitating sudden coronary events.

Arthritis in the family practice setting: associations with education and community poverty

OBJECTIVE

To examine associations of self-reported arthritis in 25 urban and rural family practice clinics with education (individual socioeconomic status) and community poverty (community socioeconomic status).

METHODS

A total of 7,770 patients at 25 family practice sites across North Carolina self-reported whether they had arthritis. Education was measured as less than a high school (HS) degree, a HS degree, and more than a HS degree. The US Census 2000 block group poverty rate (percentage of households in poverty in that block group) was grouped into low, middle, and high tertiles. We assumed heterogeneity by race (non-Hispanic white and African American) for the effects of these sociodemographic variables, and therefore stratified by race. Multilevel analyses were performed using a 2-level mixed logistic model to examine the independent associations and joint effects of education and poverty with self-reported arthritis as the outcome, adjusting for age, sex, and body mass index.

RESULTS

White participants with less than a HS degree living in block groups with high poverty had 1.55 times the odds (95% confidence interval [95% CI] 1.10-2.17) of reporting arthritis compared with white participants with more than a HS degree and low poverty rates. African American participants with less than a HS degree and high poverty rates had 2.06 times the odds (95% CI 1.16-3.66) of reporting arthritis compared with African American participants with more than a HS degree and low poverty rates.

CONCLUSION

In the family practice setting, both disadvantaged white and African American participants showed increased odds of self-reported arthritis, with stronger associations in African Americans.

Work and marital status in relation to depressive symptoms and social support among women with coronary artery disease

BACKGROUND

Work and marital status have been shown to be associated with health outcome in women. However, the effect of employment and marriage on psychosocial functioning has been studied predominantly in healthy subjects. We investigated whether work and marital status are associated with depressive symptoms, social support, and daily stress behavior in women with coronary artery disease (CAD).

METHODS

Data of 105 women with CAD and of working age were analyzed. General linear models were used to determine the association between work and marital status and depressive symptoms, social support, and daily stress behavior.

RESULTS

Women who were working at the time of measurement had lower levels of depressive symptoms (7.0 +/- 1.2 vs. 12.1 +/- 0.9, p < 0.01) and higher levels of social support (21.6 +/- 1.0 vs. 18.9 +/- 0.7, p = 0.03) than the nonworking women, whereas marital status was not related to any of the outcome variables. Results were similar after adjusting for potential confounders, that is, age, education, self-reported health, and risk factors for CAD. There was no significant interaction between marital status and working status on depressive symptoms, social support, or daily stress behavior.

CONCLUSIONS

In women with CAD, all <65 years of age, after a cardiac event, patients working had lower levels of depressive symptoms and a better social integration than those not working, regardless of reason for being nonemployed. Daily stress behavior, depression, and social support did not differ between cohabiting and not cohabiting women. Future interventions should take into consideration that women with CAD who are unemployed may have a higher risk for depression and social isolation and, therefore, poor clinical outcomes.

Impacts of educational level and employment status on mortality for Japanese women and men: the Jichi Medical School cohort study

The objective of this study was to examine educational levels and employment status as independent determinants of overall and cause-specific mortality in a Japanese population. Participants were 4,301 men and 6,780 women in a multi-center community-based prospective study, and data of the baseline survey was collected between 1992 and 1995. The participants were followed up until December 31, 2002 (the average follow-up period was 9.17 years). Early termination of education was associated with an increased risk of mortality from all causes for both men and women. This tendency was more prominent in women aged 59 and younger (hazard ratio (HR) = 3.82, 95% confidence interval (CI): 1.18-12.34), after adjusting for confounding factors using the Cox proportional hazard models. Similar trends were shown for men; specifically, cardiovascular disease mortality for all men was increased by early termination of education (HR = 2.97, 95% CI: 1.17-7.52) compared to later termination. For employment status, unemployed men showed increased mortality from all causes compared to white-collar workers (HR = 1.51, 95% CI: 1.00-2.28). Female farmers and forestry workers showed reduced mortality from all causes compared to white-collar workers (HR = 0.55, 95% CI: 0.33-0.93). Male farmers and forestry workers also showed reduced mortality from cardiovascular diseases compared to white-collar workers (HR = 0.34, 95% CI: 0.14-0.82). Educational level and employment status may affect mortality for Japanese women and men.

Eliminating racial and ethnic disparities in health care: what is the role of academic medicine?

Research has shown that minority Americans have poorer health outcomes (compared to whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, and cancer. In addition to racial and ethnic disparities in health, there is also evidence of racial and ethnic disparities in health care. The Institute of Medicine Report Unequal Treatment remains the preeminent study of the issue of racial and ethnic disparities in health care in the United States. Unequal Treatment provided a series of general and specific recommendations to address such disparities in health care, focusing on a broad set of stakeholders including academic medicine. Academic medicine has several important roles in society, including providing primary and specialty medical services, caring for the poor and uninsured, engaging in research, and educating health professionals. Academic medicine should also provide national leadership by identifying innovations and creating solutions to the challenges our health care system faces in its attempt to deliver high-quality care to all patients. Several of the recommendations of Unequal Treatment speak directly to the mission and roles of academic medicine. For instance, patient care can be improved by collecting and reporting data on patients' race/ethnicity; education can minimize disparities by integrating cross-cultural education into health professions training; and research can help improve health outcomes by better identifying sources of disparities and promising interventions. These recommendations have clear and direct implications for academic medicine. Academic medicine must make the elimination of health care disparities a critical part of its mission, and provide national leadership by identifying quality improvement innovations and creating disparities solutions.

Reliability and validity of the occupational physical activity questionnaire

INTRODUCTION

Few questionnaires have been designed for wide-scale, population-based surveillance of occupational physical activity (PA) behaviors.

PURPOSE

This study was conducted to determine the test-retest reliability and validity of the Occupational Physical Activity Questionnaire (OPAQ) designed to assess the usual weekly duration of occupational sitting or standing, walking, and heavy labor activities.

METHODS

Analyses were based on a convenience sample of 41 adults (13 men, 28 women) (mean+/- SD, 38.8+/- 9.9 yr) who worked in a broad range of occupations. Intraclass correlation coefficients (ICC) were used to evaluate the 2-wk test-retest reliability of the OPAQ. Spearman correlations were used to assess criterion (occupational PA record, Actigraph) and construct (cardiorespiratory fitness, percent body fat) related validity. Convergent validity with the current Behavioral Risk Factor Surveillance System (BRFSS) occupational PA question was evaluated with the kappa coefficient.

RESULTS

The 2-wk test-retest reliability coefficients for the OPAQ hours per week ranged from an ICC of 0.55 to 0.91. Fair-to-substantial criterion validity was observed for like activities on the OPAQ and a detailed 7-d occupational PA record for sitting or standing (r=0.37), walking (r=0.74), and heavy labor activity (r=0.31). OPAQ walking was related to PA record moderate-intensity PA (r=0.41), Actigraph occupational light-intensity counts (r=0.41), and Actigraph total counts (r=0.44). Associations observed between the OPAQ and submaximal exercise heart rate or percent body fat were low (r=-0.17 to 0.32). Convergent validity displaying the ability of the OPAQ to correctly identify participants who performed mostly sitting or standing, mostly walking, or mostly heavy labor at work was substantial [kappa=0.71 (95% CI=0.49, 0.94)].

CONCLUSIONS

The test-retest reliability and validity of the OPAQ are similar to other established occupational PA questionnaires. This preliminary study supports the use of the OPAQ in research and surveillance settings.

Do depression and anxiety mediate the link between educational attainment and CHD?

OBJECTIVE

Depression and anxiety are frequently hypothesized yet rarely examined pathways linking low socioeconomic status (SES) to coronary heart disease (CHD). This study evaluates depression and anxiety as mediators of the association between educational attainment and incident CHD.

METHODS

Subjects (n = 6265, age 25-74) were participants in NHANES I and follow-up studies, a longitudinal, nationally representative study of the US population. Measures of educational attainment and depressive and anxious symptoms (General Well-Being Schedule) were derived from the baseline interview and incident CHD from hospital records and death certificates. Analyses included logistic regression and Cox proportional hazards models.

RESULTS

In fully adjusted models, less than high school (relative risk [RR] = 1.46; 95% confidence interval [CI], 1.15-1.86) and some college (RR = 1.40; 95% CI, 1.05-1.88) education were associated with increased CHD risk relative to a college education. High depressive (RR = 1.31; 95% CI, 1.06-1.61) or anxious (RR = 1.35; 95% CI, 1.13-1.62) symptoms were associated with significantly increased CHD risk relative to low symptoms. Low educational levels were associated with increased risk for high depressive (OR = 3.43; 95% CI, 2.34-5.03) and anxious (OR = 1.71; 95% CI, 1.32-2.22) symptoms. However, depressive and anxious symptoms accounted for little of the association between education and CHD.

CONCLUSION

Education and depressive and anxious symptoms are associated with each other and risk of incident CHD. Although depressive and anxious symptoms are highest among those with lowest levels of education, they do not appear to mediate the relation between educational attainment and incident CHD. Findings suggest the importance of interventions to reduce socioeconomic disadvantage and negative affect in preventing CHD.

Suicide compared to other causes of mortality in physicians

Physicians frequently are early adopters of healthy behaviors based on their knowledge and economic resources. The mortality patterns of physicians in the United States, particularly suicide, have not been rigorously described for over a decade. Previous studies have shown lower all-cause mortality among physicians yet reported conflicting results about cause-specific mortality such as suicide. In this study, we compared all-cause and cause-specific mortality in a sample of physicians to the age-gender matched general U.S. population from 1948 through 1998. We also compared the mortality experience across medical specialties. The risk of all-cause mortality was 56% lower than expected in men, and 26% lower in women, compared to the general population. Standardized mortality ratios (SMRs) were markedly lower for diseases strongly linked to smoking, e.g., cardiovascular diseases, respiratory diseases, and lung cancer. Suicide was the only cause of death where risk was greater than the general population. Overall, we found that physicians are at substantially lower risk of dying compared to the general population for all causes of death except suicide. The findings for suicide are strikingly different than other causes of death and should provide impetus for new research on the mental health of physicians.

Evaluating the evidence for models of life course socioeconomic factors and cardiovascular outcomes: a systematic review

Background

A relatively consistent body of research supports an inverse graded relationship between socioeconomic status (SES) and cardiovascular disease (CVD). More recently, researchers have proposed various life course SES hypotheses, which posit that the combination, accumulation, and/or interactions of different environments and experiences throughout life can affect adult risk of CVD. Different life course designs have been utilized to examine the impact of SES throughout the life course. This systematic review describes the four most common life course hypotheses, categorizes the studies that have examined the associations between life course SES and CVD according to their life course design, discusses the strengths and weaknesses of the different designs, and summarizes the studies' findings.

Methods

This research reviewed 49 observational studies in the biomedical literature that included socioeconomic measures at a time other than adulthood as independent variables, and assessed subclinical CHD, incident CVD morbidity and/or mortality, and/or the prevalence of traditional CVD risk factors as their outcomes. Studies were categorized into four groups based upon life course design and analytic approach. The study authors' conclusions and statistical tests were considered in summarizing study results.

Results

Study results suggest that low SES throughout the life course modestly impacts CVD risk factors and CVD risk. Specifically, studies reviewed provided moderate support for the role of low early-life SES and elevated levels of CVD risk factors and CVD morbidity and mortality, little support for a unique influence of social mobility on CVD, and consistent support for the detrimental impact of the accumulation of negative SES experiences/conditions across the life course on CVD risk.

Conclusions

While the basic life course SES study designs have various methodologic and conceptual limitations, they provide an important approach from which to examine the influence of social factors on CVD development. Some limitations may be addressed through the analysis of study cohorts followed from childhood, the evaluation of CVD risk factors in early and middle adulthood, and the use of multiple SES measures and multiple life course analysis approaches in each life course study.

Educational level and risk profile of cardiac patients in the EUROASPIRE II substudy

STUDY OBJECTIVE

To ascertain, whether, conventional risk factors and readiness of coronary patients to modify their behaviour and to comply with recommended medication were associated with education in patients with established coronary heart disease.

DESIGN AND METHODS

EUROASPIRE II was a cross sectional survey undertaken in 1999-2000 in 15 European countries to ascertain how effectively recommendations on coronary preventions are being followed in clinical practice. Consecutive patients, men and women </=71 years who had been hospitalised for acute coronary syndrome or revascularisation procedures, were identified retrospectively. Data were collected through a review of medical records, interview, and examination at least six months after hospitalisation. The education reached was ascertained at the interview.

MAIN RESULTS

A total of 5556 patients (1319 women) were evaluated. Significantly more patients with ischaemia had only primary education, in contrast with the remaining diagnostic groups. Body mass index and glucose were negatively associated with educational level, while HDL-cholesterol was positively associated. Men with highest education had significantly lower systolic blood pressure and total cholesterol. The prevalence of current smoking decreased significantly from primary to secondary and high education only in men. Both men and women with primary educational level were more often treated with antidiabetics, and antihypertensives, but less often with lipid lowering drugs. The effectiveness of treatment was virtually the same in all education groups.

CONCLUSIONS

Patients with higher education had lower global coronary risk, than those with lower education. This should be considered in clinical practice. Particular strategies for risk communication and counselling are needed for those with lower education status.

Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care

OBJECTIVES

Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care.

METHODS

The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers.

RESULTS

Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care.

CONCLUSIONS

Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.

Poverty, process of care, and outcome in acute coronary syndromes

OBJECTIVES

We sought to determine whether income-based disparities in care processes and outcome exist in patients with acute coronary syndromes.

BACKGROUND

Using income proxies and limited clinical data, some observational studies have shown income disparities in outcome after acute myocardial infarction (MI).

METHODS

Using annual household income from the economic substudy of the PURSUIT (Platelet Glycoprotein IIB/IIIA In Unstable Angina: Receptor Suppression Using Integrilin Therapy) trial, patients were grouped into low-, middle-, and high-income categories based on the U.S. Census Bureau definition of poverty. Logistic regression analysis was used to examine the association between income category and the use of cardiac procedures and the prescription of evidence-based medications at hospital discharge. Cox regression analysis was used to examine the hazard of 30-day and six-month death or recurrent MI across income categories, after adjusting for baseline characteristics.

RESULTS

Low-income patients had more chronic medical conditions and were sicker at presentation. Among low-income patients, the use of some evidence-based medications and cardiac procedures was lower and the unadjusted rates of 30-day death and six-month death or MI was higher. After multivariable adjustment, there was no consistent pattern for disparity in care processes, but the trend for higher short and intermediate-term death or MI persisted for low-income patients.

CONCLUSIONS

Income level is associated with a trend toward worse outcome among patients with acute coronary syndromes. The disparity in 30-day and six-month death or MI between low and high-income patients could not be readily explained by differences in in-hospital medical or invasive treatment, suggesting that the poor outcomes may be due to differences occurring after hospital discharge.

Social epidemiology and rheumatic disease

Social epidemiology, a subdiscipline of epidemiology, aims to identify socioenvironmental exposures that may be related to a broad range of health status outcomes. The strong association throughout the developed world between lower levels of individual socioeconomic status and poorer health outcomes from many diseases, including arthritis, is well established. Although not yet well studied in arthritis, recent data suggest that community social determinants, the socioeconomic environment of an individual's neighborhood, may be operant in this regard as well. It is of considerable interest that the association of community social determinants with health outcomes appears to be independent of an individual's socioeconomic status, at least in some clinical situations. Both Healthy People 2010 and the National Arthritis Action Plan place high priority on reducing disparities in health outcomes in the United States. Development of effective prevention strategies will require (1) precise recognition of individual and community variables that are associated with health outcomes and (2) evaluation of the putative mediating mechanisms.

Occupational status and sleep-disordered breathing in a sample of French males

Sleep-disordered breathing (SDB) and lower socio-professional status have in common a series of risk factors for ill health such as sedentary lifestyle, weight excess, heavy alcohol and tobacco consumption. We hypothesised that SDB will be more prevalent in lower socio-professional groups. A total of 496 male middle aged subjects (23-66 years) were tested with a protocol including a self-completed structured sleep questionnaire (translation of the Madison sleep cohort study form), anthropometry (including neck, waist and hip girth) and a simple, non-invasive nose-throat examination by a specialist physician. The subjects were classified according to the 10 major groups of the ISCO-88 classification (International Labour Office). Our sampling base did not contain subjects in the major groups 1 (senior officials, legislators), 6 (fishery and agricultural workers), and zero (armed forces), thus these groups were not represented in the analysis. To improve the power of the statistical analysis, groups 3 and 4, 5 and 7, 8 and 9 were merged, the analysis thus including four categories. The differences in demographic data were negligible; as expected, smoking was more prevalent in low socio-occupational groups (difference non-significant). A history of chronic bronchitis was more frequent in low socio-occupational groups, while a low physical job labour was more frequent in higher occupational groups. We did not find any differences in the prevalence of sleep-related respiratory disturbances (snoring, sleep apnoeas). This first study of the possible association between socio-occupational factors and sleep disordered breathing was negative, but we believe further studies, on larger samples, with a more homogeneous distribution of social groups are warranted.

Cognitive appraisal biases: an approach to understanding the relation between socioeconomic status and cardiovascular reactivity in children

We tested the hypothesis that lower socioeconomic status (SES) children display heightened cardiovascular reactivity during stressful situations because they are more likely to appraise a wide variety of social situations, including ambiguous ones, as threatening. A sample of 201 children and adolescents, half White and half African American, were assessed initially. Ninety of these children were retested an average of 3 years later. At both time points, children were interviewed about appraisals of hostile intent and feelings of anger in response to scenarios with negative or ambiguous outcomes. Cardiovascular reactivity to 3 laboratory stress tasks was measured. Initially, lower SES was associated with greater hostile intent appraisal and anger during ambiguous scenarios across all participants. In addition, responses to ambiguous scenalios partially mediated the relation between SES and vascular reactivity. Longitudinally, low SES African American participants showed higher mean intensity of hostile intent appraisals during ambiguous scenarios, and these appraisals mediated the SES-reactivity relationship. These findings suggest that the way in which children appraise ambiguous social situations plays an important role in the relation between SES and cardiovascular reactivity.

Group therapy in the outpatient management of post-myocardial infarction patients

A controlled experiment of the utility of group therapy as an adjunct to the medical outpatient management of patients following myocardial infarction has been in progress for nearly a year. The long-range purpose of the experiment is to assess the possible benefits of group therapy experience in terms of subjects' job rehabilitation rates, angina pectoris prevalence, nitroglycerin use, rehospitalization for coronary heart disease, as well as reinfarction and mortality rates-compared to those for control subjects. The early results from the group therapy experience, however, have provided important information and are reported here to illustrate the psychological physiology of the rehabilitation process and emphasize patients' special needs, too often ignored during their convalescence.

Psychosocial variables in relation to various risk factors in patients with stable angina pectoris

OBJECTIVES

To evaluate relationships between psychosocial variables and common risk factors such as age, concomitant diseases (hypertension, diabetes mellitus, myocardial infarction, heart failure) and smoking habits in patients with stable angina pectoris.

SETTING

University Hospital.

SUBJECTS

Participants in the Angina Prognosis Study in Stockholm (APSIS), which comprised 809 patients (248 females) <70 years of age, with chronic stable angina pectoris, of whom 767 (236 females) participated in the present report. Patients with angina pectoris occurring only at rest constituted one group, patients with angina pectoris on effort with or without angina at rest were stratified according to signs of marked ischaemia on exercise and/or clinical signs of heart failure.

METHODS

Psychosomatic symptoms, job strain, Type-A behaviour, sleep disturbances and overall life satisfaction were evaluated by a structured interview, which also included questions regarding how the patients usually felt, and health related problems, according to a standardized check-list.

RESULTS

Age correlated with several psychosomatic symptoms and tendency to worry. When adjusted for age and sex, patients with previous myocardial infarction and heart failure described more psychosomatic symptoms, but worried less about the future than patients without these diseases. In the group with angina pectoris at rest only there were fewer smokers than amongst other groups, regardless of risk stratification.

CONCLUSIONS

Smoking habits and concomitant diseases influence psychosocial variables in patients with stable angina pectoris. The severity of angina pectoris does not seem to relate to life satisfaction and attitudes towards the future.

Placebo effect of pacemaker implantation in obstructive hypertrophic cardiomyopathy. PIC Study Group. Pacing In Cardiomyopathy

This study evaluated a possible placebo effect by pacemaker implantation. The study design was a 3-month multicenter, double-blind, randomized cross-over study to compare the effects of atrioventricular (AV) synchronous pacing with an optimal AV delay to inactive pacing in patients with obstructive hypertrophic cardiomyopathy (HC). Quality of life and left ventricular (LV) outflow tract obstruction were evaluated after the first study period in 40 patients assigned to inactive pacing. Data were compared with the corresponding results among the 41 subjects assigned to a first study period of active pacing. During inactive pacing, there was a significant improvement in perceived chest pain, dyspnea, and palpitations. Moreover, LV outflow tract gradient decreased from 71 +/- 32 mm Hg to 52 +/- 34 mm Hg (p = 0.04). In patients assigned to active pacing the reduction of the gradient was significantly more pronounced (70 +/- 24 mm Hg to 33 +/- 27 mm Hg; p <0.0001). The difference in gradient reduction between the groups was highly significant (p <0.00001). In the group assigned to active pacing there was also significant improvement in perceived symptoms as well as in alertness, the ability to be self-autonomous, and strenuous physical exercise. The improvements in the latter were significantly greater in those paced actively compared with patients paced inactively, whereas the changes in perceived symptoms did not differ between groups. In conclusion, pacemaker implantation had a placebo effect on objective and subjective parameters in this group of patients with obstructive HC.

Potential explanations for the educational gradient in coronary heart disease: a population-based case-control study of Swedish women

OBJECTIVES

This study examined the association between educational attainment and coronary heart disease (CHD) and the factors that may explain this association.

METHODS

This population-based case-control study included 292 women with CHD who were 65 years or younger and 292 age-matched controls.

RESULTS

Compared with the adjusted odds ratio for CHD associated with college education, the age-adjusted odds ratio associated with mandatory education (< or = 9 years) was 1.87 (95% confidence interval [CI] = 1.23, 2.84) and the odds ratio for high school education was 1.35 (95% CI = 0.81, 2.25) (P for trend < .01). The odds ratio for mandatory education was reduced by 82%, to 1.16 (95% CI = 0.69, 2.09), after adjustment for psychosocial stress, unhealthy lifestyle patterns, hemostatic factors, hypertension, and lipids.

CONCLUSIONS

Much of the increased risk of CHD in women with low education appears to be linked to psychosocial stress and lifestyle factors. Hemostatic factors, lipids, and hypertension also contribute to a lesser extent. These factors may be considered in strategies geared to reducing socioeconomic inequalities in cardiovascular health.

Accuracy of recall of occupational physical activity by questionnaire

The validity of the Tecumseh Occupational Activity Questionnaire (TOQ) and a modified Seven Day Recall (SDR) was measured in 46 healthy women, ages 20-60 years (mean +/- SD, 39.4 +/- 11.8). Occupational data were compared with direct (7-day occupational activity records and Caltrac accelerometer) and indirect (maximal oxygen uptake and percent body fat) measures of physical activity status. Physical activity survey and occupational record data were log transformed to normalize skewed distributions. Intraclass correlations ranged from r = 0.26 to 0.73 (P < 0.05) between similar activities on the TOQ and activity records for light intensity sitting, light-to-moderate intensity standing, and walking. Correlations between similar activities from the SDR and activity records ranged from r = 0.32 to 0.35 (P < 0.05) for light and moderate intensity activities. Correlations for total occupational activity between the surveys and activity records were r = 0.46 (P < 0.001) for the TOQ and r = 0.45 (P < 0.01) for the SDR. A modest correlation (r = 0.34, P < 0.10) was observed between the Caltrac scores and TOQ moderate intensity standing. Only the TOQ light-to-moderate intensity standing was related to maximal oxygen uptake (r = 0.32, P < 0.05). None of the measures were related to percent body fat (P > 0.05). These results suggest that the TOQ and SDR both provide reasonably accurate measurements of light and moderate intensity occupational physical activity.

Perceived overqualification and health: a longitudinal analysis

The authors examined the effects of perceived overqualification on health and health decline by means of a 2-wave panel study of members of a midwestern American Postal Workers Union local. The 1st hypothesis was that overqualification was negatively related to health at Time 2 (T2); the second hypothesis was that overqualification was positively related to perceived health decline at T2. Neither was supported by the data. However, the relationships were in the expected direction for perceived mismatch but not for the perceived no grow dimension of overqualification. The results imply that perceived no grow may have immediate threats to health, whereas perceived mismatch may have longer term implications for health. The stability of perceived health between Time 1 (T1) and T2 could overshadow a longitudinal effect of overqualification on health and health decline at T2.

Review of available instruments and methods for assessing quality of life in anti-anginal trials

Collection of patient-centred health status is a method for quantifying patient outcome in the context of clinical trials for the treatment of coronary artery disease (CAD). Traditional clinical trial end-points, such as morbidity and mortality, fail to adequately measure the health-related outcomes of disease states for which death is a rare occurrence. Health-related quality of life (QOL) and functional status surveys allow measurement of the general, and/or disease-specific, health-related limitations experienced by patients. Measures of patient preference, in turn, quantify the effects these health-related limitations have on the overall value patients ascribe to their current health state. Together, these outcomes measures may provide a more accurate appraisal of the benefit conferred by treatment. Currently, selection of the appropriate outcomes measures and methodological approaches for a clinical trial is complicated by the lack of consensus on a single quality of life measure for use with patients with (CAD). This article outlines the use of QOL measures in anti-anginal trials done to date and summarises the approaches currently available for assessing QOL, including the differences between psychometric and preference-based techniques, and general and disease-specific health measures. In conclusion, a framework is provided for selecting the appropriate instruments and methodology in the context of the clinical trial.