County-Level Cardiac Rehabilitation and Broadband Availability: Opportunities for Hybrid Care in the United States

PURPOSE

Cardiac rehabilitation (CR) improves patient outcomes and quality of life and can be provided virtually through hybrid CR. However, little is known about CR availability in conjunction with broadband access, a requirement for hybrid CR. This study examined the intersection of CR and broadband availability at the county level, nationwide.

METHODS

Data were gathered and analyzed in 2022 from the 2019 American Community Survey, the Centers for Medicare & Medicaid Services, and the Federal Communications Commission. Spatially adaptive floating catchments were used to calculate county-level percent CR availability among Medicare fee-for-service beneficiaries. Counties were categorized: by CR availability, whether lowest (ie, CR deserts), medium, or highest; and by broadband availability, whether CR deserts with majority-available broadband, or dual deserts. Results were stratified by state. County-level characteristics were examined for statistical significance by CR availability category.

RESULTS

Almost half of US adults (n = 116 325 976, 47.2%) lived in CR desert counties (1691 counties). Among adults in CR desert counties, 96.8% were in CR deserts with majority-available broadband (112 626 906). By state, the percentage of the adult population living in CR desert counties ranged from 3.2% (New Hampshire) to 100% (Hawaii and Washington, DC). Statistically significant differences in county CR availability existed by race/ethnicity, education, and income.

CONCLUSIONS

Almost half of US adults live in CR deserts. Given that up to 97% of adults living in CR deserts may have broadband access, implementation of hybrid CR programs that include a telehealth component could expand CR availability to as many as 113 million US adults.

A Dynamic Visualization Tool of Local Trends in Heart Disease and Stroke Mortality in the United States

Efforts in the US to prevent and treat cardiovascular disease (CVD) contributed to large decreases in death rates for decades; however, in the last decade, progress has stalled, and in many counties, CVD death rates have increased. Because of these increases, there is heightened urgency to disseminate high-quality data on the temporal trends in CVD mortality. The Local Trends in Heart Disease and Stroke Mortality Dashboard is an online, interactive visualization of US county-level death rates and trends for several CVD outcomes across stratifications of age, race and ethnicity, and sex. This powerful visualization tool generates national maps of death rates and trends, state maps of death rates and trends, county-level line plots of annual death rates, and bar charts of percentage changes. County-level death rates and trends were estimated by applying a Bayesian spatiotemporal model to data obtained from the National Vital Statistics System of the National Center for Health Statistics and US Census bridged-race intercensal estimates for the years 1999 through 2019. The Local Trends in Heart Disease and Stroke Mortality Dashboard makes it easy for public health practitioners, health care providers, and community leaders to monitor county-level spatiotemporal trends in CVD mortality by age group, race and ethnicity, and sex and provides key information for identifying and addressing local health inequities in CVD mortality trends.

The where of when: Geographic variation in the timing of recent increases in US county-level heart disease death rates

PURPOSE

Within the context of local increases in US heart disease death rates, we estimated when increasing heart disease death rates began by county among adults aged 35-64 years and characterized geographic variation.

METHODS

We applied Bayesian spatiotemporal models to vital statistics data to estimate the timing (i.e., the year) of increasing county-level heart disease death rates during 1999-2019 among adults aged 35-64 years. To examine geographic variation, we stratified results by US Census region and urban-rural classification.

RESULTS

The onset of increasing heart disease death rates among adults aged 35-64 years spanned the two-decade study period from 1999 to 2019. Overall, 43.5% (95% CI: 41.3, 45.6) of counties began increasing before 2011, with early increases more prevalent outside of the most urban counties and outside of the Northeast. Roughly one-in-five (18.4% [95% CI: 15.6, 20.7]) counties continued to decline throughout the study period.

CONCLUSIONS

This variation suggests that factors associated with these geographic classifications may be critical in establishing the timing of changing trends in heart disease death rates. These results reinforce the importance of spatiotemporal surveillance in the early identification of adverse trends and in informing opportunities for tailored policies and programs.

County-Level Trends in Hypertension-Related Cardiovascular Disease Mortality-United States, 2000 to 2019

Background

Amid stagnating declines in national cardiovascular disease (CVD) mortality, documenting trends in county‐level hypertension‐related CVD death rates can help activate local efforts prioritizing hypertension prevention, detection, and control.

Methods and Results

Using death certificate data from the National Vital Statistics System, Bayesian spatiotemporal models were used to estimate county‐level hypertension‐related CVD death rates and corresponding trends during 2000 to 2010 and 2010 to 2019 for adults aged ≥35 years overall and by age group, race or ethnicity, and sex. Among adults aged 35 to 64 years, county‐level hypertension‐related CVD death rates increased from a median of 23.2 per 100 000 in 2000 to 43.4 per 100 000 in 2019. Among adults aged ≥65 years, county‐level hypertension‐related CVD death rates increased from a median of 362.1 per 100 000 in 2000 to 430.1 per 100 000 in 2019. Increases were larger and more prevalent among adults aged 35 to 64 years than those aged ≥65 years. More than 75% of counties experienced increasing hypertension‐related CVD death rates among patients aged 35 to 64 years during 2000 to 2010 and 2010 to 2019 (76.2% [95% credible interval, 74.7–78.4] and 86.2% [95% credible interval, 84.6–87.6], respectively), compared with 48.2% (95% credible interval, 47.0–49.7) during 2000 to 2010 and 66.1% (95% credible interval, 64.9–67.1) for patients aged ≥65 years. The highest rates for both age groups were among men and Black populations. All racial and ethnic categories in both age groups experienced widespread county‐level increases.

Conclusions

Large, widespread county‐level increases in hypertension‐related CVD mortality sound an alarm for intensified clinical and public health actions to improve hypertension prevention, detection, and control and prevent subsequent CVD deaths in counties across the nation.

Pre-endoscopy SARS-CoV-2 testing strategy during COVID-19 pandemic: the care must go on

Background

In response to the COVID-19 pandemic, endoscopic societies initially recommended reduction of endoscopic procedures. In particular non-urgent endoscopies should be postponed. However, this might lead to unnecessary delay in diagnosing gastrointestinal conditions.

Methods

Retrospectively we analysed the gastrointestinal endoscopies performed at the Central Endoscopy Unit of Saarland University Medical Center during seven weeks from 23 March to 10 May 2020 and present our real-world single-centre experience with an individualized rtPCR-based pre-endoscopy SARS-CoV-2 testing strategy. We also present our experience with this strategy in 2021.

Results

Altogether 359 gastrointestinal endoscopies were performed in the initial period. The testing strategy enabled us to conservatively handle endoscopy programme reduction (44% reduction as compared 2019) during the first wave of the COVID-19 pandemic. The results of COVID-19 rtPCR from nasopharyngeal swabs were available in 89% of patients prior to endoscopies. Apart from six patients with known COVID-19, all other tested patients were negative. The frequencies of endoscopic therapies and clinically significant findings did not differ between patients with or without SARS-CoV-2 tests. In 2021 we were able to unrestrictedly perform all requested endoscopic procedures (> 5000 procedures) by applying the rtPCR-based pre-endoscopy SARS-CoV-2 testing strategy, regardless of next waves of COVID-19. Only two out-patients (1893 out-patient procedures) were tested positive in the year 2021.

Conclusion

A structured pre-endoscopy SARS-CoV-2 testing strategy is feasible in the clinical routine of an endoscopy unit. rtPCR-based pre-endoscopy SARS-CoV-2 testing safely allowed unrestricted continuation of endoscopic procedures even in the presence of high incidence rates of COVID-19. Given the low frequency of positive tests, the absolute effect of pre-endoscopy testing on viral transmission may be low when FFP-2 masks are regularly used.

Unequal Local Progress Towards Healthy People 2020 Objectives for Stroke and Coronary Heart Disease Mortality

BACKGROUND AND PURPOSE

Healthy People establishes objectives to monitor the nation's health. Healthy People 2020 included objectives to reduce national stroke and coronary heart disease (CHD) mortality by 20% (to 34.8 and 103.4 deaths per 100 000, respectively). Documenting the proportion and geographic distribution of counties meeting neither the Healthy People 2020 target nor an equivalent proportional reduction can help identify high-priority geographic areas for future intervention.

METHODS

County-level mortality data for stroke (International Classification of Diseases, Tenth Revision codes I60-I69) and CHD (I20-I25) and bridged-race population estimates were used. Bayesian spatiotemporal models estimated age-standardized county-level death rates in 2007 and 2017 which were used to calculate and map the proportion and 95% credible interval of counties achieving neither the national Healthy People 2020 target nor a 20% reduction in mortality.

RESULTS

In 2017, 45.8% of counties (credible interval, 42.9-48.3) met neither metric for stroke mortality. These counties had a median stroke death rate of 42.2 deaths per 100 000 in 2017, representing a median 12.8% decline. For CHD mortality, 26.1% (credible interval, 25.0-27.8) of counties met neither metric. These counties had a median CHD death rate of 127.1 deaths per 100 000 in 2017, representing a 10.2% decline. For both outcomes, counties achieving neither metric were not limited to counties with traditionally high stroke and CHD death rates.

CONCLUSIONS

Recent declines in stroke and CHD mortality have not been equal across US counties. Focusing solely on high mortality counties may miss opportunities in the prevention and treatment of cardiovascular disease and in learning more about factors leading to successful reductions in mortality.

Changing Spatiotemporal Trends in County-Level Heart Failure Death Rates in the United States, 1999 to 2018

Background

Amid recently rising heart failure (HF) death rates in the United States, we describe county‐level trends in HF mortality from 1999 to 2018 by racial/ethnic group and sex for ages 35 to 64 years and 65 years and older.

Methods and Results

Applying a hierarchical Bayesian model to National Vital Statistics data representing all US deaths, ages 35 years and older, we estimated annual age‐standardized county‐level HF death rates and percent change by age group, racial/ethnic group, and sex from 1999 through 2018. During 1999 to 2011, ~30% of counties experienced increasing HF death rates among adults ages 35 to 64 years. However, during 2011 to 2018, 86.9% (95% CI, 85.2–88.2) of counties experienced increasing mortality. Likewise, for ages 65 years and older, during 1999 to 2005 and 2005 to 2011, 27.8% (95% CI, 25.8–29.8) and 12.6% (95% CI, 11.2–13.9) of counties, respectively, experienced increasing mortality. However, during 2011 to 2018, most counties (67.4% [95% CI, 65.4–69.5]) experienced increasing mortality. These temporal patterns by age group held across racial/ethnic group and sex.

Conclusions

These results provide local context to previously documented recent national increases in HF death rates. Although county‐level declines were most common before 2011, some counties and demographic groups experienced increasing HF death rates during this period of national declines. However, recent county‐level increases were pervasive, occurring across counties, racial/ethnic group, and sex, particularly among ages 35 to 64 years. These spatiotemporal patterns highlight the need to identify and address underlying clinical risk factors and social determinants of health contributing to these increasing trends.

Progress Toward Achieving National Targets for Reducing Coronary Heart Disease and Stroke Mortality: A County-Level Perspective

Background

The American Heart Association and Healthy People 2020 established objectives to reduce coronary heart disease (CHD) and stroke death rates by 20% by the year 2020, with 2007 as the baseline year. We examined county‐level achievement of the targeted reduction in CHD and stroke death rates from 2007 to 2017.

Methods and Results

Applying a hierarchical Bayesian model to National Vital Statistics data, we estimated annual age‐standardized county‐level death rates and the corresponding percentage change during 2007 to 2017 for those aged 35 to 64 and ≥65 years and by urban‐rural classification. For those aged ≥35 years, 56.1% (95% credible interval [CI], 54.1%–57.7%) and 39.8% (95% CI, 36.9%–42.7%) of counties achieved a 20% reduction in CHD and stroke death rates, respectively. For both CHD and stroke, the proportions of counties achieving a 20% reduction were lower for those aged 35 to 64 years than for those aged ≥65 years (CHD: 32.2% [95% CI, 29.4%–35.6%] and 64.1% [95% CI, 62.3%–65.7%]), respectively; stroke: 17.9% [95% CI, 13.9%–22.2%] and 45.6% [95% CI, 42.8%–48.3%]). Counties achieving a 20% reduction in death rates were more commonly urban counties (except stroke death rates for those aged ≥65 years).

Conclusions

Our analysis found substantial, but uneven, achievement of the targeted 20% reduction in CHD and stroke death rates, defined by the American Heart Association and Healthy People. The large proportion of counties not achieving the targeted reduction suggests a renewed focus on CHD and stroke prevention and treatment, especially among younger adults living outside of urban centers. These county‐level patterns provide a foundation for robust responses by clinicians, public health professionals, and communities.

Historic and recent trends in county-level coronary heart disease death rates by race, gender, and age group, United States, 1979-2017

Given recent slowing of declines in national all-cause, heart disease, and stroke mortality, examining spatiotemporal distributions of coronary heart disease (CHD) death rates and trends can provide data critical to improving the cardiovascular health of populations. This paper documents county-level CHD death rates and trends by age group, race, and gender from 1979 through 2017. Using data from the National Vital Statistics System and a Bayesian multivariate space-time conditional autoregressive model, we estimated county-level age-standardized annual CHD death rates for 1979 through 2017 by age group (35–64 years, 65 years and older), race (white, black, other), and gender (men, women). We then estimated county-level total percent change in CHD death rates during four intervals (1979–1990, 1990–2000, 2000–2010, 2010–2017) using log-linear regression models. For all intervals, national CHD death rates declined for all groups. Prior to 2010, although most counties across age, race, and gender experienced declines, pockets of increasing CHD death rates were observed in the Mississippi Delta, Oklahoma, East Texas, and New Mexico across age groups and gender, and were more prominent among non-white populations than whites. Since 2010, across age, race, and gender, county-level declines in CHD death rates have slowed, with a marked increase in the percent of counties with increasing CHD death rates (e.g. 4.4% and 19.9% for ages 35 and older during 1979–1990 and 2010–2017, respectively). Recent increases were especially prevalent and geographically widespread among ages 35–64 years, with 40.5% of counties (95% CI: 38.4, 43.1) experiencing increases. Spatiotemporal differences in these long term, county-level results can inform responses by the public health community, medical providers, researchers, and communities to address troubling recent trends.

Stagnating National Declines in Stroke Mortality Mask Widespread County-Level Increases, 2010-2016

Background and Purpose- Recent national and state-level trends show a stalling or reversal of previously declining stroke death rates. These national trends may mask local geographic variation and changes in stroke mortality. We assessed county-level trends in stroke mortality among adults aged 35 to 64 and ≥65 years. Methods- We used data from National Vital Statistics Systems and a Bayesian multivariate space-time conditional autoregressive model to estimate age-standardized annual stroke death rates for 2010 through 2016 among middle-aged adults (35-64 years) and older adults (≥65 years) in US counties. We used log-linear regression models to estimate average annual and total percent change in stroke mortality during the period. Results- Nationally, the annual percent change in stroke mortality from 2010 to 2016 was -0.7% (95% CI, -4.2% to 3.0%) among middle-aged adults and -3.5% (95% CI, -10.7% to 4.3%) among older adults, resulting in 2016 rates of 15.0 per 100 000 and 259.8 per 100 000, respectively. Increasing county-level stroke mortality was more prevalent among middle-aged adults (56.6% of counties) compared with among older adults (26.1% of counties). About half (48.3%) of middle-aged adults, representing 60.2 million individuals, lived in counties in which stroke mortality increased. Conclusions- County-level increases in stroke mortality clarify previously reported national and state-level trends, particularly among middle-aged adults. Roughly 3×as many counties experienced increases in stroke death rates for middle-aged adults compared with older adults. This highlights a need to address stroke prevention and treatment for middle-aged adults while continuing efforts to reduce stroke mortality among the more highly burdened older adults. Efforts to reverse these troubling local trends will likely require joint public health and clinical efforts to develop innovative and integrated approaches for stroke prevention and care, with a focus on community-level characteristics that support stroke-free living for all.

Changing rate orders of race-gender heart disease death rates: An exploration of county-level race-gender disparities

A holistic view of racial and gender disparities that simultaneously compares multiple groups can suggest associated underlying contextual factors. Therefore, to more comprehensively understand temporal changes in combined racial and gender disparities, we examine variations in the orders of county-level race-gender specific heart disease death rates by age group from 1973-2015. We estimated county-level heart disease death rates by race, gender, and age group (35-44, 45-54, 55-64, 65-74, 75-84, ≥ 85, and ≥ 35) from the National Vital Statistics System of the National Center for Health Statistics from 1973-2015. We then ordered these rates from lowest to highest for each county and year. The predominant national rate order (i.e., white women (WW) < black women (BW) < white men (WM) < black men (BM)) was most common in younger age groups. Inverted rates for black women and white men (WW Collapse

Key Words

• BM, black men
• BW, black women
• CDC, Centers for Disease Control and Prevention
• County-level
• Gender
• Heart disease mortality
• ICD, International Classification of Diseases
• MCMC, Markov chain Monte Carlo
• NCHS, National Center for Health Statistics
• Race
• Spatiotemporal
• Temporal trends
• WM, white men
• WW, white women

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MESH Headings Collapse

Grants

• K01 HD074726 NICHD NIH HHS

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Affiliation(s)

Adam S. Vaughan Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States
Harrison Quick Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Nesbitt Hall, 3215 Market St., Philadelphia, PA 19104, United States
Linda Schieb Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States
Michael R. Kramer Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, United States
Herman A. Taylor Cardiovascular Research Institute, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, United States
Michele Casper Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States

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The Rate Stabilizing Tool: Generating Stable Local-Level Measures of Chronic Disease

Accurate and precise estimates of local-level epidemiologic measures are critical to informing policy and program decisions, but they often require advanced statistical knowledge, programming/coding skills, and extensive computing power. In response, we developed the Rate Stabilizing Tool (RST), an ArcGIS-based tool that enables users to input their own record-level data to generate more reliable age-standardized measures of chronic disease (eg, prevalence rates, mortality rates) or other population health outcomes at the county or census tract levels. The RST uses 2 forms of empirical Bayesian modeling (nonspatial and spatial) to estimate age-standardized rates and 95% credible intervals for user-specified geographic units. The RST also provides indicators of the reliability of point estimates. In addition to reviewing the RST's statistical techniques, we present results from a simulation study that illustrates the key benefit of smoothing. We demonstrate the dramatic reduction in root mean-squared error (rMSE), indicating a better compromise between accuracy and stability for both smoothing approaches relative to the unsmoothed estimates. Finally, we provide an example of the RST's use. This example uses heart disease mortality data for North Carolina census tracts to map the RST output, including reliability of estimates, and demonstrates a subsequent statistical test.

How to improve success rates of endoscopic management for buried bumper syndrome

BACKGROUND

Buried bumper syndrome (BBS) is a rare complication of percutaneous endoscopic gastrostomy. Complete BBS without visible parts of the inner bumper is a challenge for endoscopic treatment.

METHODS AND AIMS

Data base analysis of all procedures performed at our tertiary university endoscopy center between 2000 and 2015 was conducted. Our aim was to improve the success rates of endoscopic treatment using a standardized approach and a pull-modification of the papillotome-based extraction technique in a prospective cohort.

RESULTS

Retrospectively, 55 patients were identified (37 men; age 54 ± 16 years). The prospective series comprised 11 patients (8 men; age 63 ± 27 years). Patients with partial BBS were effectively treated by endoscopy in both cohorts (24/25 and 4/4 patients, respectively). For complete BBS (Cyrany grade 3), success rates of endoscopic therapy differed significantly between the cohorts (P = 0.017). In the retrospective cohort, only 38% of patients (9/24 patients) were successfully treated. In the prospective cohort, all six patients (deep-type in five cases) were managed without complications. Patients with extra-gastric tubes underwent primary surgery in both cohorts (six and one patients, respectively).

CONCLUSION

A structured approach improved success rates of endoscopic treatment. All patients with an internal bumper verified to lie within the gastric wall can be treated by an experienced investigator using a papillotome-based technique.

Heart Disease Death Rates Among Blacks and Whites Aged ≥35 Years - United States, 1968-2015

PROBLEM/CONDITION

Heart disease is the leading cause of death in the United States. In 2015, heart disease accounted for approximately 630,000 deaths, representing one in four deaths in the United States. Although heart disease death rates decreased 68% for the total population from 1968 to 2015, marked disparities in decreases exist by race and state.

PERIOD COVERED

1968-2015.

DESCRIPTION OF SYSTEM

The National Vital Statistics System (NVSS) data on deaths in the United States were abstracted for heart disease using diagnosis codes from the eighth, ninth, and tenth revisions of the International Classification of Diseases (ICD-8, ICD-9, and ICD-10) for 1968-2015. Population estimates were obtained from NVSS files. National and state-specific heart disease death rates for the total population and by race for adults aged ≥35 years were calculated for 1968-2015. National and state-specific black-white heart disease mortality ratios also were calculated. Death rates were age standardized to the 2000 U.S. standard population. Joinpoint regression was used to perform time trend analyses.

RESULTS

From 1968 to 2015, heart disease death rates decreased for the total U.S. population among adults aged ≥35 years, from 1,034.5 to 327.2 per 100,000 population, respectively, with variations in the magnitude of decreases by race and state. Rates decreased for the total population an average of 2.4% per year, with greater average decreases among whites (2.4% per year) than blacks (2.2% per year). At the national level, heart disease death rates for blacks and whites were similar at the start of the study period (1968) but began to diverge in the late 1970s, when rates for blacks plateaued while rates for whites continued to decrease. Heart disease death rates among blacks remained higher than among whites for the remainder of the study period. Nationwide, the black-white ratio of heart disease death rates increased from 1.04 in 1968 to 1.21 in 2015, with large increases occurring during the 1970s and 1980s followed by small but steady increases until approximately 2005. Since 2005, modest decreases have occurred in the black-white ratio of heart disease death rates at the national level. The majority of states had increases in black-white mortality ratios from 1968 to 2015. The number of states with black-white mortality ratios >1 increased from 16 (40%) to 27 (67.5%).

INTERPRETATION

Although heart disease death rates decreased both for blacks and whites from 1968 to 2015, substantial differences in decreases were found by race and state. At the national level and in most states, blacks experienced smaller decreases in heart disease death rates than whites for the majority of the period. Overall, the black-white disparity in heart disease death rates increased from 1968 to 2005, with a modest decrease from 2005 to 2015.

PUBLIC HEALTH ACTION

Since 1968, substantial increases have occurred in black-white disparities of heart disease death rates in the United States at the national level and in many states. These increases appear to be due to faster decreases in heart disease death rates for whites than blacks, particularly from the late 1970s until the mid-2000s. Despite modest decreases in black-white disparities at the national level since 2005, in 2015, heart disease death rates were 21% higher among blacks than among whites. This study demonstrates the use of NVSS data to conduct surveillance of heart disease death rates by race and of black-white disparities in heart disease death rates. Continued surveillance of temporal trends in heart disease death rates by race can provide valuable information to policy makers and public health practitioners working to reduce heart disease death rates both for blacks and whites and disparities between blacks and whites.

Widespread recent increases in county-level heart disease mortality across age groups

PURPOSE

Recent national trends show decelerating declines in heart disease mortality, especially among younger adults. National trends may mask variation by geography and age. We examined recent county-level trends in heart disease mortality by age group.

METHODS

Using a Bayesian statistical model and National Vital Statistics Systems data, we estimated overall rates and percent change in heart disease mortality from 2010 through 2015 for four age groups (35-44, 45-54, 55-64, and 65-74 years) in 3098 US counties.

RESULTS

Nationally, heart disease mortality declined in every age group except ages 55-64 years. County-level trends by age group showed geographically widespread increases, with 52.3%, 58.5%, 69.1%, and 42.0% of counties experiencing increases with median percent changes of 0.6%, 2.2%, 4.6%, and -1.5% for ages 35-44, 45-54, 55-64, and 65-74 years, respectively. Increases were more likely in counties with initially high heart disease mortality and outside large metropolitan areas.

CONCLUSIONS

Recent national trends have masked local increases in heart disease mortality. These increases, especially among adults younger than age 65 years, represent challenges to communities across the country. Reversing these trends may require intensification of primary and secondary prevention-focusing policies, strategies, and interventions on younger populations, especially those living in less urban counties.

County Health Factors Associated with Avoidable Deaths from Cardiovascular Disease in the United States, 2006-2010

OBJECTIVE

Many cardiovascular deaths can be avoided through primary prevention to address cardiovascular disease (CVD) risk factors or better access to quality medical care. In this cross-sectional study, we examined the relationship between four county-level health factors and rates of avoidable death from CVD during 2006-2010.

METHODS

We defined avoidable deaths from CVD as deaths among U.S. residents younger than 75 years of age caused by the following underlying conditions, using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes: ischemic heart disease (I20-I25), chronic rheumatic heart disease (I05-I09), hypertensive disease (I10-I15), or cerebrovascular disease (I60-I69). We stratified county-level death rates by race (non-Hispanic white or non-Hispanic black) and age-standardized them to the 2000 U.S. standard population. We used County Health Rankings data to rank county-level z scores corresponding to four health factors: health behavior, clinical care, social and economic factors, and physical environment. We used Poisson rate ratios (RRs) and 95% confidence intervals (CIs) to compare rates of avoidable death from CVD by health-factor quartile.

RESULTS

In a comparison of worst-ranked and best-ranked counties, social and economic factors had the strongest association with rates of avoidable death per 100,000 population from CVD for the total population (RR=1.49; 95% CI 1.39, 1.60) and for each racial/ethnic group (non-Hispanic white: RR=1.37; 95% CI 1.29, 1.45; non-Hispanic black: RR=1.54; 95% CI 1.42, 1.67). Among the non-Hispanic white population, health behaviors had the next strongest association, followed by clinical care. Among the non-Hispanic black population, we observed a significant association with clinical care and physical environment in a comparison of worst-ranked and best-ranked counties.

CONCLUSION

Social and economic factors have the strongest association with rates of avoidable death from CVD by county, which reinforces the importance of social and economic interventions to address geographic disparities in avoidable deaths from CVD.

Geographic Variations in Incremental Costs of Heart Disease Among Medicare Beneficiaries, by Type of Service, 2012

Using 2012 data on fee-for-service Medicare claims, we documented regional and county variation in incremental standardized costs of heart disease (ie, comparing costs between beneficiaries with heart disease and beneficiaries without heart disease) by type of service (eg, inpatient, outpatient, post-acute care). Absolute incremental total costs varied by region. Although the largest absolute incremental total costs of heart disease were concentrated in southern and Appalachian counties, geographic patterns of costs varied by type of service. These data can be used to inform development of policies and payment models that address the observed geographic disparities.

Changes in the Geographic Patterns of Heart Disease Mortality in the United States: 1973 to 2010

BACKGROUND

Although many studies have documented the dramatic declines in heart disease mortality in the United States at the national level, little attention has been given to the temporal changes in the geographic patterns of heart disease mortality.

METHODS AND RESULTS

Age-adjusted and spatially smoothed county-level heart disease death rates were calculated for 2-year intervals from 1973 to 1974 to 2009 to 2010 for those aged ≥35 years. Heart disease deaths were defined according to the International Classification of Diseases codes for diseases of the heart in the eighth, ninth, and tenth revisions of the International Classification of Diseases. A fully Bayesian spatiotemporal model was used to produce precise rate estimates, even in counties with small populations. A substantial shift in the concentration of high-rate counties from the Northeast to the Deep South was observed, along with a concentration of slow-decline counties in the South and a nearly 2-fold increase in the geographic inequality among counties.

CONCLUSIONS

The dramatic change in the geographic patterns of heart disease mortality during 40 years highlights the importance of small-area surveillance to reveal patterns that are hidden at the national level, gives communities the historical context for understanding their current burden of heart disease, and provides important clues for understanding the determinants of the geographic disparities in heart disease mortality.

Disparities in Temporal and Geographic Patterns of Declining Heart Disease Mortality by Race and Sex in the United States, 1973-2010

BACKGROUND

Examining small-area differences in the strength of declining heart disease mortality by race and sex provides important context for current racial and geographic disparities and identifies localities that could benefit from targeted interventions. We identified and described temporal trends in declining county-level heart disease mortality by race, sex, and geography between 1973 and 2010.

METHODS AND RESULTS

Using a Bayesian hierarchical model, we estimated age-adjusted mortality with diseases of the heart listed as the underlying cause for 3099 counties. County-level percentage declines were calculated by race and sex for 3 time periods (1973-1985, 1986-1997, 1998-2010). Strong declines were statistically faster or no different than the total national decline in that time period. We observed county-level race-sex disparities in heart disease mortality trends. Continual (from 1973 to 2010) strong declines occurred in 73.2%, 44.6%, 15.5%, and 17.3% of counties for white men, white women, black men, and black women, respectively. Delayed (1998-2010) strong declines occurred in 15.4%, 42.0%, 75.5%, and 76.6% of counties for white men, white women, black men, and black women, respectively. Counties with the weakest patterns of decline were concentrated in the South.

CONCLUSIONS

Since 1973, heart disease mortality has declined substantially for these race-sex groups. Patterns of decline differed by race and geography, reflecting potential disparities in national and local drivers of these declines. Better understanding of racial and geographic disparities in the diffusion of heart disease prevention and treatment may allow us to find clues to progress toward racial and geographic equity in heart disease mortality.

Multidisciplinary treatment of desmoid tumours in Gardner's syndrome due to a large interstitial deletion of chromosome 5q

BACKGROUND AND AIMS

Classic autosomal-dominant familial adenomatous polyposis (FAP) is clinically defined by the development of hundreds to thousands of colorectal adenomas beginning in childhood and adolescence. A variant of FAP characterized by polyposis in combination with osteomas or soft tissue tumours is called Gardner's syndrome. FAP is caused by germline inactivation of the APC (adenomatous polyposis coli) tumour-suppressor gene located on the long arm of chromosome 5 (5q21-5q22). Cytogenetically visible deletions of chromosome 5q encompassing APC have very rarely been reported. Here, we aimed to phenotypically and genetically characterize a patient with a heterozygous 5q deletion resulting in Gardner's syndrome.

METHODS AND RESULTS

A 26-year-old female patient with mild mental handicap and dysmorphic features due to a cytogenetically visible deletion on chromosome 5q (microscopically estimated region 5q14-5q23) presented at our tertiary referral centre because of mild adenomatous polyposis (<500 polyps). Twenty months after prophylactic proctocolectomy with definitive ileostomy, three rapidly growing desmoids were observed. Tumour-associated complications necessitated a multidisciplinary approach including medical treatment, surgery and radiation therapy. The characterization of the deletion by comparative genomic hybridization identified a large 5q deletion expanding over a 20-Mb region (5q21.3-5q23.3) including the APC gene.

CONCLUSION

Chromosome deletions must be suspected in patients presenting with FAP together with mental handicap and dysmorphic features. This case also impressively shows that FAP-associated desmoids need multimodal treatment taking into account the patient's individual symptoms, disease progression and tumour location.

Putting chronic disease on the map: building GIS capacity in state and local health departments

Techniques based on geographic information systems (GIS) have been widely adopted and applied in the fields of infectious disease and environmental epidemiology; their use in chronic disease programs is relatively new. The Centers for Disease Control and Prevention’s Division for Heart Disease and Stroke Prevention is collaborating with the National Association of Chronic Disease Directors and the University of Michigan to provide health departments with capacity to integrate GIS into daily operations, which support priorities for surveillance and prevention of chronic diseases. So far, 19 state and 7 local health departments participated in this project. On the basis of these participants’ experiences, we describe our training strategy and identify high-impact GIS skills that can be mastered and applied over a short time in support of chronic disease surveillance. We also describe the web-based resources in the Chronic Disease GIS Exchange that were produced on the basis of this training and are available to anyone interested in GIS and chronic disease (www.cdc.gov/DHDSP/maps/GISX). GIS offers diverse sets of tools that promise increased productivity for chronic disease staff of state and local health departments.

Tracking stroke hospitalization clusters over time and associations with county-level socioeconomic and healthcare characteristics

BACKGROUND AND PURPOSE

This study evaluated clustering of stroke hospitalization rates, patterns of the clustering over time, and associations with community-level characteristics.

METHODS

We used Medicare hospital claims data from 1995-1996 to 2005-2006 with a principal discharge diagnosis of stroke to calculate county-level stroke hospitalization rates. We identified statistically significant clusters of high- and low-rate counties by using local indicators of spatial association, tracked cluster status over time, and assessed associations between cluster status and county-level socioeconomic and healthcare profiles.

RESULTS

Clearly defined clusters of counties with high- and low-stroke hospitalization rates were identified in each time. Approximately 75% of counties maintained their cluster status from 1995-1996 to 2005-2006. In addition, 243 counties transitioned into high-rate clusters, and 148 transitioned out of high-rate clusters. Persistently high-rate clusters were located primarily in the Southeast, whereas persistently low-rate clusters occurred mostly in New England and in the West. In general, persistently low-rate counties had the most favorable socioeconomic and healthcare profiles, followed by counties that transitioned out of or into high-rate clusters. Persistently high-rate counties experienced the least favorable socioeconomic and healthcare profiles.

CONCLUSIONS

The persistence of clusters of high- and low-stroke hospitalization rates during a 10-year period suggests that the underlying causes of stroke in these areas have also persisted. The associations found between cluster status (persistently high, transitional, persistently low) and socioeconomic and healthcare profiles shed new light on the contributions of community-level characteristics to geographic disparities in stroke hospitalizations.

MUTYH hotspot mutations in unselected colonoscopy patients

AIM

Biallelic MutY human homologue (MUTYH) germline mutations predispose to recessively inherited adenomatous polyposis, designated MUTYH-associated polyposis (MAP), and colorectal cancer (CRC). The hotspot mutations p.Y179C and p.G396D account for the majority of pathogenic variants of MUTYH in Caucasians. Our aim was to evaluate the prevalence of MUTYH mutations in a prospective cohort of unselected patients with different colorectal diseases.

METHOD

The hotspot mutations p.Y179C and p.G396D were genotyped in 352 consecutive patients undergoing colonoscopy at our tertiary referral centre. Exons 2-14 were sequenced in hotspot mutation carriers to exclude additional variants.

RESULTS

Overall, we identified five heterozygous p.Y179C mutations and three heterozygous p.G396D mutations in seven hotspot mutation carriers (risk allele frequencies 0.7% and 0.4%, respectively). Two of these hotspot mutation carriers harboured a heterozygous p.Q338H variant, which is of uncertain clinical significance, on the other allele. Three individuals were biallelic MUTYH variant carriers (p.Y179C/p.G382D: typical MAP; p.Y179C/p.Q338H: atypical MAP with late onset and lower polyp burden; p.G382D/p.Q338H: inflammatory bowel disease), and four subjects were monoallelic mutation carriers.

CONCLUSION

MUTYH-associated disease, and hence genetic counselling and MUTYH genetic testing, should be considered in the clinical routine of an endoscopy unit, but the wide range of phenotypes represents a challenge for patient identification. The clinical significance of p.Q338H should be evaluated in future case-control studies because compound heterozygotes for pathogenic mutations and p.Q338H may be at increased risk for mild polyposis or CRC. In addition, MUTYH should be assessed as a potential susceptibility gene for the development of colitis-associated CRC in future.

[Gallstone disease: basic mechanisms, diagnosis and therapy]

Gallstone disease is one of the most common gastroenterological diseases and represents a major burden for our heath care systems. Cholesterol gallstones, responsible for about 90% of stones, represent a multifactorial disease with an important genetic component. Most gallstone-carriers remain asymptomatic and hence in general, they not need any therapy. In contrast those with symptomatic (biliary colic) or complicated gallstone disease (cholecystitis, obstructive cholangitis, biliary pancreatitis) have to be treated interdisciplinary by surgeons and endoscopists. Laparoscopic cholecystectomy represents the causal therapy to avoid recurrent symptoms as well as the therapy of choice for cholecystitis as the most common complication of gallstone disease. Bile duct stones and the associated complications (cholangitis, biliary pancreatitis) are primarily treated endoscopically.

Geographic and sociodemographic disparities in drive times to Joint Commission-certified primary stroke centers in North Carolina, South Carolina, and Georgia

INTRODUCTION

Timely access to facilities that provide acute stroke care is necessary to reduce disabilities and death from stroke. We examined geographic and sociodemographic disparities in drive times to Joint Commission-certified primary stroke centers (JCPSCs) and other hospitals with stroke care quality improvement initiatives in North Carolina, South Carolina, and Georgia.

METHODS

We defined boundaries for 30- and 60-minute drive-time areas to JCPSCs and other hospitals  by  using geographic information systems (GIS) mapping technology and calculated the proportions of the population living in these drive-time areas by sociodemographic characteristics. Age-adjusted county-level stroke death rates were overlaid onto the drive-time areas.

RESULTS

Approximately 55% of the population lived within a 30-minute drive time to a JCPSC; 77% lived within a 60-minute drive time. Disparities in percentage of the population within 30-minute drive times were found by race/ethnicity, education, income, and urban/rural status; the disparity was largest between urban areas (70% lived within 30-minute drive time) and rural areas (26%). The rural coastal plains had the largest concentration of counties with high stroke death rates and the fewest JCPSCs.

CONCLUSION

Many areas in this tri-state region lack timely access to JCPSCs. Alternative strategies are needed to expand provision of quality acute stroke care in this region. GIS modeling is valuable for examining and strategically planning the distribution of hospitals providing acute stroke care.

Racial residential segregation and stroke mortality in Atlanta

OBJECTIVE

To assess the association between neighborhood-level racial residential segregation and stroke mortality using a spatially derived segregation index.

DESIGN

Cross-sectional study

SETTING

Atlanta Metropolitan Statistical Area

METHODS

The study population consisted of non-Hispanic Black and White residents of the Atlanta Metropolitan Statistical Area during the time period Jan 1, 2000 to December 31, 2006. Census tract-level stroke death rates for Blacks and Whites were modeled as a function of the segregation index while controlling for two neighborhood-level chronic stressors (poverty, low education).

RESULTS

Racial segregation was positively associated with stroke mortality for both Blacks and Whites aged 35-64 years. Among Blacks and Whites aged 65 or older, segregation was negatively associated with stroke mortality after controlling for the two stressors, suggesting that they were pathways between segregation and stroke death rates.

CONCLUSION

Future studies are needed to identify additional pathways between residential segregation and other health outcomes, and to collect data that support a life course approach to understanding the impact of residential segregation on health.

Rejuvenation of periosteal chondrogenesis using local growth factor injection

OBJECTIVE

To examine the potential for rejuvenation of aged periosteum by local injection of transforming growth factor-beta1 (TGF-beta1) and insulin-like growth factor-1 (IGF-1) alone or in combination to induce cambium cell proliferation and enhance in vitro periosteal cartilage formation.

METHODS

A total of 367 New Zealand white rabbits (6, 12, and 24+ month-old) received subperiosteal injections of TGF-beta1 and/or IGF-1 percutaneously. After 1, 3, 5, or 7 days, the rabbits were sacrificed and cambium cellularity or in vitro cartilage forming capacity was determined.

RESULTS

A significant increase in cambium cellularity and thickness, and in vitro cartilage formation was observed after injection of TGF-beta1 alone or in combination with IGF-1. In 12 month-old rabbits, mean cambium cellularity increased 5-fold from 49 to 237 cells/mm and in vitro cartilage production increased 12-fold from 0.8 to 9.7 mg 7 days after TGF-beta1 (200 ng) injection compared to vehicle controls (P<0.0001). A correlation was observed between cambium cellularity and in vitro cartilage production (R2=0.98). An added benefit of IGF-1 plus TGF-beta1 on in vitro cartilage production compared to TGF-beta1 alone was observed in the 2 year-old rabbits. IGF-1 alone generally had no effect on either cambium cellularity or in vitro cartilage production in any of the age groups.

CONCLUSIONS

These results clearly demonstrate that it is possible to increase cambium cellularity and in vitro cartilage production in aged rabbit periosteum, to levels comparable to younger rabbits, using local injection of TGF-beta1 alone or in combination with IGF-1, thereby rejuvenating aged periosteum.

Measuring contextual characteristics for community health

OBJECTIVE

To conceptualize and measure community contextual influences on population health and health disparities.

DATA SOURCES

We use traditional and nontraditional secondary sources of data comprising a comprehensive array of community characteristics.

STUDY DESIGN

Using a consultative process, we identify 12 overarching dimensions of contextual characteristics that may affect community health, as well as specific subcomponents relating to each dimension.

DATA COLLECTION

An extensive geocoded library of data indicators relating to each dimension and subcomponent for metropolitan areas in the United States is assembled.

PRINCIPAL FINDINGS

We describe the development of community contextual health profiles, present the rationale supporting each of the profile dimensions, and provide examples of relevant data sources.

CONCLUSIONS

Our conceptual framework for community contextual characteristics, including a specified set of dimensions and components, can provide practical ways to monitor health-related aspects of the economic, social, and physical environments in which people live. We suggest several guiding principles useful for understanding how aspects of contextual characteristics can affect health and health disparities.

Geographic disparities in heart disease and stroke mortality among black and white populations in the Appalachian region

In this paper, we examine geographic and racial/ethnic differences in heart disease and stroke mortality in the Appalachian region. Initial comparisons are made between national rates for heart disease and stroke mortality and those for the Appalachian region. County-level analyses were performed to examine the relative mortality experience of populations in Appalachian counties compared to other counties in the United States and to assess the degree of geographic disparity in mortality from heart disease and stroke among these race/ethnic and gender groups within Appalachia. The Appalachian region exhibits higher rates of both heart disease and stroke mortality for all race/ethnic, gender, and age groups examined. We found that many counties in the Appalachian region endure a considerable burden of the national excess in both heart disease and stroke mortality, and these counties tend to be aggregated in particular areas as opposed to being dispersed regionwide. Finally, we compare 2 groups of counties in Appalachia based on the designation as an "economically distressed county," defined by the Appalachian Regional Commission. As a group, distressed counties in Appalachia exhibit higher rates of both heart disease and stroke mortality than the rest of Appalachia.

Prevalence of lower extremity arterial disease defined by the ankle-brachial index among American Indians: the Inter-Tribal Heart Project

OBJECTIVES

This study examines the prevalence of lower extremity arterial disease (LEAD) and its association with cardiovascular disease (CVD) risk factors.

METHODS

Linear and logistic regression were used to analyze cross-sectional data from 1333 Chippewa and Menominee Indians.

RESULTS

Approximately 6.4% of participants (6.9% of men, 6.1% of women) had LEAD. Among women, LEAD was associated with lower high-density lipoprotein cholesterol; higher levels of diastolic blood pressure, creatinine, and triglycerides; and current smoking, diabetes, microalbuminuria, prior myocardial infarction, and stroke (P < or = .05). Among men, LEAD was associated with higher levels of creatinine (P < or = .05).

CONCLUSIONS

Use of the ankle-brachial index to assess LEAD is a noninvasive and inexpensive measurement that can be used by clinicians to identify persons at increased risk of developing CVD, and may provide opportunities to prevent CVD.