Practice Facilitation and Peer Coaching for Uncontrolled Hypertension Among Black Individuals: A Randomized Clinical Trial

Importance

Rural Black participants need effective intervention to achieve better blood pressure (BP) control.

Objective

Among Black rural adults with persistently uncontrolled hypertension attending primary care clinics, to determine whether peer coaching (PC), practice facilitation (PF), or both (PCPF) are superior to enhanced usual care (EUC) in improving BP control.

Design, Setting, and Participants

A cluster randomized clinical trial was conducted in 69 rural primary care practices across Alabama and North Carolina between September 23, 2016, and September 26, 2019. The participating practices were randomized to 4 groups: PC plus EUC, PF plus EUC, PCPF plus EUC, and EUC alone. The baseline EUC approach included a laptop for each participating practice with hyperlinks to participant education on hypertension, a binder of practice tips, a poster showing an algorithm for stepped care to improve BP, and 25 home BP monitors. The trial was stopped on February 28, 2021, after final data collection. The study included Black participants with persistently uncontrolled hypertension. Data were analyzed from February 28, 2021, to December 13, 2022.

Interventions

Practice facilitators helped practices implement at least 4 quality improvement projects designed to improve BP control throughout 1 year. Peer coaches delivered a structured program via telephone on hypertension self-management throughout 1 year.

Main Outcomes and Measures

The primary outcome was the proportion of participants in each trial group with BP values of less than 140/90 mm Hg at 6 months and 12 months. The secondary outcome was a change in the systolic BP of participants at 6 months and 12 months.

Results

A total of 69 practices were randomized, and 1209 participants' data were included in the analysis. The mean (SD) age of participants was 58 (12) years, and 748 (62%) were women. In the intention-to-treat analyses, neither intervention alone nor in combination improved BP control or BP levels more than EUC (at 12 months, PF vs EUC odds ratio [OR], 0.94 [95% CI, 0.58-1.52]; PC vs EUC OR, 1.30 [95% CI, 0.83-2.04]; PCPF vs EUC OR, 1.02 [95% CI, 0.64-1.64]). In preplanned subgroup analyses, participants younger than 60 years in the PC and PCPF groups experienced a significant 5 mm Hg greater reduction in systolic BP than participants younger than 60 years in the EUC group at 12 months. Practicewide BP control estimates in PF groups suggested that BP control improved from 54% to 61%, a finding that was not observed in the trial's participants.

Conclusions and Relevance

The results of this cluster randomized clinical trial demonstrated that neither PC nor PF demonstrated a superior improvement in overall BP control compared with EUC. However, PC led to a significant reduction in systolic BP among younger adults.

Trial Registration

ClinicalTrials.gov Identifier: NCT02866669.

Risk Prediction for Atherosclerotic Cardiovascular Disease With and Without Race Stratification

Importance

Use of race-specific risk prediction in clinical medicine is being questioned. Yet, the most commonly used prediction tool for atherosclerotic cardiovascular disease (ASCVD)-pooled cohort risk equations (PCEs)-uses race stratification.

Objective

To quantify the incremental value of race-specific PCEs and determine whether adding social determinants of health (SDOH) instead of race improves model performance.

Design, Setting, and Participants

Included in this analysis were participants from the biracial Reasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort study. Participants were aged 45 to 79 years, without ASCVD, and with low-density lipoprotein cholesterol level of 70 to 189 mg/dL or non-high-density lipoprotein cholesterol level of 100 to 219 mg/dL at baseline during the period of 2003 to 2007. Participants were followed up to 10 years for incident ASCVD, including myocardial infarction, coronary heart disease death, and fatal and nonfatal stroke. Study data were analyzed from July 2022 to February 2023.

Main outcome/measures

Discrimination (C statistic, Net Reclassification Index [NRI]), and calibration (plots, Nam D'Agostino test statistic comparing observed to predicted events) were assessed for the original PCE, then for a set of best-fit, race-stratified equations including the same variables as in the PCE (model C), best-fit equations without race stratification (model D), and best-fit equations without race stratification but including SDOH as covariates (model E).

Results

This study included 11 638 participants (mean [SD] age, 61.8 [8.3] years; 6764 female [58.1%]) from the REGARDS cohort. Across all strata (Black female, Black male, White female, and White male participants), C statistics did not change substantively compared with model C (Black female, 0.71; 95% CI, 0.68-0.75; Black male, 0.68; 95% CI, 0.64-0.73; White female, 0.77; 95% CI, 0.74-0.81; White male, 0.68; 95% CI, 0.64-0.71), in model D (Black female, 0.71; 95% CI, 0.67-0.75; Black male, 0.68; 95% CI, 0.63-0.72; White female, 0.76; 95% CI, 0.73-0.80; White male, 0.68; 95% CI, 0.65-0.71), or in model E (Black female, 0.72; 95% CI, 0.68-0.76; Black male, 0.68; 95% CI, 0.64-0.72; White female, 0.77; 95% CI, 0.74-0.80; White male, 0.68; 95% CI, 0.65-0.71). Comparing model D with E using the NRI showed a net percentage decline in the correct assignment to higher risk for male but not female individuals. The Nam D'Agostino test was not significant for all race-sex strata in each model series, indicating good calibration in all groups.

Conclusions

Results of this cohort study suggest that PCE performed well overall but had poorer performance in both BM and WM participants compared with female participants regardless of race in the REGARDS cohort. Removal of race or the addition of SDOH did not improve model performance in any subgroup.

Myocardial infarction and physical function: the REasons for Geographic And Racial Differences in Stroke prospective cohort study

Objective

To examine associations between myocardial infarction (MI) and multiple physical function metrics.

Methods

Among participants aged ≥45 years in the REasons for Geographic And Racial Differences in Stroke prospective cohort study, instrumental activities of daily living (IADL), activities of daily living (ADL), gait speed, chair stands, and Short Form-12 physical component summary (PCS) were assessed after approximately 10 years of follow-up. We examined associations between MI and physical function (no MI [n = 9,472], adjudicated MI during follow-up [n = 288, median 4.7 years prior to function assessment], history of MI at baseline [n = 745], history of MI at baseline and adjudicated MI during follow-up [n = 70, median of 6.7 years prior to function assessment]). Models were adjusted for sociodemographic characteristics, health behaviours, depressive symptoms, cognitive impairment, body mass index, diabetes, hypertension, and urinary albumin to creatinine ratio. We examined subgroups defined by age, gender, and race.

Results

The average age at baseline was 62 years old, 56% were women, and 35% Black. MI was significantly associated with worse IADL and ADL scores, IADL dependency, chair stands, and PCS, but not ADL dependency or gait speed. For example, compared to participants without MI, IADL scores (possible range 0-14, higher score represents worse function) were greater for participants with MI during follow-up (difference: 0.37 [95% CI 0.16, 0.59]), MI at baseline (0.26 [95% CI 0.12, 0.41]), and MI at baseline and follow-up (0.71 [95% CI 0.15, 1.26]), p < 0.001. Associations tended to be greater in magnitude among participants who were women and particularly Black women.

Conclusion

MI was associated with various measures of physical function. These decrements in function associated with MI may be preventable or treatable.

Treatment Intensity, Prescribing Patterns, and Blood Pressure Control in Rural Black Patients with Uncontrolled Hypertension

BACKGROUND/OBJECTIVE

Because racial disparities in hypertension treatment persist, the objective of the present study was to examine patient vs. practice characteristics that influence antihypertensive selection and treatment intensity for non-Hispanic Black (hereafter "Black") patients with uncontrolled hypertension in the rural southeastern USA.

METHODS

We enrolled 25 Black patients from each of 69 rural practices in Alabama and North Carolina with uncontrolled hypertension (systolic blood pressure (BP) ≥ 140 mm Hg) in a 4-arm cluster randomized trial of BP control interventions. Patients' antihypertensive medications were abstracted from medical records and reconciled at the baseline visit. Treatment intensity was computed using the defined daily dose (DDD) method of the World Health Organization. Correlates of greater antihypertensive medication intensity were assessed by linear regression modeling, and antihypertensive medication classes were compared by baseline systolic BP (SBP) level.

RESULTS

A total of 1431 patients were enrolled and had complete baseline data. Antihypertensive treatment intensity averaged 3.7 ± 2.6 equivalent medications at usual dosages and was significantly related to higher baseline systolic BP, older age, male sex, insurance availability, higher BMI, and concurrent diabetes, but not to practice type or medication barriers in regression models. Renin-angiotensin system inhibitors were the most commonly used medications, followed by diuretics and calcium channel blockers.

CONCLUSION/RELEVANCE

Antihypertensive treatment intensity for Black patients in the rural southeastern USA with a history of uncontrolled hypertension averaged the equivalent of almost four medications at usual dosages and was significantly associated with baseline SBP levels and other patient characteristics, but not clinic type.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02866669.

Implementing practice facilitation in research: how facilitators spend their time guiding practices to improve blood pressure control

BACKGROUND

Practice facilitators (PFs) coach practices through quality improvement (QI) initiatives aimed at enhancing patient outcomes and operational efficiencies. Practice facilitation is a dynamic intervention that, by design, is tailored to practices' unique needs and contexts. Little research has explored the amount of time PFs spend with practices on QI activities. This short report expands on previously published work that detailed a 12-month practice facilitation intervention as part of the Southeastern Collaboration to Improve Blood Pressure Control (SEC) trial, which focused on improving hypertension control among people living in rural settings in the southeastern USA. This report analyzes data on the time PFs spent to guide 32 primary care practices in implementing QI activities to support enhanced outcomes in patients with high blood pressure.

METHODS

The SEC trial employed four certified PFs across all practice sites, who documented time spent: (1) driving to support practices; (2) working on-site with staff and clinicians; and (3) communicating remotely (phone, email, or video conference) with practice members. We analyzed the data using descriptive statistics to help understand time devoted to individual and aggregated tasks. Additionally, we explored correlations between practice characteristics and time spent with PFs.

RESULTS

In aggregate, the PFs completed 416 visits to practices and spent an average of 130 (SD 65) min per visit driving to and from practices. The average time spent on-site per visit with practices was 87 (SD 37) min, while an average of 17 (SD 12) min was spent on individual remote communications. During the 12-month intervention, 1131 remote communications were conducted with practices. PFs spent most of their time with clinical staff members (n = 886 instances) or with practice managers alone (n = 670 instances) while relatively few on-site visits were conducted with primary care providers alone (n = 15). In 19 practices, no communications were solely with providers. No significant correlations were found between time spent on PF activities and a practices' percent of Medicaid and uninsured patients, staff-provider ratio, or federally qualified health center (FQHC) status.

CONCLUSIONS

PFs working with practices serving rural patients with hypertension devote substantial time to driving, highlighting the importance of optimizing a balance between time spent on-site vs. communicating remotely. Most time spent was with clinical staff, not primary care providers. These findings may be useful to researchers and business leaders who design, test, and implement efficient facilitation services.

TRIAL REGISTRATION

NIH ClinicalTrials.gov NCT02866669 . Registered on 15 August 2016. NHLBI AWARD number: PCS-1UH3HL130691.

The design and rationale of a multicenter real-world trial: The southeastern collaboration to improve blood pressure control in the US Black Belt - Addressing the triple threat

BACKGROUND

Impoverished African Americans (AA) with hypertension face poor health outcomes.

PURPOSE

To conduct a cluster-randomized trial testing two interventions, alone and in combination, to improve blood pressure (BP) control in AA with persistently uncontrolled hypertension.

METHODS

We engaged primary care practices serving rural Alabama and North Carolina residents, and in each practice we recruited approximately 25 AA adults with persistently uncontrolled hypertension (mean systolic BP >140 mmHg over the year prior to enrollment plus enrollment day BP assessed by research assistants ≥140/90 mmHg). Practices were randomized to peer coaching (PC), practice facilitation (PF), both PC and PF (PC + PF), or enhanced usual care (EUC). Coaches met with participants from PC and PC + PF practices weekly for 8 weeks then monthly over one year, discussing lifestyle changes, medication adherence, home monitoring, and communication with the healthcare team. Facilitators met with PF and PC + PF practices monthly to implement ≥1 quality improvement intervention in each of four domains. Data were collected at 0, 6, and 12 months.

RESULTS

We recruited 69 practices and 1596 participants; 18 practices (408 participants) were randomized to EUC, 16 (384 participants) to PF, 19 (424 participants) to PC, and 16 (380 participants) to PC + PF. Participants had mean age 57 years, 61% were women, and 56% reported annual income <$20,000.

LIMITATIONS

The PF intervention acts at the practice level, possibly missing intervention effects in trial participants. Neither PC nor PF currently has established clinical reimbursement mechanisms.

CONCLUSIONS

This trial will fill evidence gaps regarding practice-level vs. patient-level interventions for rural impoverished AA with uncontrolled hypertension.

Suboptimal Cardiology Follow-Up Among Patients With and Without Cancer Hospitalized for Heart Failure

Many patients hospitalized for heart failure (HF) do not receive recommended follow-up cardiology care, and non-White patients are less likely to receive follow-up than White patients. Poor HF management may be particularly problematic in patients with cancer because cardiovascular co-morbidity can delay cancer treatments. Therefore, we sought to describe outpatient cardiology care patterns in patients with cancer hospitalized for HF and to determine if receipt of follow-up varied by race/ethnicity. SEER (Surveillance, Epidemiology, and End Results) data from 2007 to 2013 linked to Medicare claims from 2006 to 2014 were used. We included patients aged 66+ years with breast, prostate, or colorectal cancer, and preexisting HF. Patients with cancer were matched to patients in a noncancer cohort that included individuals with HF and no cancer. The primary outcome was receipt of an outpatient, face-to-face cardiologist visit within 30 days of HF hospitalization. We compared follow-up rates between cancer and noncancer cohorts, and stratified analyses by race/ethnicity. A total of 2,356 patients with cancer and 2,362 patients without cancer were included. Overall, 43% of patients with cancer and 42% of patients without cancer received cardiologist follow-up (p = 0.30). After multivariable adjustment, White patients were 15% more likely to receive cardiology follow-up than Black patients (95% confidence interval [CI] 1.02 to 1.30). Black patients with cancer were 41% (95% CI 1.11 to 1.78) and Asian patients with cancer were 66% (95% CI 1.11 to 2.49) more likely to visit a cardiologist than their noncancer counterparts. In conclusion, less than half of patients with cancer hospitalized for HF received recommended follow-up with a cardiologist, and significant race-related differences in cardiology follow-up exist. Future studies should investigate the reasons for these differences.

Abstract P569: Social Determinants of Health and 30-day Readmission or Emergency Department Use After Acute Myocardial Infarction

Background: A more complete understanding of associations between social determinants of health (SDOH) and 30-day readmission or emergency department (ED) use following hospitalization for acute myocardial infarction (AMI) will facilitate development of targeted interventions and root cause policies to reduce readmissions.

Methods: We analyzed 753 adults ≥65 years with linked Medicare data from the REasons for Geographic and Racial Differences in Stroke study who were discharged from the hospital after an adjudicated AMI between 2003-19. We selected SDOH (race, education, income, Medicare+Medicaid, zip code with high poverty, rural residence, living in a Health Professional Shortage Area, and social support) with relative risk for readmission/ED use >1. We grouped participants into 0 or 1, 2, 3, and 4+ SDOH. Poisson models examined crude and fully adjusted associations on risk for readmission/ED visit within 30 days.

Results: Participant characteristics: 40% were women, mean age was 77 years, and 29% were readmitted or had an ED visit within 30 days. Compared to those without readmission/ED visit, those readmitted had more cognitive impairment (17 vs 10%) and depressive symptoms (57 vs. 46%); were more likely to be hospitalized in the year prior to AMI (42 vs 28%) and have adjudicated heart failure at index AMI (36 vs 25%); and were less likely to have a physician visit within 10 days (41 vs 32%) and 30 days (0/1 SDOH: 79%, 2: 73%, 3: 66%, 4+: 60%, p trend < 0.0001) (all contrast p<0.05). Participants with 4+ SDOH had higher risk of readmission (Table).

Conclusion: 4+ SDOH were associated with higher risk of readmission/ED visit after AMI. Those with the greatest burden of SDOH were also least likely to follow up within 10 or 30 days. Policies such as the American College of Cardiology’s “See You in 7 Challenge” program may be even more effective at reducing readmission after MI if specifically targeted at patients with high burden of SDOH.

Recruitment and retention of primary care practices in the Southeastern Collaboration to Improve Blood Pressure Control

Background

Racial disparities related to hypertension prevalence and control persist, with Black persons continuing to have both high prevalence and suboptimal control. The Black Belt region of the US Southeast is characterized by multiple critical priority populations: rural, low-income, and minority (Black).

Methods

In a cluster-randomized, controlled, pragmatic implementation trial, the Southeastern Collaboration to Improve Blood Pressure Control evaluated two multi-component, multi-level functional interventions - peer coaching (PC) and practice facilitation (PF) (separately and combined) - as adjuncts to usual care to improve blood pressure control in the Black Belt. The overall goal was to randomize 80 primary care practices (later reduced to 69 practices) in Alabama and North Carolina to one of four interventions: 1) enhanced usual care (EUC); 2) EUC plus PC; 3) EUC plus PF; or 4) EUC plus both PC and PF. Several measures to facilitate recruitment and retention of practices were employed, including practice readiness assessment.

Results

Contact was initiated with 248 practices during the study enrollment period. Of these, 99 declined participation, 39 were ineligible, and 41 were being evaluated for inclusion when the target number of practices was reached. The remaining 69 practices eventually were enrolled, with 18 practices randomized to EUC, 19 to PC, 16 to PF, and 16 to PC plus PF. Only two practices (2.9%) were withdrawn during the study. Several facilitators of and barriers to practice recruitment and retention were identified.

Conclusion

Our findings underscore the importance of a structured approach to recruiting primary care practices in a pragmatic implementation trial.ClinicalTrials.gov registration number NCT02866669.

Fatalistic cancer beliefs and self-reported cancer screening behaviors among diverse urban residents

Cancer fatalism-the belief that death is inevitable when cancer is present-has been identified as a barrier to cancer screening, detection, and treatment. Our study examined the relationship between self-reported cancer fatalism and adherence to cancer screening guidelines of the breasts, cervix, colon, and prostate among a diverse sample of urban-dwelling adults in Brooklyn, New York. Between May 2019 and August 2020, we conducted a cross-sectional survey of adults 40 + years of age (n = 2,341) residing in Brooklyn neighborhoods with high cancer mortality. Multivariable logistic regression models were used to assess the odds of reporting cancer screening completion across three fatalistic cancer belief categories (low, med, high). Participants' median age was 61 (IQR 51, 71) years, 61% were women, 49% self-identified as non-Hispanic black, 11% Hispanic, 4% Asian, and 6% more than one race. There were no statistically significant differences in the proportion of low, some, or high fatalistic beliefs identified among male respondents compared to women. Among women, we observed that high fatalistic cancer beliefs were associated with higher odds (OR 2.01; 95% CI 1.10-3.65) of completing breast but not cervical (1.04; CI 0.55-1.99) or colon (1.54; CI 0.88-2.69) cancer screening. Men with high fatalistic cancer beliefs had a trend towards lower odds of prostate screening (OR 0.53: 95% CI 0.18-1.57) compared to men with low fatalistic beliefs, but neither was statistically significant. Findings suggest that high fatalistic cancer beliefs may be an important factor in cancer screening utilization among women. Further examination in longitudinal cohorts with a larger sample of men may be needed in order to identify any significant effect.

Analysis of Eligibility for Lung Cancer Screening by Race After 2021 Changes to US Preventive Services Task Force Screening Guidelines

IMPORTANCE

Lung cancer incidence and mortality have disproportionate consequences for racial and ethnic minority populations. The extent to which the 2021 changes to the US Preventive Services Task Force (USPSTF) screening guidelines have reduced the racial disparity gap in lung cancer screening eligibility is not known.

OBJECTIVE

To assess the consequences of the changes in USPSTF low-dose computed tomography eligibility criteria for lung cancer screening between 2013 and 2021 among Black and White community-dwelling adults.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from the Reasons for Geographic and Racial Differences in Stroke study, a prospective longitudinal cohort study of community-dwelling Black and White adults 45 years and older who were initially recruited across the US between January 2003 and October 2007, with ongoing follow-up. All participants who would have been potentially eligible for lung cancer screening based on the 2021 USPSTF guidelines (N = 14 285) were included. Follow-up data for the current cohort study were collected and analyzed between January 2013 and December 2017, with final analysis performed in 2021.

EXPOSURES

Self-reported Black vs White race.

PRIMARY OUTCOMES AND MEASURES

Differences in the proportion of Black vs White participants eligible for lung cancer screening according to 2013 and 2021 guidelines were assessed using modified Poisson models with robust SEs. Associations between important covariates (demographic characteristics and social factors associated with health), including interaction and dissimilarity indices (2 measures of residential segregation), and differences in screening eligibility were also examined.

RESULTS

Among 14 285 participants (mean [SD] age, 64.7 [7.5] years; 7675 men [53.7%]), 5787 (40.5%) self-identified as Black and 8498 (59.5%) as White. Based on the 2013 USPSTF guidelines, 1109 of 5787 Black participants (19.2%) and 2313 of 8498 White participants (27.2%) were eligible for lung cancer screening (difference, -8.06 percentage points; 95% CI, -9.44 to -6.67 percentage points). Based on the 2021 guidelines, 1667 of 5787 Black participants (28.8%) and 2940 of 8498 White participants (34.6%) were eligible for screening (difference, -5.73 percentage points; 95% CI, -7.28 to -4.19 percentage points). After adjustment for differences in individual characteristics and residential segregation, the 2013 difference in screening eligibility among Black vs White participants was -12.66 percentage points (95% CI, -14.71 to -10.61 percentage points), and the 2021 difference was -12.15 percentage points (95% CI, -14.37 to -9.93 percentage points).

CONCLUSIONS AND RELEVANCE

In this study, 2021 changes to the USPSTF lung cancer screening guidelines were associated with reductions in but not elimination of existing eligibility disparities in lung cancer screening among Black and White adults. These findings suggest that accounting for factors beyond age and pack-years of smoking is needed when tailoring guidelines to improve screening eligibility among groups at high risk of lung cancer.

Racial Disparities in Diabetes-Related Emergency Department Visits and Hospitalizations Among Cancer Survivors

PURPOSE

Black and Hispanic individuals with diabetes receive less recommended diabetes care after cancer diagnosis than non-Hispanic Whites (NHW). We sought to determine whether racial/ethnic minorities with diabetes and cancer were at increased risk of diabetes-related emergency department (ED) visits and hospitalizations compared with NHW.

METHODS

Using SEER cancer registry data linked to Medicare claims from 2006 to 2014, we included Medicare beneficiaries age 66+ years diagnosed with incident nonmetastatic breast, prostate, or colorectal cancer between 2007 and 2012 who had diabetes. Our primary outcome was any diabetes-related ED visit or hospitalization 366-731 days after cancer diagnosis. Using Fine-Gray subdistribution hazard models, we examined whether risk of ED visits or hospitalizations was higher for racial/ethnic minorities compared with NHW.

RESULTS

We included 40,059 beneficiaries with mean age 75.5 years (standard deviation 6.3), 45.6% were women, and 28.9% were non-White. Overall, 825 (2.1%) had an ED visit and 3,324 (8.3%) had a hospitalization related to diabetes in the 366-731 days after cancer diagnosis. Compared with NHW, Black individuals were more likely to have ED visits (2.9% v 2.0%; P < .0001) and hospitalizations (11.7% v 7.8%; P < .0001). Adjusting for potential confounders, Black (adjusted hazard ratio, 1.22; 95% CI, 1.12 to 1.35) individuals had a higher risk of any ED visit or hospitalization compared with NHW.

CONCLUSION

Black individuals with diabetes and cancer were at increased risk for diabetes-related ED visits and hospitalizations in the second year after cancer diagnosis compared with NHW even after accounting for confounders.

Cancer and cardiovascular-related perceived risk in a diverse cancer center catchment area

Purpose

Despite cancer and cardiovascular disease (CVD) sharing several modifiable risk factors, few unified prevention efforts exist. We sought to determine the association between risk perception for cancer and CVD and engagement in healthy behaviors.

Methods

Between May 2019 and August 2020, we conducted a cross-sectional survey of adults ≥ 40 years residing in Brooklyn neighborhoods with high cancer mortality. We considered one’s perceived risk of cancer and CVD compared to age counterparts as the primary exposures. The primary study outcome was a weighted health behavior score (wHBS) composed of 5 domains: physical activity, no obesity, no smoking, low alcohol intake, and healthy diet. Modified Poisson regression models with robust error variance were used to assess associations between perceived risk for cancer and CVD and the wHBS, separately.

Results

We surveyed 2448 adults (mean [SD] age, 61.4 [12.9] years); 61% female, 30% Non-Hispanic White, and 70% racial/ethnic minorities. Compared to their age counterparts nearly one-third of participants perceived themselves to be at higher CVD or cancer risk. Perceiving higher CVD risk was associated with an 8% lower likelihood of engaging in healthy behaviors (RR 0.92; 95% CI 0.86–0.99). Perceiving greater cancer risk was associated with a 14% lower likelihood of engaging in healthy behaviors (RR 0.86; 95% CI 0.79–0.95). The association between cancer risk and wHBS attenuated but remained significant (aRR 0.90; 95% CI 0.82–0.98) after adjustment.

Conclusion

Identifying high-risk subgroups and intervening on shared risk behaviors could have the greatest long-term impact on reducing CVD and cancer morbidity and mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-022-01560-3.

Developing Faith-Based Health Promotion Programs that Target Cardiovascular Disease and Cancer Risk Factors

The aim of this study was to evaluate the impact of a faith-based health promotion program on the ideal health behaviors shared between cardiovascular disease (CVD) and cancer. The primary purpose was to measure the individual-level change in three categories of shared risk behaviors between CVD and cancer (body weight, physical activity, and nutrition) among program participants. Additionally, we evaluated the association of churches' perceived environmental support on these ideal health behaviors. Baseline and 10-week surveys were conducted to assess BMI, ideal health behaviors (diet and physical activity), and a Healthy Lifestyle Score (HLS) was created to measure adherence to health behaviors. A Supportive Church Environment Score (SCES) was designed to address the second objective. Psychosocial factors (stress and coping skills) and demographics were also measured. The percentage of participants meeting diet and exercise recommendations significantly increased with the completion of the program. Whole-grain intake increased by 64% (p = 0.085), vegetable intake increased by 58% (p =  < 0.001), fruit intake increased by 39% (p =  < 0.001), physical activity increased by 14% (p =  < 0.001), and red meat consumption decreased by 19% (p =  < 0.001). The median HLS increased from 7 to 8 (p =  < 0.001). At baseline the association between ideal health behaviors and the SCES was significant for fruit intake (r = 0.22, p-value = 0.003) and red meat consumption (r = 0.17, p-value = 0.02). The aggregate behaviors as represented by the HLS were associated with the SCES (r = 0.19, p-value = 0.03). The significant increase in the HLS indicates an average improvement in the degree to which participants were meeting recommendations after completing the program. Therefore, adherence to these ideal health behaviors increased over the 10-week program.

Association of healthy lifestyle and all-cause mortality according to medication burden

BACKGROUND

Healthy lifestyle is associated with reduced all-cause mortality, but it is not known whether this association persists for individuals with high medication burden. We examined the association between healthy lifestyle behaviors and all-cause mortality across different degrees of polypharmacy.

METHODS

This was a secondary analysis of 20,417 adults aged ≥45 years from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study. The primary exposure was healthy lifestyle (adherence to Mediterranean diet, physical activity, smoking abstinence, sedentary behavior avoidance, and composite healthy behavior score [HBS]). The primary outcome was all-cause mortality. Strata of medication burden were based on the number of medications taken (no polypharmacy: 0-4, polypharmacy: 5-9, hyperpolypharmacy: ≥10). We used Cox proportional hazards regression models to examine the association between healthy lifestyle behaviors and mortality within each medication burden stratum and examined for interactions with age.

RESULTS

The healthiest category of each lifestyle behavior, except sedentary behavior avoidance among the hyperpolypharmacy group, was associated with lower all-cause mortality (hazard ratio [HR]) regardless of medication burden: Mediterranean diet (no polypharmacy: HR 0.77, polypharmacy: HR 0.78, hyperpolypharmacy: HR 0.85), physical activity (no polypharmacy: HR 0.87, polypharmacy: HR 0.82, hyperpolypharmacy: HR 0.79), smoking abstinence (no polypharmacy: HR 0.40, polypharmacy: HR 0.45, hyperpolypharmacy: HR 0.52), and sedentary behavior avoidance (no polypharmacy: HR 0.88, polypharmacy: HR 0.86, hyperpolypharmacy: HR 0.95). Higher HBS was inversely associated with all-cause mortality within each medication burden stratum (no polypharmacy: HR 0.52, polypharmacy: HR 0.55, hyperpolypharmacy: HR 0.69). Although there was an interaction with age among those with no polypharmacy and those with polypharmacy, point estimates for HBS followed a graded pattern whereby higher HBS was incrementally associated with improved mortality across all age strata.

CONCLUSION

Greater adherence to a healthy lifestyle was associated with lower all-cause mortality irrespective of medication burden and age.

Atrial Fibrillation and Stroke Symptoms in the REGARDS Study

Background

It is unknown if stroke symptoms in the absence of a stroke diagnosis are a sign of subtle cardioembolic phenomena. The objective of this study was to examine associations between atrial fibrillation (AF) and stroke symptoms among adults with no clinical history of stroke or transient ischemic attack (TIA).

Methods and Results

We evaluated associations between AF and self‐reported stroke symptoms in the national, prospective REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort. We conducted cross‐sectional (n=27 135) and longitudinal (n=21 932) analyses over 8 years of follow‐up of REGARDS participants without stroke/transient ischemic attack and stratified by anticoagulant or antiplatelet agent use. The mean age was 64.4 (SD±9.4) years, 55.3% were women, and 40.8% were Black participants; 28.6% of participants with AF reported stroke symptoms. In the cross‐sectional analysis, comparing participants with and without AF, the risk of stroke symptoms was elevated for adults with AF taking neither anticoagulants nor antiplatelet agents (odds ratio [OR], 2.22; 95% CI, 1.89–2.59) or antiplatelet agents only (OR, 1.92; 95% CI, 1.61–2.29) but not for adults with AF taking anticoagulants (OR, 1.08; 95% CI, 0.71–1.65). In the longitudinal analysis, the risk of stroke symptoms was also elevated for adults with AF taking neither anticoagulants nor antiplatelet agents (hazard ratio [HR], 1.41; 95% CI, 1.21–1.66) or antiplatelet agents only (HR, 1.23; 95% CI, 1.04–1.46) but not for adults with AF taking anticoagulants (HR, 0.86; 95% CI, 0.62–1.18).

Conclusions

Stroke symptoms in the absence of a stroke diagnosis may represent subclinical cardioembolic phenomena or “whispering strokes.” Future studies examining the benefit of stroke symptom screening may be warranted.

Association between overcrowded households, multigenerational households, and COVID-19: a cohort study

OBJECTIVES

The role of overcrowded and multigenerational households as a risk factor for COVID-19 remains unmeasured. The objective of this study is to examine and quantify the association between overcrowded and multigenerational households and COVID-19 in New York City (NYC).

STUDY DESIGN

Cohort study.

METHODS

We conducted a Bayesian ecological time series analysis at the ZIP Code Tabulation Area (ZCTA) level in NYC to assess whether ZCTAs with higher proportions of overcrowded (defined as the proportion of the estimated number of housing units with more than one occupant per room) and multigenerational households (defined as the estimated percentage of residences occupied by a grandparent and a grandchild less than 18 years of age) were independently associated with higher suspected COVID-19 case rates (from NYC Department of Health Syndromic Surveillance data for March 1 to 30, 2020). Our main measure was an adjusted incidence rate ratio (IRR) of suspected COVID-19 cases per 10,000 population. Our final model controlled for ZCTA-level sociodemographic factors (median income, poverty status, White race, essential workers), the prevalence of clinical conditions related to COVID-19 severity (obesity, hypertension, coronary heart disease, diabetes, asthma, smoking status, and chronic obstructive pulmonary disease), and spatial clustering.

RESULTS

39,923 suspected COVID-19 cases were presented to emergency departments across 173 ZCTAs in NYC. Adjusted COVID-19 case rates increased by 67% (IRR 1.67, 95% CI = 1.12, 2.52) in ZCTAs in quartile four (versus one) for percent overcrowdedness and increased by 77% (IRR 1.77, 95% CI = 1.11, 2.79) in quartile four (versus one) for percent living in multigenerational housing. Interaction between both exposures was not significant (β_interaction = 0.99, 95% CI: 0.99-1.00).

CONCLUSIONS

Overcrowdedness and multigenerational housing are independent risk factors for suspected COVID-19. In the early phase of the surge in COVID cases, social distancing measures that increase house-bound populations may inadvertently but temporarily increase SARS-CoV-2 transmission risk and COVID-19 disease in these populations.

Association Between Racial Disparities in Hospital Length of Stay and the Hospital Readmission Reduction Program

Background:

On average Black patients have longer LOS than comparable White patients. Longer hospital length of stay (LOS) may be associated with higher readmission risk. However, evidence suggests that the Hospital Readmission Reduction Program (HRRP) reduced overall racial differences in 30-day adjusted readmission risk. Yet, it is unclear whether the HRRP narrowed these LOS racial differences.

Objective:

We examined the relationship between Medicare-insured Black-White differences in average, adjusted LOS (ALOS) and the HRRP’s implementation and evaluation periods.

Methods:

Using 2009-2017 data from State Inpatient Dataset from New York, New Jersey, and Florida, we employed an interrupted time series analysis with multivariate generalized regression models controlling for patient, disease, and hospital characteristics. Results are reported per 100 admissions.

Results:

We found that for those discharged home, Black-White ALOS differences significantly widened by 4.15 days per 100 admissions (95% CI: 1.19 to 7.11, P < 0.001) for targeted conditions from before to after the HRRP implementation period, but narrowed in the HRRP evaluation period by 1.84 days per 100 admissions for every year-quarter (95% CI: −2.86 to −0.82, P < 0.001); for those discharged to non-home destinations, there was no significant change between HRRP periods, but ALOS differences widened over the study period. Black-White ALOS differences for non-targeted conditions remained unchanged regardless of HRRP phase and discharge destination.

Conclusion:

Increased LOS for Black patients may have played a role in reducing Black-White disparities in 30-day readmission risks for targeted conditions among patients discharged to home.

Racial and ethnic differences in the utilization of autologous transplantation for lymphoma in the United States

Background

Racial/ethnic disparities in the utilization of hematopoietic cell transplantation (HCT) have been reported for patients with hematologic malignancies, but population‐based data are lacking for lymphoma patients. The objective of this study was to determine whether racial and ethnic disparities exist in the utilization of autologous HCT for lymphoma in the United States.

Method

We used Surveillance, Epidemiology, and End Results data linked to Medicare fee‐for‐service claims. We included Medicare beneficiaries aged 66+ years with Hodgkin or Non‐Hodgkin lymphomas diagnosed between 2008 and 2015. The primary outcome was time‐to‐autologous HCT. We used Cox proportional hazards models to estimate racial/ethnic differences in utilization. Missing data were handled using multiple imputation with chained equations.

Results

We included 40,605 individuals with lymphoma. A total of 452 autologous transplants were performed. In the unadjusted model, Non‐Hispanic Black patients were 51% less likely to receive a transplant than Non‐Hispanic White patients (95% CI, 0.26–0.96; p = 0.04). After adjusting for age at diagnosis and sex, Non‐Hispanic Black patients were 61% less likely to receive a transplant (95% CI, 0.20–0.76; p = 0.01). However, observed differences attenuated and became non‐significant after adjustment for socioeconomic factors (adjusted hazard ratio [aHR], 0.62; 95% CI, 0.32–1.21; p = 0.16) and disease‐specific factors (aHR, 0.58; 95% CI, 0.30–1.12; p = 0.11), separately. In the fully adjusted model, we also did not observe a statistically significant association between Non‐Hispanic Black race/ethnicity and receipt of transplant (aHR, 0.54; 95% CI, 0.28–1.05; p = 0.07).

Conclusion

In this population‐based cohort study of lymphoma patients, Non‐Hispanic Black patients were less likely to receive autologous HCT compared to Non‐Hispanic White patients, but this difference was partially explained by socioeconomic and disease‐specific factors.

Association of Serious Hypoglycemic Events in Older Adults With Changes in Glycemic Performance Measures

BACKGROUND

Reducing serious hypoglycemic events is a Federal-wide objective. Despite studies of trends for rates of serious hypoglycemia in existing literature, rigorous evaluation of links between the observed trends and changes in professional guidelines or performance measures for glycemic control is lacking.

OBJECTIVE

To evaluate whether changes in professional society guidelines and performance measures for glycemic control correspond to changes in rates of serous hypoglycemia.

RESEARCH DESIGN

This was a retrospective observational study. We merged Veterans Health Administration (VHA) and Medicare patient-level databases of VHA patients and identified those aged 65 years and above and receiving hypoglycemic agents. We derived age-adjusted and sex-adjusted annual rates and constructed piecewise Poisson regression models adjusting for age and sex to assess time trends of the rates.

SUBJECTS

VHA patients, 2002-2015.

MEASURES

The main outcome was the annual rates (2004-2015) of serious hypoglycemia, defined as hypoglycemia-related emergency department visits or hospitalizations. Secondary outcomes were annual rates of hemoglobin (Hb) A1c level <7% and >9%. Age and sex were additional variables.

RESULTS

The annual rate for hypoglycemia decreased by 4.8% (rate ratio: 0.952; 95% confidence interval, 0.949-0.956) for 2008-2015 but did not change (1.001; 0.994-1.001) in 2004-2008. In 2008-2015, the annual rate for HbA1c <7% decreased by 5.0% (0.950; 0.949-0.951) but for HbA1c >9%, increased by 7.9% (1.079; 1.076-1.082).

CONCLUSION

The cooccurrence of decreasing rates for HbA1c<7% and serious hypoglycemia since 2008 supports the possibility that withdrawal of a <7% HbA1c measure in 2008 impacted clinical practice and patient outcomes.

Mediterranean Diet Score, Dietary Patterns, and Risk of Sudden Cardiac Death in the REGARDS Study

Background

Sudden cardiac death (SCD) is a common cause of death in the United States. Few previous studies have investigated the associations of diet scores and dietary patterns with risk of SCD. We investigated the associations of the Mediterranean diet score and various dietary patterns with risk of SCD in participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study cohort.

Methods and Results

Diet was assessed with a food frequency questionnaire administered at baseline in REGARDS. The Mediterranean diet score was derived based on the consumption of specific food groups considered beneficial or detrimental components of that diet. Dietary patterns were derived previously using factor analysis, and adherence to each pattern was scored. SCD events were ascertained through regular contacts. Cox proportional hazards regression was used to examine the risk of SCD events associated with the Mediterranean diet score and adherence to each of the 5 dietary patterns overall and stratifying on history of coronary heart disease at baseline. The analytic sample included 21 069 participants with a mean 9.8±3.8 years of follow‐up. The Mediterranean diet score showed a trend toward an inverse association with risk of SCD after multivariable adjustment (hazard ratio [HR] comparing highest with lowest group, 0.74; 95% CI, 0.55–1.01; P_trend=0.07). There was a trend toward a positive association of the Southern dietary pattern with risk of SCD (HR comparing highest with lowest quartile of adherence, 1.46; 95% CI, 1.02–2.10; P_trend=0.06).

Conclusions

In REGARDS participants, we identified trends toward an inverse association of the Mediterranean diet score and a positive association of adherence to the Southern dietary pattern with risk of SCD.

Association between overcrowded households, multigenerational households, and COVID-19: a cohort study

Introduction

The role of overcrowded and multigenerational households as a risk factor for COVID-19 remains unmeasured. The objective of this study is to examine and quantify the association between overcrowded and multigenerational households, and COVID-19 in New York City (NYC).

Methods

We conducted a Bayesian ecological time series analysis at the ZIP Code Tabulation Area (ZCTA) level in NYC to assess whether ZCTAs with higher proportions of overcrowded (defined as proportion of estimated number of housing units with more than one occupant per room) and multigenerational households (defined as the estimated percentage of residences occupied by a grandparent and a grandchild less than 18 years of age) were independently associated with higher suspected COVID-19 case rates (from NYC Department of Health Syndromic Surveillance data for March 1 to 30, 2020). Our main measure was adjusted incidence rate ratio (IRR) of suspected COVID-19 cases per 10,000 population. Our final model controlled for ZCTA-level sociodemographic factors (median income, poverty status, White race, essential workers), prevalence of clinical conditions related to COVID-19 severity (obesity, hypertension, coronary heart disease, diabetes, asthma, smoking status, and chronic obstructive pulmonary disease), and spatial clustering.

Results

39,923 suspected COVID-19 cases presented to emergency departments across 173 ZCTAs in NYC. Adjusted COVID-19 case rates increased by 67% (IRR 1.67, 95% CI = 1.12, 2.52) in ZCTAs in quartile four (versus one) for percent overcrowdedness and increased by 77% (IRR 1.77, 95% CI = 1.11, 2.79) in quartile four (versus one) for percent living in multigenerational housing. Interaction between both exposures was not significant (β _interaction = 0.99, 95% CI: 0.99-1.00).

Conclusions

Over-crowdedness and multigenerational housing are independent risk factors for suspected COVID-19. In the early phase of surge in COVID cases, social distancing measures that increase house-bound populations may inadvertently but temporarily increase SARS-CoV-2 transmission risk and COVID-19 disease in these populations.

Trends in Medical and Surgical Admission Length of Stay by Race/Ethnicity and Socioeconomic Status: A Time Series Analysis

BACKGROUND

Length of stay (LOS), a metric of hospital efficiency, differs by race/ethnicity and socioeconomic status (SES) and longer LOS is associated with adverse health outcomes. Historically, projects to improve LOS efficiency have yielded LOS reductions by 0.3 to 0.7 days per admission.

OBJECTIVE

To assess differences in average adjusted length of stay (aALOS) over time by race/ethnicity, and SES stratified by discharge destination (home or non-home).

METHOD

Data were obtained from 2009-2014 Healthcare Cost and Utilization Project State Inpatient Datasets for New York, New Jersey, and Florida. Multivariate generalized linear models were used to examine trends in aALOS differences by race/ethnicity, and by high vs low SES patients (defined first vs fourth quartile of median income by zip code) controlling for patient, disease and hospital characteristics.

RESULTS

For those discharged home, racial/ethnic and SES aALOS differences remained stable from 2009 to 2014. However, among those discharged to non-home destinations, Black vs White aALOS differences increased from 0.21 days in Q1 2009, (95% confidence interval (CI): 0.13 to 0.30) to 0.32 days in Q3 2013, (95% CI: 0.23 to 0.40), and for low vs high SES patients from 0.03 days in Q1 2009 (95% CI: -0.04 to 0.1) to 0.26 days, (95% CI: 0.19 to 0.34). Notably, for patients not discharged home, racial/ethnic and SES aALOS differences increased and persisted after Q3 2011, coinciding with the introduction of the Affordable Care Act (ACA).

CONCLUSION

Further research to understand the ACA's policy impact on hospital efficiencies, and relationship to racial/ethnic and SES differences in LOS is warranted.

COVID-19 Severity and Outcomes in Patients With Cancer: A Matched Cohort Study

PURPOSE

SARS-CoV-2 (COVID-19) is a systemic infection. Patients with cancer are immunocompromised and may be vulnerable to COVID-related morbidity and mortality. The objectives of this study were to determine if patients with cancer have worse outcomes compared with patients without cancer and to identify demographic and clinical predictors of morbidity and mortality among patients with cancer.

METHODS

We used data from adult patients who tested positive for COVID-19 and were admitted to two New York-Presbyterian hospitals between March 3 and May 15, 2020. Patients with cancer were matched 1:4 to controls without cancer in terms of age, sex, and number of comorbidities. Using Kaplan-Meier curves and the log-rank test, we compared morbidity (intensive care unit admission and intubation) and mortality outcomes between patients with cancer and controls. Among those with cancer, we identified demographic and clinical predictors of worse outcomes using Cox proportional hazard models.

RESULTS

We included 585 patients who were COVID-19 positive, of whom 117 had active malignancy, defined as those receiving cancer-directed therapy or under active surveillance within 6 months of admission. Presenting symptoms and in-hospital complications were similar between the cancer and noncancer groups. Nearly one half of patients with cancer were receiving therapy, and 45% of patients received cytotoxic or immunosuppressive treatment within 90 days of admission. There were no statistically significant differences in morbidity or mortality (P = .894) between patients with and without cancer.

CONCLUSION

We observed that patients with COVID-19 and cancer had similar outcomes compared with matched patients without cancer. This finding suggests that a diagnosis of active cancer alone and recent anticancer therapy do not predict worse COVID-19 outcomes and therefore, recommendations to limit cancer-directed therapy must be considered carefully in relation to cancer-specific outcomes and death.

Abstract S10-01: COVID-19 severity and outcomes in hospitalized patients with cancer at a New York City tertiary medical center: A matched cohort study

Background: New York City has been at the epicenter of the SARS-CoV-2 (COVID-19) pandemic. Immunocompromised cancer patients may be more vulnerable to COVID-related morbidity and mortality. The objectives of this study were to determine if patients with cancer have worse outcomes compared to their noncancer counterparts and to identify potential demographic and clinical predictors of morbidity and mortality among cancer patients.

Methods: We used data from a retrospective observational cohort of adult patients who tested positive for COVID-19 at New York-Presbyterian hospitals between March 3 and April 25, 2020. Patients with active cancer were matched 1:4 to noncancer controls on age, gender, and diabetes status. Using Kaplan-Meier curves and the log-rank test, we compared morbidity (intensive care unit admission and intubation) and mortality outcomes between cancer patients and controls. We identified demographic and clinical predictors of worse outcomes using Cox Proportional Hazard models. Hazard ratios and 95% confidence intervals were calculated for all estimates.

Results: We included 445 COVID-19 positive adult patients of whom 89 had active malignancy. Among cancer patients, the median age was 72 years, 54% were male, and 52% were non-white. Presenting symptoms were similar between cancer and noncancer groups. Nearly half of cancer patients were on active treatment including cytotoxic and immunosuppressive therapy, and 40.9% of patients received cytotoxic treatment within 90 days of admission. Both patients with and without cancer received hydroxychloroquine in similar proportions (64% vs. 65.5%), and more cancer patients received remdesivir (7.9% vs. 3.7%). Overall, age (HR 1.14; 95% CI 1.00-1.29; p=0.049), male sex (HR 1.43; 95% CI 1.04-1.96, p=0.07), dyspnea on presentation (HR 1.81, 95% CI 1.3-2.58; p=0.0005), and bilateral lung infiltrates (HR 1.94; 95% CI 1.30-2.89; p=0.001) were associated with worse outcomes. Observed complications were similar for cancer and noncancer patients, including myocardial infarction (3.4% vs. 4.2%), vasopressor requirements (24.7% vs. 26.2%), bacteremia (9% vs. 10.4%), and venous thromboembolic events (7.9% vs. 7.3%), respectively. There were no statistically significant differences in morbidity or mortality between cancer and noncancer patients (p=0.287).

Conclusion: We demonstrate that COVID-19 hospitalized patients with active malignancies have comparable morbidity and mortality to patients without cancer. In contrast to previous findings, we observed no differences in risk of ICU admission, intubation, or death between cancer and noncancer patients. Our findings suggest that active malignancy may not be a contributive risk factor in comparison to other significant comorbidities that may be more responsible for the unfavorable prognosis of COVID-19 in cancer patients. We should consider the consequences of limiting care for cancer patients on cancer-specific outcomes and mortality in the context of COVID-19.

Citation Format: Gagandeep Brar, Laura C. Pinheiro, Michael Shusterman, Brandon Swed, Evgeniya Reshentnyak, Orysya Soroka, Frank Chen, Samuel Yamshon, John Vaughn, Peter Martin, Doru Paul, Manuel Hidalgo, Manish A. Shah. COVID-19 severity and outcomes in hospitalized patients with cancer at a New York City tertiary medical center: A matched cohort study [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S10-01.

Racial differences in trends of serious hypoglycemia among higher risk older adults in US Veterans Health Administration, 2004-2015: Relationship to comorbid conditions, insulin use, and hemoglobin A1c level

AIMS

To evaluate temporal trends in racial/ethnic groups in rates of serious hypoglycemia among higher risk patients dually enrolled in Veterans Health Administration and Medicare fee-for-service and assess the relationship(s) between hypoglycemia rates, insulin/secretagogues and comorbid conditions.

METHODS

Retrospective observational serial cross-sectional design. Patients were ≥65 years receiving insulin and/or secretagogues. The primary outcome was the annual (period prevalence) rates (2004-2015), per 1000 patient years, of serious hypoglycemic events, defined as hypoglycemic-related emergency department visits or hospitalizations.

RESULTS

Subjects were 77-83% White, 7-10% Black, 4-5% Hispanic, <2% women; 38-58% were ≥75 years old; 72-75% had ≥1 comorbidity. In 2004-2015, rates declined from 63.2 to 33.6(-46.9%) in Blacks; 29.7 to 20.3 (-31.6%) in Whites; and 41.8 to 29.6 (-29.3%) in Hispanics. The Black-White rate differences narrowed regardless of insulin use, hemoglobin A1c level, and frequency and various combinations of comorbid conditions. Among insulin users, the Black-White contrast decreased from 34.7 (98.5 vs. 63.8) in 2004 to 13.2 (43.6 vs. 30.4) in 2015; in non-insulin users, the contrast was 25.7 (44.1 vs. 18.4) in 2004 and 10.1 (18.9 vs. 8.8) in 2015.

CONCLUSION

Marked declines in serious hypoglycemia events occurred across race, medications, and comorbidities, suggesting significant changes in clinical practice.

Diabetes care management patterns before and after a cancer diagnosis: A SEER-Medicare matched cohort study

BACKGROUND

Diabetes places patients with cancer at an increased risk of infections, hospitalizations, and mortality. The objective of the current study was to characterize diabetes care management patterns among patients with cancer in the year before and, separately, after cancer diagnosis. The authors hypothesized that diabetes care declines after a diagnosis of cancer.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) cancer registry linked to Medicare claims data was used. The authors included diabetic beneficiaries aged ≥65 years who were diagnosed with incident, nonmetastatic breast, prostate, or colorectal cancer between 2008 and 2013. Controls were diabetic Medicare beneficiaries in SEER regions who did not have cancer. Cases were matched to controls based on age, sex, Charlson Comorbidity Index, and diabetes severity. Primary outcomes were diabetes care received over 12 months: 1) hemoglobin A1c testing; 2) eye examination; and 3) low-density lipoprotein testing. Using a difference-in-difference (DID) approach, the authors examined use differences 12 months before to after diagnosis for patients with cancer and controls. To avoid capturing testing related to diagnosis and not diabetes management, the authors implemented a 90-day washout period (45 days before and/or after diagnosis).

RESULTS

A total of 32,728 diabetic patients with cancer and 32,728 matched noncancer controls were included. After diagnosis, patients with cancer were found to have modest, but significantly lower, rates of diabetes care use compared with controls. Patients with cancer had greater declines in hemoglobin A1c testing (DID, 2.4%; 95% CI, 1.7%-3.0%), low-density lipoprotein testing (DID, 4.3%; 95% CI, 3.6%-5.0%), and receipt of all diabetes indicators (DID, 2.7%; 95% CI, 1.8%-3.5%) 12 months before to after diagnosis.

CONCLUSIONS

Compared with controls, less diabetes care use was observed among patients with cancer in the year after diagnosis. Understanding and addressing the reasons for this may improve outcomes in this population.

An expanded prevention quality diabetes composite: Quantifying the burden of preventable hospitalizations for older adults with diabetes

AIM

To expand the existing United States Agency for Health Research and Quality (AHRQ) Diabetes composite (AHRQ-DC) to include additional preventable hospitalizations specific or relevant to diabetes.

METHODS

A cross-sectional analysis of 834,696 veteran patients with diabetes aged ≥65 years in 2012. An Expanded Diabetes Composite (Expanded-DC) was developed utilizing: (1) the diabetes-specific category: the AHRQ-DC (short-term and long-term complications, uncontrolled diabetes, lower extremity amputations) and two proposed conditions: hypoglycemia and lower extremity ulcers/inflammation/infections (LEU) and (2) the diabetes-relevant category: the AHRQ-Acute Composite (dehydration, pneumonia, urinary tract infections) and one proposed condition, acute kidney injury (AKI).

RESULTS

The study population was 98% male, 80% White, 10% Black, and 5% Hispanic; 71% had complex comorbidities. There were 64,243 (77.0 admissions/1000 patients) hospitalizations in the Expanded-DC, compared to 13,523 (16.2) in the AHRQ-DC, a 4.7 fold increase. Hospitalizations from AHRQ-Acute Composite and the three proposed conditions added 79% to the Expanded-DC. LEU and hypoglycemia added 39% to the diabetes-specific category. AKI added 18% to the diabetes-relevant category. Blacks incurred more preventable hospitalizations (85.9) than Whites (74.7); as did patients with complex comorbidities (93.6) versus those without (34.6).

CONCLUSION

The AHRQ-DC substantially underestimates rates of clinically important preventable hospitalizations in older diabetes patients.

State-Level Variability in Veteran Reliance on Veterans Health Administration and Potentially Preventable Hospitalizations: A Geospatial Analysis

Most Veterans who use the Veterans Health Administration (VHA) also utilize private-sector health care providers. To better inform local and regional health care planning, we assessed the association between reliance on VHA ambulatory care and total and system-specific preventable hospitalization rates (PHRs) at the state level. We conducted a retrospective dynamic cohort study using Veterans with diabetes mellitus, aged 66 years or older, and dually enrolled in VHA and Medicare parts A and B from 2004 to 2010. While controlling for median age and proportion of males, we measured the association between reliance on VHA ambulatory care and PHRs at the state level using multivariable ordinary least square regression, geographically weighted regression, and generalized additive models. We measured geospatial patterns in PHRs using global Moran’s I and univariate local indicator spatial analysis. Approximately 30% of hospitalized Veterans experienced a preventable hospitalization. Reliance on VHA ambulatory care at the state level ranged from 13.92% to 67.78% and was generally not associated with PHRs. Geospatial analysis consistently identified a cluster of western states with low PHRs from 2006 to 2010. Given the generally low reliance on VHA ambulatory care and lack of association between this reliance and PHRs, policy changes to improve Veterans’ health care outcomes should address private-sector care in addition to VHA care.

A Proposal for an Out-of-Range Glycemic Population Health Safety Measure for Older Adults With Diabetes

OBJECTIVE

To evaluate patient-level glycemic control and facility variation of a proposed out-of-range (OOR) measure (overtreatment [OT] [HbA_1c <7% (53 mmol/mol)] or undertreatment [UT] [>9% (75 mmol/mol)]) compared with the standard measure (SM) (HbA_1c <8% [64 mmol/mol]) in high-risk older adults.

RESEARCH DESIGN AND METHODS

Veterans Health Administration patients ≥65 years of age in 2012 who were taking antihyperglycemic agents in 2013 were identified. Patient-level rates and facility-level rates/rankings were calculated by age and comorbid illness burden.

RESULTS

We identified 303,097 patients who were taking antiglycemic agents other than metformin only. The study population comprised 193,689 patients with at least one significant medical, neurological, or mental health condition; 98.2% were taking a sulfonylurea and/or insulin; 55.2% were aged 65-75 years; and 44.8% were aged >75 years. The 47.4% of patients 65-75 years met the OOR measure (33.4% OT, 14% UT), and 65.7% met the SM. For patients aged >75 years, rates were 48.1% for OOR (39.2% OT; 8.9% UT) and 73.2% for SM. Facility-level rates for OOR for patients aged 65-75 years ranged from 33.7 to 60.4% (median 47.4%), with a strong inverse correlation (ρ = -0.41) between SM and OOR performance rankings. Among the best-performing 20% facilities on the SM, 14 of 28 ranked in the worst-performing 20% on the OOR measure; 12 of 27 of the worst-performing 20% facilities on the SM ranked in the best-performing 20% on the OOR measure.

CONCLUSIONS

Facility rankings that are based on an SM (potential benefits) and OOR measure (potential risks) differ substantially. An OOR for high-risk populations can focus quality improvement on individual patient evaluation to reduce the risk for short-term harms.

Variability in estimated glomerular filtration rate values is a risk factor in chronic kidney disease progression among patients with diabetes

Background

It is unknown whether variability of estimated Glomerular Filtration Rate (eGFR) is a risk factor for dialysis or death in patients with chronic kidney disease (CKD). This study aimed to evaluate variability of estimated Glomerular Filtration Rate (eGFR) as a risk factor for dialysis or death to facilitate optimum care among high risk patients.

Methods

A longitudinal retrospective cohort study of 70,598 Veterans Health Administration veteran patients with diabetes and CKD (stage 3–4) in 2000 with up to 5 years of follow-up. VHA and Medicare files were linked to derive study variables. We used Cox proportional hazards models to evaluate association between time to initial dialysis/death and key independent variables: time-varying eGFR variability (measured by standard deviation (SD)) and eGFR means and slopes while adjusting for prior hospitalizations, and comorbidities.

Results

There were 76.7% older than 65 years, 97.5% men, and 81.9% Whites. Patients were largely in early stage 3 (61.2%), followed by late stage 3 (28.9%), and stage 4 (9.9%); 29.1%, 46.8%, and 73.3%, respectively, died or had dialysis during the follow-up. eGFR SDs (median: 5.8, 5.1, and 4.0 ml/min/1.73 m² ) and means (median: 54.1, 41.0, 27.2 ml/min/1.73 m²) from all two-year moving intervals decreased as CKD advanced; eGFR variability (relative to the mean) increased when CKD progressed (median coefficient of variation: 10.9, 12.8, and 15.4). Cox regressions revealed that one unit increase in a patient’s standard deviation of eGFRs from prior two years was significantly associated with about 7% increase in risk of dialysis/death in the current year, similarly in all three CKD stages. This was after adjusting for concurrent means and slopes of eGFRs, demographics, prior hospitalization, and comorbidities. For example, the hazard of dialysis/death increased by 7.2% (hazard ratio:1.072; 95% CI = 1.067, 1.080) in early stage 3.

Conclusion

eGFR variability was independently associated with elevated risk of dialysis/death even after controlling for eGFR means and slopes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-015-0025-5) contains supplementary material, which is available to authorized users.

Assessing potential glycemic overtreatment in persons at hypoglycemic risk

IMPORTANCE

Although serious hypoglycemia is a common adverse drug event in ambulatory care, current performance measures do not assess potential overtreatment.

OBJECTIVE

To identify high-risk patients who had evidence of intensive glycemic management and thus were at risk for serious hypoglycemia.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of patients in the Veterans Health Administration receiving insulin and/or sulfonylureas in 2009.

MAIN OUTCOMES AND MEASURES

Intensive control was defined as the last hemoglobin A1c (HbA1c) measured in 2009 that was less than 6.0%, less than 6.5%, or less than 7.0%. The primary outcome measure was an HbA1c less than 7.0% in patients who were aged 75 years or older who had a serum creatinine value greater than 2.0 mg/dL or had a diagnosis of cognitive impairment or dementia. We also assessed the rates in patients with other significant medical, neurologic, or mental comorbid illness. Variation in rates of possible glycemic overtreatment was evaluated among 139 Veterans Health Administration facilities grouped within 21 Veteran Integrated Service Networks.

RESULTS

There were 652,378 patients who received insulin and/or a sulfonylurea with an HbA1c test result. Fifty percent received sulfonylurea therapy without insulin; the remainder received insulin therapy. We identified 205,857 patients (31.5%) as the denominator for the primary outcome measure; 11.3% had a last HbA1c value less than 6.0%, 28.6% less than 6.5%, and 50.0% less than 7.0%. Variation in rates by Veterans Integrated Service Network facility ranged 8.5% to 14.3%, 24.7% to 32.7%, and 46.2% to 53.4% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The magnitude of variation by facility was larger, with overtreatment rates ranging from 6.1% to 23.0%, 20.4% to 45.9%, and 39.7% to 65.0% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The maximum rate was nearly 4-fold compared with the minimum rates for HbA1c less than 6.0%, followed by 2.25-fold for HbA1c less than 6.5% and less than 2-fold for HbA1c less than 7.0%. When comorbid conditions were included, 430,178 patients (65.9%) were identified as high risk. Rates of overtreatment were 10.1% for HbA1c less than 6.0%, 25.2% for less than 6.5%, and 44.3% for less than 7.0%.

CONCLUSIONS AND RELEVANCE

Patients with risk factors for serious hypoglycemia represent a large subset of individuals receiving hypoglycemic agents; approximately one-half had evidence of intensive treatment. A patient safety indicator derived from administrative data can identify high-risk patients for whom reevaluation of glycemic management may be appropriate, consistent with meaningful use criteria for electronic medical records.

A clinical action measure to assess glycemic management in the 65-74 year old veteran population

OBJECTIVES

To evaluate the effect of including of clinical actions within 6 months of a glycosylated hemoglobin (HbA1c) level greater than 8% upon measure adherence (pass rates) and to assess the association between patient factors and the likelihood of not passing.

SETTING

Veterans Health Administration.

DESIGN

Retrospective cohort study for FY2002 to FY2004.

PARTICIPANTS

One hundred fifty-three thousand one hundred thirty-two veterans aged 65-74 with diabetes mellitus not taking insulin; 99% were male and 86% white.

MEASUREMENTS

The clinical action measure included three categories: (a) initial pass (index HbA1c < 8%); (b) modified pass (index HbA1c ≥ 8%), and the hierarchical occurrence of one of the following events within 6 months after date of index HbA1c: subsequent HbA1c < 8%, being started on insulin (100% weight), new oral medication (50% weight), care in a diabetes mellitus-related clinic (25% weight); and (c) failure (no category met or HbA1c > 9%). Multinomial logistic regression models were used to evaluate associations between participant factors and the likelihood of not passing initially.

RESULTS

Most (82.6%) or the participants had an index HbA1c of less than 8%, and 10.6% were in the modified pass group. The failure rate (17.4%) fell to 6.8% when actions were weighted equally and to 9.4% using different weights. Veterans who are African American (odds ratios (ORs) = 1.43 and 1.44), unmarried (ORs = 1.19 and 1.24), poor (ORs = 1.36 and 1.17), or taking two or more oral antihyperglycemic agents (ORs = 2.61 and 3.72) were significantly more likely to be in the modified pass and failure groups, respectively.

CONCLUSION

Most veterans with an initial HbA1c of 8% or greater had clinical actions within 6 months. A measure that incorporates multiple treatment options, including education and nutrition, could be of benefit by encouraging dialogue of such options between patients and clinicians.

Risk of hypoglycemia in older veterans with dementia and cognitive impairment: implications for practice and policy

OBJECTIVES

To examine the relationship between management of diabetes mellitus and hypoglycemia in older adults with and without dementia and cognitive impairment.

DESIGN

Cross-sectional database analysis of veterans aged 65 years and older stratified according to dementia, cognitive impairment, age, antiglycemic medications, and glycosylated hemoglobin (Hba1c) level.

SETTING

Research database with linked clinical, laboratory, pharmacy, and International Classification of Diseases, Ninth Revision, Clinical Modification, codes.

PARTICIPANTS

Four hundred ninety-seven thousand nine hundred veterans aged 65 and older with diabetes mellitus who obtained services from the Department of Veterans Affairs in fiscal years (FYs) 2002 and 2003.

MEASUREMENTS

Hypoglycemia, the outcome variable, was identified from outpatient visits, emergency department and inpatient admission codes in FY2003. Independent variables (FY2002-03) included dementia and cognitive impairment, comorbid conditions, extended care and nursing home stays, demographics, antiglycemic medication, and HbA1c levels.

RESULTS

Prevalence of combined dementia and cognitive impairment was 13.1% for individuals aged 65 to 74 and 24.2% for those aged 75 and older. Mean HbA1c levels were 7.0 ± 1.3% for all participants and 6.9 ± 1.3% for those with dementia. The proportion of participants taking insulin was higher in those with dementia or cognitive impairment (30%) than in those with neither condition (24%). Of all participants taking insulin, more with dementia (26.5%) and cognitive impairment (19.5%) were hypoglycemic than of those with neither condition (14.4%). For all participants, unadjusted odds ratios (ORs) for hypoglycemia were 2.42 (95% confidence interval (CI) = 2.36-2.48) for dementia and 1.72 (95% CI = 1.65-1.79) for cognitive impairment; adjusted ORs were 1.58 (95% CI = 1.53-1.62) for dementia and 1.13 (95% CI = 1.08-1.18) for cognitive impairment.

CONCLUSION

Diabetes mellitus was managed more intensively in older veterans with dementia and cognitive impairment, and dementia and cognitive impairment were independently associated with greater risk of hypoglycemia.