Reply Deo, Rajat; Safford, Monika M.; Albert, Christine M.
Journal of the American College of Cardiology,
03/2019, Letnik:
73, Številka:
10
Journal Article
There are racial and geographic disparities in stroke mortality, with higher rates among African Americans (AAs) and those living in the southeastern US ('stroke belt'). Racial and geographic ...differences in dyslipidemia prevalence, awareness, treatment and control may, in part, account for the observed disparities in stroke mortality.
Reasons for Geographic and Racial Differences in Stroke (REGARDS) is a national observational study of community-dwelling black and white participants aged 45 and older, with oversampling from the stroke belt. As of January 15, 2007, 26,122 participants were enrolled and a fasting lipid panel was available of 21,068. Awareness, treatment and control of dyslipidemia were estimated overall and compared across race-sex-region strata.
There were 55% of the participants with dyslipidemia and no racial differences in prevalence. Adjusting for demographic and established stroke risk factors, AAs had a lower prevalence (OR 0.74; 95% CI: 0.66, 0.77) and were less likely to be aware (0.69; 0.61, 0.78), treated (0.77; 0.67, 0.89) and controlled (0.67; 0.58, 0.77) than whites. There was lower control outside of the stroke belt (0.87; 0.76, 0.99).
Racial, but not geographic, differences in dyslipidemia management may play a role in the excess stroke burden in the Southeast.
Chronic kidney disease (CKD) and systemic inflammation are risk factors for sepsis. While often viewed as a marker of chronic kidney disease, Cystatin C (Cyst-C) may also reflect systemic ...inflammation. We sought to determine the association between elevated baseline Cyst-C and long-term rates of community-acquired sepsis, and to determine if this relationship is influenced by traditional markers of CKD (estimated glomerular filtration rate eGFR, albumin-to-creatinine ratio ACR) and inflammation (high sensitivity C-reactive protein hsCRP).
We studied 30,239 adults ≥45 years old from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The primary exposure was elevated Cyst-C (>1.12 mg/dL) measured at study baseline. The primary outcome was the first sepsis hospitalization during a 10-year observation period. Using Cox regression, we evaluated the association between elevated Cyst-C and first sepsis event, adjusted for sociodemographics, health behaviors, chronic medical conditions, eGFR, ACR and hsCRP.
Among participants, 1,532 experienced a sepsis event. Median Cyst-C levels were: sepsis 1.08 (IQR 0.91-1.33) mg/dL (43.8% >1.12 mg/dL), non-sepsis 0.94 (IQR 0.82-1.10) mg/dL (23.4% >1.12 mg/dL). Cyst-C > 1.12 mg/dL was independently associated with increased rates of sepsis, adjusted for participant demographics, health behaviors and chronic medical conditions (HR 1.75; 95% CI: 1.55-1.96). The addition of eGFR < 60 mg/min/1.73 m(2,) ACR ≥ 30 mg/g and hsCRP > 3.0 mg/dL only partially attenuated the association between Cyst-C > 1.12 mg/dL and rates of sepsis (adjusted HR 1.51; 1.32-1.72).
Elevated Cyst-C is associated with increased long-term rates of community-acquired sepsis, independent of abnormal eGFR, ACR or hsCRP. Cyst-C may play a role in long-term sepsis risk prediction and prevention.
Persons with kidney disease often have cardiovascular disease, but they are less likely to use recommended medications for secondary prevention. The hypothesis was that participants with reduced ...estimated GFR have lower use of medications recommended for secondary prevention of cardiovascular events (antiplatelet agents, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, β-blockers, and statins) and lower medication adherence than participants with preserved estimated GFR.
In this cross-sectional analysis, we analyzed data from 6913 participants in the Reasons for Geographic and Racial Differences in Stroke study with a history of cardiovascular disease. Medication use was ascertained by an in-home pill bottle review. Medication adherence was assessed using a validated four-item scale.
Among participants with a history of cardiovascular disease, 59.8% used antiplatelet agents, 49.9% used angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, 41.6% used β-blockers, and 53.0% used statins. Compared with the referent group (estimated GFR ≥60 ml/min per 1.73 m(2)), participants with estimated GFR <45 ml/min per 1.73 m(2) were more likely to use angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (adjusted prevalence ratio=1.14, 95% confidence interval=1.06-1.23), β-blockers (adjusted prevalence ratio=1.20, 95% confidence interval=1.09-1.32), and statins (adjusted prevalence ratio=1.10, 95% confidence interval=1.01-1.19). Antiplatelet agent use did not differ by estimated GFR category; 30% of participants reported medication nonadherence across all categories of estimated GFR.
Among participants with a history of cardiovascular disease, mild to moderate reductions in estimated GFR were associated with similar and even more frequent use of medications for secondary prevention compared with participants with preserved estimated GFR. Overall medication use and adherence were suboptimal.
Despite the increased shifting of health care costs to consumers, little is known about the impact of financial barriers on health care utilization. This study investigated the effect of ...out-of-pocket expenditures on the utilization of recommended diabetes preventive services.
This was a survey-based observational study (2000-2001) in 10 managed care health plans and 68 provider groups across the U.S. serving approximately 180,000 patients with diabetes. From 11,922 diabetic survey respondents, we studied the occurrence of self-reported annual dilated eye exams and diabetes health education and among insulin users, daily self-monitoring of blood glucose (SMBG). Conditional probabilities were estimated for outcomes at each level of self-reported out-of-pocket expenditure by using hierarchical logistic regression models with random intercepts.
Conditional probabilities of utilization (95% CI) varied by expenditure for dilated eye exam no cost 78% (75-82), copay 79% (75-82), and full price 70% (64-75); P < 0.0001; diabetes health education no cost 29% (23-36), copay 29% (23-36), and full price 19% (14-25); P < 0.0001; and daily SMBG no cost 75% (68-81), copay 68% (60-75), and full price 59% (49-68); P < 0.0001. Extensive adjustment for patient factors had no discernible effect on the estimates or their significance, and cost-utilization relationships were similar across income levels and other patient characteristics.
Benefit packages structured to derive greater fiscal contribution from the health plan membership result in suboptimal use of diabetes preventive services and may thus lead to poorer clinical outcomes, greater future costs, and lower health plan quality ratings.
D-dimer, a biomarker of coagulation, is higher in blacks than in whites and has been associated with stroke and coronary heart disease (CHD). It was our objective to assess the association of higher ...D-dimer with stroke and CHD in blacks and whites. REGARDS recruited 30,239 black and white participants across the contiguous US and measured baseline D-dimer in stroke (n=646) and CHD (n=654) cases and a cohort random sample (n=1,104). Cox models adjusting for cardiovascular risk factors determined the hazard ratio (HR) for increasing D-dimer for cardiovascular disease with bootstrapping to assess the difference in HR for CHD versus stroke by race. D-dimer was higher with increasing age, female sex, diabetes, hypertension, pre-baseline cardiovascular disease and higher C-reactive protein (CRP). Accounting for cardiovascular risk factors, each doubling of D-dimer was associated with increased stroke (hazard ratio HR 1.15; 95 % confidence interval CI 1.01, 1.31) and CHD (HR 1.27; 95 % CI 1.11, 1.45) risk. The difference in the HR between CHD and stroke was 0.20 (95 % CI >0.00, 0.58) for blacks and 0.02 (95 % CI -0.30, 0.27) for whites. CRP mediated 22 % (95 % CI 5 %, 41 %) of the association between D-dimer and CHD and none of the association with stroke. Higher D-dimer increased the risk of stroke and CHD independent of cardiovascular risk factors and CRP, with perhaps a stronger association for CHD versus stroke in blacks than whites. These findings highlight potential different pathophysiology of vascular disease by disease site and race suggesting potential further studies targeting haemostasis in primary prevention of vascular disease.
Abstract only
Introduction:
While participant advisory boards (PABs) are common among public health initiatives and clinical trials, they are less common among national, epidemiologic cohort studies. ...PABs could add value to researchers and participants alike, but their formation and functioning in this context is less understood. We aimed to elicit the perspectives of participants from the national REasons for Geographic and Racial Differences in Stroke (REGARDS) Study towards the formation of a PAB, which can inform future efforts to form one for this cohort study and others like it.
Methods:
REGARDS is a national prospective cohort study that enrolled >30,000 Black and White community-dwelling adults aged ≥45 years from 48 states 2003-2007. Enrollment and follow-up is ongoing and done through mail and telephone. We used a convenience sampling approach to recruit from a subset of participants who responded to a newsletter about joining a PAB. Participants completed a one-on-one telephone or Zoom-based interview with study staff following a semi-structured interview guide. Interviews were recorded and professionally transcribed. Data were organized with NVivo software. Informed by the Cargo and Mercer’s Health Equity Research Practice Framework for Academic-Community Partnerships, we conducted a thematic analysis. Each transcript was independently coded by two team members, then reconciled by a third. Major themes and subthemes were identified.
Results:
The 18 participants had a median age of 69 years, 67% were women, 39% were Black, and 78% had a college degree or higher. Overall, participants were enthusiastic about the PAB and were inclined to meet as a group regularly via Zoom or telephone. Four key themes emerged: (1) The PAB should form and function with a core set of principles, including: trust, diversity, mutual respect, and accountability; of these, diversity was most important; (2) The PAB should not only inform studies (i.e. research questions, methodology), but also assist with the dissemination of science to diverse networks; (3) A formal process is required to form and maintain the PAB, as well as keeping members engaged; (4) Core values influenced participants’ willingness to serve on the PAB; they included internal motivation, the desire to translate knowledge into action, and social and environmental justice.
Conclusion:
This study highlights a willingness of participants in large epidemiologic cohort to participate in a PAB. Our results can inform the formation of a PAB in the REGARDS Study, and may be important for other observational cohorts interested in including participants in an advisory capacity.
Abstract only
Introduction:
Emerging evidence suggests that beta-blockers may not be efficacious in preventing mortality in patients with heart failure with preserved ejection fraction (HFpEF) and ...could worsen exercise capacity. HFpEF patients’ symptoms often overlap with medication side effects, making precise decision-making about the need for beta-blockers a challenge.
Objective:
Evaluate patient attitudes toward using a patient-reported outcome (PRO) monitoring tool to facilitate shared decision-making about beta-blocker use in an N-of-1 clinical trial.
Methods:
Eligible HFpEF patients taking a beta-blocker were recruited from a heart failure clinic. Patients alternated between taking and not taking their beta-blocker for 2-week periods, with dedicated titration time in-between. Data were ascertained through exercise assessments, weekly/bi-weekly online PRO surveys, and remote vital measurements. Average symptom scores on and off beta-blocker were presented in a visualized report to patients, intended to facilitate a discussion about continuing vs. discontinuing their beta-blocker. We interviewed patients about feedback on study procedures and agency for decision-making at baseline and study visits. Interviews were recorded and transcribed. Three study team members analyzed interviews using directed content analysis.
Results:
To date, 9 patients completed the intervention, and 28 interviews were completed. Most participants were female and White (89%) with an average age of 78. Participants reported that their visualized PRO results were aligned their experiences, which reinforced their use of the tool and agency in beta-blocker decision-making (Table).
Conclusions:
Patients found that the visualized report helped to facilitate beta-blocker shared decision-making. Future research should evaluate the utility of integrating longitudinal PRO monitoring tools into usual care to facilitate individualized decisions about medications.
PDF
