Short-term trends in heart failure-related hospitalizations in a high-risk state.

OBJECTIVES: We sought to determine whether there are signs of improvement in the rates of heart failure (HF) hospitalizations given the recent reports of improvement in national trends. METHODS: HF admissions data from the Tennessee Hospital Discharge Data System were analyzed. RESULTS: Hospitalization for primary diagnosis of HF (HFPD) in adults (aged 20 years old or older) decreased from 4.5% in 2006 to 4.2% in 2008. Similarly, age-adjusted HF hospitalization (per 10,000 population) declined by 19.1% (from 45.5 in 2006 to 36.8 in 2008). The age-adjusted rates remain higher among blacks than whites and higher among men than women. Notably, the rate ratio of black-to-white men ages 20 to 34 years admitted with HFPD increased from 8.5 in 2006 to 11.1 in 2008; similarly, the adjusted odds ratios for HFPD were 4.75 (95% confidence interval 3.29-6.86) and 5.61 (95% confidence interval 3.70-8.49), respectively. There was, however, a significant improvement in odds ratio for HF rates among young black women, as evidenced by a decrease from 4.60 to 3.97 (aged 20-34 years) and 4.21 to 3.12 (aged 35-44 years) between 2006 and 2008, respectively. Among patients aged 20 to 34 and 35 to 44 years, hypertension was the strongest independent predictor for HF. Diabetes and myocardial infarction emerged as predictors for HF among patients aged 35 years and older. CONCLUSIONS: The overall rate of HF hospitalization declined during the period surveyed, but the persistent disproportionate involvement of blacks with evidence of worsening among younger black men, requires close attention.

Rural-urban differences in breast cancer screening among African American women.

This study reports on rural-urban differences in the effectiveness of a church-based educational program aimed at increasing breast cancer screening among African American women ages 40 and over. The data were drawn from an intervention study in urban Nashville, and a pilot extension of the study in five rural counties of West Tennessee. The partial program was equally effective in rural Tennessee (17.6% increase in mammography attainment from baseline to Time 3) and in urban Nashville (22.3% increase). The rural women reported more barriers to mammography screening than the urban women. The rural women were more likely not to get a mammogram because they did not perceive a need, because they thought mammography was embarrassing, and because of their religious beliefs. The results of this study demonstrate that an inexpensive church-based educational program was equally effective in both rural and urban Tennessee for increasing mammography rates among African American women.

Increasing mammography screening among African American women in rural areas.

The objective of this study was to evaluate the effectiveness of a church-based breast cancer screening education program on mammography attainment by African American women 40 years old and older in rural Alabama. The sample consisted of 192 women who volunteered to participate in the study through 13 African American churches in a rural, economically-depressed Alabama county. The design was quasi-experimental and had some features of community-based participatory research. Churches were randomly assigned to three groups (full program, partial program and control). The full program (group educational session plus an in-home visit from a Home Health Educator) positively affected mammography attainment (38% increase from baseline to Time 2). In addition, barriers to mammography attainment were reduced for women who had not obtained a mammogram by follow-up. Community-based participatory projects in collaboration with churches and cooperative extension programs have the potential to reduce racial disparities in breast cancer in rural areas.

Explaining race differences in mortality among the Tennessee Medicare elderly: the role of physician services.

We investigated the impact of socioeconomic conditions, patterns of morbidity, and physician service utilization on race differences in rates of mortality, and mortality associated with specific diagnoses. Longitudinal data from the Center for Medicare and Medicaid Services (CMS) Physician Billing File data and the Medicare Enrollment Database (EDB) were analyzed to assess physician-diagnosed morbidity, health service use, and mortality, among the population of Medicare beneficiaries in Tennessee (N=665,887). Proportional hazards models were used to examine the effects of race, socioeconomic status, morbidity, and physician service utilization on mortality. Race differences in physician visits explain the largest portion of mortality differentials between African Americans and Whites. Race disparities in mortality associated with particular forms of morbidity are also mostly a function of differences in physician service use. Our examination suggested that race differences in patterns of physician service use principally explain race disparities in mortality. Further, race differences in the use of physician services were substantially responsible for race disparities in mortality associated with particular forms of morbidity.

Racial/ethnic and Weight Status Differences in Food Preparation among WIC Participants.

The main purpose of this study was to examine whether the Supplemental Nutrition Program for Women, Infants and Children (WIC) helped mothers of overweight/obese preschool children to cut down on dietary fat and sugar intake for their families. Data from the Children Eating Well for Health (CHEW) Nutrition Survey, a probability sample of 150 (50 each White, Black and Hispanic) families with preschoolers participating in the WIC program in Nashville/Davidson County, Tennessee, were analyzed using logistic regression modeling. Mothers who reported that the WIC program helped them reduce fat intake were 2.5 times more likely to have an overweight/obese child and 2.1 times more likely to be obese themselves. No significant effects were found for adding sugar. These results suggest that the mothers in this sample were applying WIC nutritional counseling to use food preparation techniques that cut down on added fats for themselves and their children who were at risk due to weight status.

Racial differences in the diagnosis of dementia and in its effects on the use and costs of health care services.

OBJECTIVE: This study examined differences in the prevalence of dementia among Medicare beneficiaries by race and gender as well as racial differences in the effects of dementia on the use and costs of health care services. METHODS: Data from a 5 percent random sample of Medicare beneficiaries in the state of Tennessee who filed claims between 1991 and 1993 (N=33,680) were analyzed. Dementia was assessed on the basis of ICD-9 codes in the billing records of the Health Care Financing Administration (HCFA), along with information on gender, race, comorbid psychiatric conditions, use of health services, and the actual amounts paid by HCFA. Patients with dementia related to Alzheimer's disease were excluded. RESULTS: Diagnoses of dementia were significantly more prevalent among African-American beneficiaries than among white beneficiaries (5 percent compared with 3.9 percent). Persons with dementia had higher rates of health service use, particularly for inpatient care, and African-American persons with dementia had the highest levels of service use. Health care costs were also significantly higher for African Americans with a diagnosis of dementia. Among patients of either race, costs were substantially higher among those with comorbid psychiatric conditions. CONCLUSIONS: Racial differences in the prevalence of dementia are clearly evident. Race also plays a role in the effects of dementia on the use and costs of health services, with higher rates of expensive inpatient care among African Americans. Racial differences in both the prevalence and costs of dementia produce a considerable burden on the health care system. Addressing racial disparities in the prevalence of dementia would result in substantial cost savings.

Diabetes, depression, and healthcare utilization among African Americans in primary care.

PURPOSE: This study tested for an association between diabetes and depressive symptoms and assessed the effect of co-occurring diabetes and depressive symptoms on healthcare utilization outcomes among African-American patients. PROCEDURE: The sample consisted of 303 adult African-American patients age 40 and over from a primary care clinic serving the low-income population in Nashville, TN. Measures were based on self-reports during a structured interview. Multivariate analyses adjusted for age, gender, socioeconomic status, and comorbid chronic conditions. FINDINGS: African-American patients with and without diabetes did not differ on the presence or severity of depressive symptoms. However, the co-occurrence of major depressive symptoms with diabetes among African Americans was associated with nearly three times more reported emergency room visits and three times more inpatient days, but was only marginally associated with a lower number of physician visits. CONCLUSIONS: In contrast to previous studies with predominantly white samples that found a positive association between diabetes and depression, no association was found in this African-American sample. Nevertheless, the results did concur with research findings based on other samples, in that the co-occurrence of depression with diabetes was associated with more acute care utilization, such as emergency room visits and inpatient hospitalizations. This pattern of utilization may lead to higher healthcare costs among patients with diabetes who are depressed, regardless of race.

Group therapy for depressed elderly women.

We describe and evaluate a group therapy program targeting depression among elderly residents (N=303) of subsidized high-rise apartments in Nashville, TN. This eclectic program was comprised of 12 sessions (a total of 24 hours) that included modules on exercise and preventive health behaviors, cognitive and re-motivation therapy, reminiscence and grief therapy, and social skills development. Our multivariate regression analyses of pre-post measures using the Geriatric Depression Scale (GDS) showed that the effects of the group therapy varied by race, age, and level of initial depression among the participants. The program was effective in reducing depression, but only among Caucasian women who reported at least moderate depression prior to the program, and it yielded greater benefits for women between 55 and 75 years of age.

Challenges and strategies in serving the uninsured in Nashville, Tennessee.

This study identified challenges faced by a healthcare safety net system. Surveys of safety net outpatient clinic and hospital emergency department (ED) facilities and key informant interviews ascertained barriers to providing necessary client services and strategies to overcome them. About 60% of key informants responded that Medicaid cuts greatly increased the numbers of uninsured clients. The outpatient clinic and ED personnel reported that the capacity of providers to care for these increasing numbers of uninsured was primarily strained by limited referral resources for needed specialty care. The most commonly cited successful coping strategies for clinics were networking and partnering. [corrected].

TennCare disenrollment and avoidable hospital visits in Davidson County, Tennessee.

The objective of this study was to determine if an association existed between the mid-2005 TennCare (Medicaid) disenrollment and increases in uninsured ambulatory care sensitive condition (ACSC) non-admitted ER visits and inpatient hospitalizations in Davidson County, Tennessee (= the city of Nashville). Logistic regression modeling, using an interactive term for insurance category x year, indicated that the effect of no insurance on ACSC ER visits increased by 18% from 2003 to 2007 (p<.001), but no significant effect was found for uninsured ACSC inpatient hospitalizations. These greater odds of ACSC ER visits among uninsured patients were associated with a 60% increase in hospitals' bad debt write offs during this same time period. Therefore, the TennCare disenrollment was associated with increased likelihood of uninsured ACSC non-admitted ER visits and greater financial losses for Davidson County hospitals during this time period.

Race, sex, and age differences in heart failure-related hospitalizations in a southern state: implications for prevention.

BACKGROUND: Because heart failure (HF) is the final common pathway for most heart diseases, we examined its 10-year prevalence trend by race, sex, and age in Tennessee. METHODS AND RESULTS: HF hospitalization data from the Tennessee Hospital Discharge Data System were analyzed by race, sex, and age. Rates were directly age-adjusted using the Year 2000 standard population. Adult (age 20+ years) inpatient hospitalization for primary diagnosis of HF (HFPD) increased from 4.2% in 1997 to 4.5% in 2006. Age-adjusted hospitalization for HF (per 10 000 population) rose by 11.3% (from 29.3 in 1997 to 32.6 in 2006). Parallel changes in secondary HF admissions were also noted. Age-adjusted rates were higher among blacks than whites and higher among men than women. The ratios of black to white by sex admitted with HFPD in 2006 were highest (9:1) among the youngest age categories (20 to 34 and 35 to 44 years). Furthermore, for each age category of black men below 65 years, there were higher HF admission rates than for white men in the immediate older age category. In 2006, the adjusted rate ratios for HFPD in black to white men ages 20 to 34 and 35 to 44 years were odds ratio, 4.75; 95% confidence interval, 3.29 to 6.86 and odds ratio, 5.10; 95% confidence interval, 4.15 to 6.25, respectively. Hypertension was the independent predictor of HF admissions in black men ages 20 to 34 years. CONCLUSIONS: The higher occurrence of HF among young adults in general, particularly among young black men, highlights the need for prevention by identifying modifiable biological and social determinants to reduce cardiovascular health disparities in this vulnerable group.