Neighborhood Environment Characteristics and Control of Hypertension and Diabetes in a Primary Care Patient Sample.

BACKGROUND: Hypertension control and diabetes control are important for reducing cardiovascular disease burden. A growing body of research suggests an association between neighborhood environment and hypertension or diabetes control among patients engaged in clinical care. OBJECTIVE: To investigate whether neighborhood conditions (i.e., healthy food availability, socioeconomic status (SES), and crime) were associated with hypertension and diabetes control. DESIGN: Cross-sectional analyses using electronic medical record (EMR) data, U.S. Census data, and secondary data characterizing neighborhood food environments. Multivariate logistic regression analyses adjusted for potential confounders. Analyses were conducted in 2017. PARTICIPANTS: Five thousand nine hundred seventy adults receiving primary care at three Baltimore City clinics in 2010-2011. MAIN MEASURES: Census tract-level neighborhood healthy food availability, neighborhood SES, and neighborhood crime. Hypertension control defined as systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg. Diabetes control defined as HgbA1c < 7. KEY RESULTS: Among patients with hypertension, neighborhood conditions were not associated with lower odds of blood pressure control after accounting for patient and physician characteristics. However, among patients with diabetes, in fully adjusted models accounting for patient and physician characteristics, we found that patients residing in neighborhoods with low and moderate SES had reduced odds of diabetes control (OR = 0.74 (95% CI = 0.57-0.97) and OR = 0.75 (95% CI = 0.57-0.98), respectively) compared to those living in high-SES neighborhoods. CONCLUSIONS: Neighborhood disadvantage may contribute to poor diabetes control among patients in clinical care. Community-based chronic disease care management strategies to improve diabetes control may be optimally effective if they also address neighborhood SES among patients engaged in care.

Placental alpha-microglobulin-1 and combined traditional diagnostic test: a cost-benefit analysis.

OBJECTIVE: We sought to evaluate if the placental alpha-microglobulin (PAMG)-1 test vs the combined traditional diagnostic test (CTDT) of pooling, nitrazine, and ferning would be a cost-beneficial screening strategy in the setting of potential preterm premature rupture of membranes. STUDY DESIGN: A decision analysis model was used to estimate the economic impact of PAMG-1 test vs the CTDT on preterm delivery costs from a societal perspective. Our primary outcome was the annual net cost-benefit per person tested. Baseline probabilities and costs assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2013 US dollars. RESULTS: Annual net benefit from PAMG-1 was $20,014 per person tested, while CTDT had a net benefit of $15,757 per person tested. If the probability of rupture is <38%, PAMG-1 will be cost-beneficial with an annual net benefit of $16,000-37,000 per person tested, while CTDT will have an annual net benefit of $16,000-19,500 per person tested. If the probability of rupture is >38%, CTDT is more cost-beneficial. Monte Carlo simulations of 1 million trials selected PAMG-1 as the optimal strategy with a frequency of 89%, while CTDT was only selected as the optimal strategy with a frequency of 11%. Sensitivity analyses were robust. CONCLUSION: Our cost-benefit analysis provides the economic evidence for the adoption of PAMG-1 in diagnosing preterm premature rupture of membranes in uncertain presentations and when CTDT is equivocal at 34 to <37 weeks' gestation.

Late life socioeconomic status and hypertension in an aging cohort: the Atherosclerosis Risk in Communities Study.

OBJECTIVE: To investigate the association between individual and area-level socioeconomic status and hypertension risk among individuals later in life. METHODS: We used Cox proportional hazards models to examine the association of socioeconomic status with incident hypertension using race-specific neighborhood socioeconomic status, median household income, and education among 3372 participants (mean age, 61 years) from the Atherosclerosis Risk in Communities Study at Visit 4 (1996-1998). Incident hypertension was defined as self-reported diagnosis or reported use of antihypertensive medications. RESULTS: Over a median follow-up time of 9.4 years, there were 1874 new cases of hypertension (62.1 per 1000 person-years). Overall, being in high as compared with low socioeconomic status categories was associated with a lower risk of developing hypertension in late life, with hazard ratios (95% confidence intervals) of 0.87 (0.77-0.98) for high neighborhood socioeconomic status tertile, 0.79 (0.69-0.90) for high individual income, and 0.75 (0.63-0.89) for college education after adjustment for traditional risk factors. These findings were consistent and robust whenever accounting for competing risks of all-cause mortality. No significant interactions by race and age (dichotomized at age 65) were observed. CONCLUSION: Among participants free of hypertension in midlife, high neighborhood and individual socioeconomic status are associated with a decreased risk of incident hypertension. Our findings support population-level interventions, such as blood pressure screening at senior centers and faith-based organizations, that are tailored to shift the distribution of blood pressure and reduce hypertension health inequalities among older adults.

Placental Alpha-Microglobulin-1 Test in Resource-Limited Settings: A Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate whether the use of placental alpha-microglobulin-1 (PAMG-1) for the diagnosis of preterm premature rupture of membranes is cost-effective in resource-limited settings. METHODS: We designed a decision-analytic model from a third-party payer's perspective to determine the cost-effectiveness of the PAMG-1 test compared with the traditional diagnostic test of pooling, Nitrazine, and ferning in diagnosing preterm premature rupture of membranes in a resource-limited setting. The primary health outcome of interest is the number of hospital transfers averted by each strategy per 1,000 patients screened. Baseline probabilities and cost assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2015 U.S. dollars. RESULTS: Under our baseline parameters, the use of a PAMG-1 test was the preferred cost-effective strategy. The PAMG-1 test averted hospital transfers of 447 true-negative patients per 1,000 tested at a cost of $143,407 ($320.82 per hospital transfer averted). The traditional test averted hospital transfers of 395 true-negative patients per 1,000 tested at a cost of $172,652 ($437.40 per hospital transfer averted). In a Monte Carlo simulation of 10 million trials, the PAMG-1 test was selected as the most cost-effective strategy with a frequency of 74%. The traditional test was only selected with a frequency of 26%. The "do-nothing" strategy was not selected throughout the trial. CONCLUSION: Among women presenting at resource-limited settings with a history suspicious of preterm premature rupture of membranes between 24 and 36 weeks of gestation, our analysis provides evidence suggesting that PAMG-1 is the most cost-effective testing strategy.

How older black women perceive the effects of stigma and social support on engagement in HIV care.

As black women over age 50 represent a growing share of women living with HIV, understanding what helps them persist and engage in ongoing HIV care will become increasingly important. Delineating the specific roles of social support and stigma on HIV care experiences among this population remains unclear. We qualitatively examined how experiences with stigma and social support either facilitated or inhibited engagement in HIV care, from the perspective of older black women. Semi-structured interviews were conducted with 20 older black women currently receiving HIV care at primary care clinics in the Metropolitan Boston area. Women expressed that experiences with stigma and seeking support played an important role in evaluating the risks and benefits of engaging in care. Social support facilitated their ability to engage in care, while stigma interfered with their ability to engage in care throughout the course of their illness. Providers in particular, can facilitate engagement by understanding the changes in these women's lives as they struggle with stigma and disclosure while engaging in HIV care. The patient's experiences with social support and stigma and their perceptions about engagement are important considerations for medical teams to tailor efforts to engage older black women in regular HIV care.

Prophylactic use of negative pressure wound therapy after cesarean delivery.

OBJECTIVE: To evaluate the economic benefit of prophylactic negative pressure wound therapy on a closed laparotomy incision after cesarean delivery in comparison with standard postoperative dressing. METHODS: We designed a decision-analytic model from a third-party payer's perspective to determine the cost-benefit of prophylactic application of negative pressure wound therapy compared with standard postoperative dressing on a closed laparotomy incision after cesarean delivery. Our primary outcome measure was the expected value of the cost per strategy. Baseline probabilities and cost assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2014 U.S. dollars. RESULTS: Under our baseline parameters, standard postoperative dressing was the preferred strategy. Standard postoperative dressing and prophylactic negative pressure wound therapy cost $547 and $804 per strategy, respectively. Sensitivity analyses showed that prophylactic negative pressure wound therapy can be cost-beneficial if it is priced below $192; standard postoperative dressing is the preferred strategy among patients with surgical site infection rate of 14% or less. If surgical site infection rates are greater than 14%, prophylactic negative pressure wound therapy could be cost-beneficial depending on the degree of reduction in surgical site infections. At a surgical site infection rate of 30%, the rate must be reduced by 15% for negative pressure wound therapy to become the preferred strategy. Monte Carlo simulation of 1,000 patients in 1 million trials showed that standard postoperative dressing was the preferred cost-beneficial strategy with a frequency of 85%. CONCLUSION: Our cost-benefit analysis provides economic evidence suggesting that negative pressure wound therapy should not be used on closed laparotomy incisions of patients with low risk of postcesarean delivery surgical site infections. However, among patients with a high risk of surgical site infections, prophylactic negative pressure wound therapy is potentially cost-beneficial.