Trends and Predictors of Glycemic Control Among Adults With Type 2 Diabetes Covered by Alabama Medicaid, 2011-2019.

INTRODUCTION: Despite advances in diabetes management, only one-quarter of people with diabetes in the US achieve optimal targets for glycated hemoglobin A1c (HbA1c), blood pressure, and cholesterol. We sought to evaluate temporal trends and predictors of achieving glycemic control among adults with type 2 diabetes covered by Alabama Medicaid from 2011 through 2019. METHODS: We completed a retrospective analysis of Medicaid claims and laboratory data, using person-years as the unit of analysis. Inclusion criteria were being aged 19 to 64 years, having a diabetes diagnosis, being continuously enrolled in Medicaid for a calendar year and preceding 12 months, and having at least 1 HbA1c result during the study year. Primary outcomes were HbA1c thresholds of <7% and <8%. Primary exposure was study year. We conducted separate multivariable-adjusted logistic regressions to evaluate relationships between study year and HbA1c thresholds. RESULTS: We included 43,997 person-year observations. Mean (SD) age was 51.0 (9.9) years; 69.4% were women; 48.1% were Black, 42.9% White, and 0.4% Hispanic. Overall, 49.1% had an HbA1c level of <7% and 64.6% <8%. Later study years and poverty-based eligibility were associated with lower probability of reaching target HbA1c levels of <7% or <8%. Sex, race, ethnicity, and geography were not associated with likelihood of reaching HbA1c <7% or <8% in any model. CONCLUSION: Later study years were associated with lower likelihood of meeting target HbA1c levels compared with 2011, after adjusting for covariates. With approximately 35% not meeting an HbA1c target of <8%, more work is needed to improve outcomes of low-income adults with type 2 diabetes.

Association of Perceived Stress With Incident Heart Failure.

BACKGROUND: The relationship between psychological stress and heart failure (HF) has not been well studied. We sought to assess the relationship between perceived stress and incident HF. METHODS: We used data from the national REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a large prospective biracial cohort study that enrolled community-dwellers aged 45 years and older between 2003 and 2007, with follow-up. We included participants free of suspected prevalent HF who completed the Cohen 4-item Perceived Stress Scale (PSS-4). Our outcome variables were incident HF event, HF with reduced ejection fraction events, and HF with preserved ejection fraction events. We estimated Cox proportional hazard models to determine if PSS-4 quartiles were independently associated with incident HF events, adjusting for sociodemographics, social support, unhealthy behaviors, comorbid conditions, and physiologic parameters. We also tested interactions by baseline statin use, given its anti-inflammatory properties. RESULTS: Among 25,785 participants with a mean age of 64 ± 9.3 years, 55% were female and 40% were Black. Over a median follow-up of 10.1 years, 1109 ± 4.3% experienced an incident HF event. In fully adjusted models, the PSS-4 was not associated with HF or HF with reduced ejection fraction. However, PSS-4 quartiles 2-4 (compared with the lowest quartile) were associated with incident HF with preserved ejection fraction (Q2 hazard ratio 1.37, 95% confidence interval 1.00-1.88; Q3 hazard ratio 1.42, 95% confidence interval 1.03-1.95; Q4 hazard ratio 1.41, 95% confidence interval 1.04-1.92). Notably, this association was attenuated among participants who took a statin at baseline (P for interaction = .07). CONCLUSIONS: Elevated perceived stress was associated with incident HF with preserved ejection fraction but not HF with reduced ejection fraction.

Gender differences in association of prescription opioid use and mortality: A propensity-matched analysis from the REasons for Geographic And Racial Differences in Stroke (REGARDS) prospective cohort.

BACKGROUND: Prescription opioids (PO) have been widely used for chronic non-cancer pain, with commensurate concerns for overdose. The long-term effect of these medications on non-overdose mortality in the general population remains poorly understood. This study's objective was to examine the association of prescription opioid use and mortality in a large cohort, accounting for gender differences and concurrent benzodiazepine use, and using propensity score matching. Methods: 29,025 US community-dwellers were enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort between 2003 and 2007, and followed through December 31, 2012. At baseline there were 1907 participants with PO; 1864 of them were matched to participants without PO, based on the model-derived propensity to receive opioid prescriptions. Causes of death were expert-adjudicated. Results: Over median follow-up of 6 years there were 4428 deaths (413 among persons with PO). The risk for all-cause mortality was 12% higher, in absolute terms, for persons with PO compared to those without PO in the overall sample, with gender differences (interaction p = .0008). The risk of death was increased for women with PO (hazard ratio [HR] 1.21 [95% Confidence Interval (CI) 1.04-1.40]), but not men (HR 0.92 [95% CI 0.77-1.10]). Women with PO were at higher risk of cardiovascular disease (CVD) death (HR 1.43 [95% CI 1.12-1.84]), sudden death (HR 2.02 [95% CI 1.29-3.15]) (a subset of CVD death), and accidents (HR 2.18 [95% CI 1.03-4.60]). These risks were not observed for men with PO. Conclusion: Over 6 years of follow-up, women but not men who had opioid prescriptions were at higher risk of all-cause mortality, CVD death, sudden death, and accidents. Special caution in prescribing opioids for women may be warranted until these findings are confirmed.

Depressive symptoms, perceived stress, and metabolic health: The REGARDS study.

OBJECTIVE: To describe the relationship between metabolic health parameters and depressive symptoms and perceived stress, and whether the co-occurrence of these two psychological stressors has an additive influence on metabolic dysregulation in adults at different levels of body mass index (BMI) without diabetes. METHODS: Participants without diabetes (N = 20,312) from the population-based REasons for Geographic And Racial Differences in Stroke (REGARDS) study (recruited between 2003-2007) who had a body mass index (BMI) ≥ 18.5 kg/m2 were included in this cross-sectional analysis. Mean age of sample was 64.4 years, with 36% African American, and 56% women. Depressive symptoms and perceived stress were measured using brief versions of the Center for Epidemiologic Studies Depression (CES-D-4 item) questionnaire and Cohen Perceived Stress Scale (PSS), respectively. Metabolic health parameters included waist circumference, blood pressure (systolic and diastolic), low- and high-density lipoprotein (LDL, HDL) cholesterol, triglycerides, fasting glucose, and high sensitivity C-reactive protein (hs-CRP). Sequentially adjusted general linear regression models (GLM) for each metabolic parameter were used to assess the association between having both elevated depressive symptoms and stress, either of these psychological risk factors, or none with all analyses stratified by BMI category (i.e., normal, overweight, and obesity). RESULTS: The presence of elevated depressive symptoms and/or perceived stress was generally associated with increased waist circumference, higher CRP, and lower HDL. The combination of depressive symptoms and perceived stress, compared to either alone, was typically associated with poorer metabolic health outcomes. However, sociodemographic and lifestyle factors generally attenuated the associations between psychological factors and metabolic parameters. CONCLUSIONS: Elevated depressive symptoms in conjunction with high levels of perceived stress were more strongly associated with several parameters of metabolic health than only one of these psychological constructs in a large, diverse cohort of adults. Findings suggest that healthy lifestyle factors may attenuate the association between psychological distress and metabolic health impairment.

N-terminal pro-B-type natriuretic peptide and microsize myocardial infarction risk in the reasons for geographic and racial differences in stroke study.

BACKGROUND: N-terminal pro B-type peptide (NT-proBNP) has been associated with risk of myocardial infarction (MI), but less is known about the relationship between NT-proBNP and very small non ST-elevation MI, also known as microsize MI. These events are now routinely detectable with modern troponin assays and are emerging as a large proportion of all MI. Here, we sought to compare the association of NT-proBNP with risk of incident typical MI and microsize MI in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. METHODS: The REGARDS Study is a national cohort of 30,239 US community-dwelling black and white adults aged ≥ 45 years recruited from 2003 to 2007. Expert-adjudicated outcomes included incident typical MI (definite/probable MI with peak troponin ≥ 0.5 µg/L), incident microsize MI (definite/probable MI with peak troponin < 0.5 µg/L), and incident fatal CHD. Using a case-cohort design, we estimated the hazard ratio of the outcomes as a function of baseline NT-proBNP. Competing risk analyses tested whether the associations of NT-proBNP differed between the risk of incident microsize MI and incident typical MI as well as if the association of NT-proBNP differed between incident non-fatal microsize MI and incident non-fatal typical MI, while accounting for incident fatal coronary heart disease (CHD) as well as heart failure (HF). RESULTS: Over a median of 5 years of follow-up, there were 315 typical MI, 139 microsize MI, and 195 incident fatal CHD. NT-proBNP was independently and strongly associated with all CHD endpoints, with significantly greater risk observed for incident microsize MI, even after removing individuals with suspected HF prior to or coincident with their incident CHD event. CONCLUSION: NT-proBNP is associated with all MIs, but is a more powerful risk factor for microsize than typical MI.

Antidepressant Medication Use and Its Association With Cardiovascular Disease and All-Cause Mortality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

BACKGROUND: Mixed evidence suggests that second-generation antidepressants may increase the risk of cardiovascular and cerebrovascular events. OBJECTIVE: To assess whether antidepressant use is associated with acute coronary heart disease (CHD), stroke, cardiovascular disease (CVD) death, and all-cause mortality. METHODS: Secondary analyses of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) longitudinal cohort study were conducted. Use of selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, bupropion, nefazodone, and trazodone was measured during the baseline (2003-2007) in-home visit. Outcomes of CHD, stroke, CVD death, and all-cause mortality were assessed every 6 months and adjudicated by medical record review. Cox proportional hazards time-to-event analysis followed patients until their first event on or before December 31, 2011, iteratively adjusting for covariates. RESULTS: Among 29 616 participants, 3458 (11.7%) used an antidepressant of interest. Intermediate models adjusting for everything but physical and mental health found an increased risk of acute CHD (hazard ratio [HR] = 1.21; 95% CI = 1.04-1.41), stroke (HR = 1.28; 95% CI = 1.02-1.60), CVD death (HR = 1.29; 95% CI = 1.09-1.53), and all-cause mortality (HR = 1.27; 95% CI = 1.15-1.41) for antidepressant users. Risk estimates trended in this direction for all outcomes in the fully adjusted model but only remained statistically associated with increased risk of all-cause mortality (HR = 1.12; 95% CI = 1.01-1.24). This risk was attenuated in sensitivity analyses censoring follow-up time at 2 years (HR = 1.37; 95% CI = 1.11-1.68). CONCLUSIONS: In fully adjusted models, antidepressant use was associated with a small increase in all-cause mortality.

Prescription Opioid Use and Risk of Coronary Heart Disease, Stroke, and Cardiovascular Death Among Adults from a Prospective Cohort (REGARDS Study).

OBJECTIVE: Despite unknown risks, prescription opioid use (POU) for nonmalignant chronic pain has grown in the US over the last decade. The objective of this study was to examine associations between POU and coronary heart disease (CHD), stroke, and cardiovascular disease (CVD) death in a large cohort. DESIGN, SETTING, SUBJECTS: POU was assessed in the prospective cohort study of 29,025 participants of the REasons for Geographic and Racial Differences in Stroke study, enrolled between 2003 and 2007 from the continental United States and followed through December 31, 2010. CHD, stroke, and CVD death were expert adjudicated outcome measures. METHODS: Cox proportional hazards models adjusted for CVD risk factors were used. RESULTS: Over a median (SD) of 5.2 (1.8) years of follow-up, 1,362 CHD events, 749 strokes, and 1,120 CVD death occurred (105, 55, and 104, respectively, in the 1,851 opioid users). POU was not associated with CHD (adjusted hazard ratio [aHR]) 1.03 [95% CI 0.83-1.26] or stroke (aHR 1.04 [95% CI 0.78-1.38]), but was associated with CVD death (aHR 1.24 [95% CI 1.00-1.53]) in the overall sample. In the sex-stratified analyses, POU was associated with increased risk of CHD (aHR 1.38 [95% CI 1.05-1.82]) and CVD death (aHR 1.66 [95% CI 1.27-2.17]) among females but not males (aHR 0.70 [95% CI 0.50-0.97] for CHD and 0.78 [95% CI 0.54-1.11] for CVD death). CONCLUSION: Female but not male POU were at higher risk of CHD and CVD death. POU was not associated with stroke in overall or sex-stratified analyses.

The impact of the combination of income and education on the incidence of coronary heart disease in the prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study.

BACKGROUND: We investigated the association between income-education groups and incident coronary heart disease (CHD) in a national prospective cohort study. METHODS: The REasons for Geographic And Racial Differences in Stroke study recruited 30,239 black and white community-dwelling adults between 2003 and 2007 and collected participant-reported and in-home physiologic variables at baseline, with expert adjudicated CHD endpoints during follow-up. Mutually exclusive income-education groups were: low income (annual household income <$35,000)/low education (< high school), low income/high education, high income/low education, and high income/high education. Cox models estimated hazard ratios (HR) for incident CHD for each exposure group, examining differences by age group. RESULTS: At baseline, 24,461 participants free of CHD experienced 809 incident CHD events through December 31, 2011 (median follow-up 6.0 years; interquartile range 4.5-7.3 years). Those with low income/low education had the highest incidence of CHD (10.1 [95% CI 8.4-12.1]/1000 person-years). After full adjustment, those with low income/low education had higher risk of incident CHD (HR 1.42 [95% CI: 1.14-1.76]) than those with high income/high education, but findings varied by age. Among those aged <65 years, compared with those reporting high income/high education, risk of incident CHD was significantly higher for those reporting low income/low education and low income/high education (adjusted HR 2.07 [95% CI 1.42-3.01] and 1.69 [95% CI 1.30-2.20], respectively). Those aged ≥ 65 years, risk of incident CHD was similar across income-education groups after full adjustment. CONCLUSION: For younger individuals, low income, regardless of education, was associated with higher risk of CHD, but not observed for ≥ 65 years. Findings suggest that for younger participants, education attainment may not overcome the disadvantage conferred by low income in terms of CHD risk, whereas among those ≥ 65 years, the independent effects of income and education are less pronounced.

Neighborhood Disadvantage and Risk of Heart Failure: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

BACKGROUND: Heart failure (HF) affects >6 million US adults, with recent increases in HF hospitalizations. We aimed to investigate the association between neighborhood disadvantage and incident HF events and potential differences by diabetes status. METHODS: We included 23 645 participants from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), a prospective cohort of Black and White adults aged ≥45 years living in the continental United States (baseline 2005-2007). Neighborhood disadvantage was assessed using a Z score of 6 census tract variables (2000 US Census) and categorized as quartiles. Incident HF hospitalizations or HF-related deaths through 2017 were adjudicated. Multivariable-adjusted Cox regression was used to examine the association between neighborhood disadvantage and incident HF. Heterogeneity by diabetes was assessed using an interaction term. RESULTS: The mean age was 64.4 years, 39.5% were Black adults, 54.9% females, and 18.8% had diabetes. During a median follow-up of 10.7 years, there were 1125 incident HF events with an incidence rate of 3.3 (quartile 1), 4.7 (quartile 2), 5.2 (quartile 3), and 6.0 (quartile 4) per 1000 person-years. Compared to adults living in the most advantaged neighborhoods (quartile 1), those living in neighborhoods in quartiles 2, 3, and 4 (most disadvantaged) had 1.30 (95% CI, 1.06-1.60), 1.36 (95% CI, 1.11-1.66), and 1.45 (95% CI, 1.18-1.79) times greater hazard of incident HF even after accounting for known confounders. This association did not significantly differ by diabetes status (interaction P=0.59). For adults with diabetes, the adjusted incident HF hazards comparing those in quartile 4 versus quartile 1 was 1.34 (95% CI, 0.92-1.96), and it was 1.50 (95% CI, 1.16-1.94) for adults without diabetes. CONCLUSIONS: In this large contemporaneous prospective cohort, neighborhood disadvantage was associated with an increased risk of incident HF events. This increase in HF risk did not differ by diabetes status. Addressing social, economic, and structural factors at the neighborhood level may impact HF prevention.

Association between urinary albumin excretion and coronary heart disease in black vs white adults.

IMPORTANCE: Excess urinary albumin excretion is more common in black than white individuals and is more strongly associated with incident stroke risk in black vs white individuals. Whether similar associations extend to coronary heart disease (CHD) is unclear. OBJECTIVE: To determine whether the association of urinary albumin excretion with CHD events differs by race. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of black and white US adults aged 45 years and older who were enrolled within the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study between 2003 and 2007 with follow-up through December 31, 2009. We examined race-stratified associations of urinary albumin-to-creatinine ratio (ACR) in 2 groups: (1) incident CHD among 23,273 participants free of CHD at baseline; and (2) first recurrent CHD event among 4934 participants with CHD at baseline. MAIN OUTCOMES AND MEASURES: Expert-adjudicated incident and recurrent myocardial infarction and acute CHD death. RESULTS: A total of 616 incident CHD events (421 nonfatal MIs and 195 CHD deaths) and 468 recurrent CHD events (279 nonfatal MIs and 189 CHD deaths) were observed over a mean time of 4.4 years of follow-up. Among those free of CHD at baseline, age- and sex-adjusted incidence rates of CHD per 1000 person-years of follow-up increased with increasing categories of ACR in black and white participants, with rates being nearly 1.5-fold greater in the highest category of ACR (>300 mg/g) in black participants (20.59; 95% CI, 14.36-29.51) vs white participants (13.60; 95% CI, 7.60-24.25). In proportional hazards models adjusted for traditional cardiovascular risk factors and medications, higher baseline urinary ACR was associated with greater risk of incident CHD among black participants (hazard ratio [HR] comparing ACR >300 vs <10 mg/g, 3.21 [95% CI, 2.02-5.09]) but not white participants (HR comparing ACR >300 vs <10 mg/g, 1.49 [95% CI, 0.80-2.76]) (P value for interaction = .03). Among those with CHD at baseline, fully adjusted associations of baseline urinary ACR with first recurrent CHD event were similar between black participants (HR comparing ACR >300 vs <10 mg/g, 2.21 [95% CI, 1.22-4.00]) vs white participants (HR comparing ACR >300 vs <10 mg/g, 2.48 [95% CI, 1.61-3.78]) (P value for interaction = .53). CONCLUSIONS AND RELEVANCE: Higher urinary ACR was associated with greater risk of incident but not recurrent CHD in black individuals when compared with white individuals. These data confirm that black individuals appear more susceptible to vascular injury.

Disparities in Postdischarge Ambulatory Care Follow-Up Among Medicaid Beneficiaries With Diabetes, Hospitalized for Heart Failure.

Background Ambulatory follow-up for all patients with heart failure (HF) is recommended within 7 to 14 days after hospital discharge to improve HF outcomes. We examined postdischarge ambulatory follow-up of patients with comorbid diabetes and HF from a low-income population in primary and specialty care. Methods and Results Adults with diabetes and first hospitalizations for HF, covered by Alabama Medicaid in 2010 to 2019, were included and the claims analyzed for ambulatory care use (any, primary care, cardiology, or endocrinology) within 60 days after discharge using restricted mean survival time regression and negative binomial regression. Among 9859 Medicaid-covered adults with diabetes and first hospitalization for HF (mean age, 53.7 years; SD, 9.2 years; 47.3% Black; 41.8% non-Hispanic White; 10.9% Hispanic/Other [Other included non-White Hispanic, American Indian, Pacific Islander and Asian adults]; 65.4% women, 34.6% men), 26.7% had an ambulatory visit within 0 to 7 days, 15.2% within 8 to 14 days, 31.3% within 15 to 60 days, and 26.8% had no visit; 71% saw a primary care physician and 12% a cardiology physician. Black and Hispanic/Other adults were less likely to have any postdischarge ambulatory visit (P<0.0001) or the visit was delayed (by 1.8 days, P=0.0006 and by 2.8 days, P=0.0016, respectively) and were less likely to see a primary care physician than non-Hispanic White adults (adjusted incidence rate ratio, 0.96 [95% CI, 0.91-1.00] and 0.91 [95% CI, 0.89-0.98]; respectively). Conclusions More than half of Medicaid-covered adults with diabetes and HF in Alabama did not receive guideline-concordant postdischarge care. Black and Hispanic/Other adults were less likely to receive recommended postdischarge care for comorbid diabetes and HF.

Patient-level factors associated with hemoglobin A1C testing in Alabama Medicaid beneficiaries with diabetes.

AIM: We evaluated patient-level factors associated with receipt of hemoglobin A1c (HbA1c) testing among Alabama Medicaid beneficiaries with type 2 diabetes. METHODS: We conducted a retrospective analysis of person-year observations from Medicaid claims data from 2011 to 2020. Adults aged 19-64 years with type 2 diabetes and continuous enrollment in Medicaid for study year and year prior were included. Primary outcomes were ≥ 1 and ≥ 2 HbA1c test(s) per year. We conducted multivariable Poisson regression stratified by Medicaid eligibility reason (disability, poverty) examining the association of study year, demographics, clinical factors, and healthcare utilization with HbA1c testing. RESULTS: We analyzed 288,379 observations, 51% with disability-based, 49% poverty-based eligibility. Overall, 57% observations had ≥ 1 HbA1c, 35% had ≥ 2 HbA1c tests. More observations with disability-based than poverty-based eligibility had ≥ 1 (76% vs. 38%) and ≥ 2 HbA1c tests (49% vs. 20%). Patient-level factors were associated with a higher likelihood of having ≥ 1 HbA1c: Black race and older age (disability-based eligibility); year after 2011, female sex, and younger age (poverty-based eligibility); and rurality, insulin use, endocrinology care, diabetes complications, and ambulatory care visits (both groups). CONCLUSIONS: Just over one-third of adult Alabama Medicaid beneficiaries with diabetes had ≥ 2 HbA1c tests per year; testing frequency differed by Medicaid eligibility.

Trajectories of drug use and mortality outcomes among adults followed over 18 years.

BACKGROUND: For adults in general population community settings, data regarding long-term course and outcomes of illicit drug use are sparse, limiting the formulation of evidence-based recommendations for drug use screening of adults in primary care. OBJECTIVE: To describe trajectories of three illicit drugs (cocaine, opioids, amphetamines) among adults in community settings, and to assess their relation to all-cause mortality. DESIGN: Longitudinal cohort, 1987/88-2005/06. SETTING: Community-based recruitment from four cities (Birmingham, Chicago, Oakland, Minneapolis). PARTICIPANTS: Healthy adults, balanced for race (black and white) and gender were assessed for drug use from 1987/88-2005/06, and for mortality through 12/31/2008 (n = 4301) MEASUREMENTS: Use of cocaine, amphetamines, and opioids (last 30 days) was queried in the following years: 1987/88, 1990/91, 1992/93, 1995/96, 2000/01, 2005/06. Survey-based assessment of demographics and psychosocial characteristics. Mortality over 18 years. RESULTS: Trajectory analysis identified four groups: Nonusers (n = 3691, 85.8%), Early Occasional Users (n = 340, 7.9%), Persistent Occasional Users (n = 160, 3.7%), and Early Frequent/Later Occasional Users (n = 110, 2.6%). Trajectories conformed to expected patterns regarding demographics, other substance use, family background and education. Adjusting for demographics, baseline health status, health behaviors (alcohol, tobacco), and psychosocial characteristics, Early Frequent/Later Occasional Users had greater all-cause mortality (Hazard Ratio, HR = 4.94, 95% CI = 1.58-15.51, p = 0.006). LIMITATIONS: Study is restricted to three common drugs, and trajectory analyses represent statistical approximations rather than identifiable "types". Causal inferences are tentative. CONCLUSIONS: Four trajectories describe illicit drug use from young adulthood to middle age. Two trajectories, representing over one third of adult users, continued use into middle age. These persons were more likely to continue harmful risk behaviors such as smoking, and more likely to die.

Depressive Symptoms and Incident Hospitalization for Heart Failure: Findings From the REGARDS Study.

Background Depressive symptoms are risk factors for several forms of cardiovascular disease including coronary heart disease (CHD). However, it is unclear whether depressive symptoms are associated with incident heart failure (HF), including hospitalization for HF overall or by subtype: HF with preserved (HFpEF) or reduced ejection fraction (HFrEF). Methods and Results Among 26 268 HF-free participants in the REGARDS (Reasons for Geographic And Racial Differences in Stroke) study, a prospective biracial cohort of US community-dwelling adults ≥45 years, baseline depressive symptoms were defined as a score ≥4 on the 4-item Center for Epidemiologic Studies Depression scale. Incident HF hospitalizations were expert-adjudicated and categorized as HFpEF (EF ≥50%) and HFrEF, including mid-range EF (EF<50%). Over a median of 9.2 [IQR 6.2-10.9] years of follow-up, there were 872 incident HF hospitalizations, 526 among those without CHD and 334 among those with CHD. The age-adjusted HF hospitalization incidence rates per 1000 person-years were 4.9 (95% CI 4.0-5.9) for participants with depressive symptoms versus 3.2 (95% CI 3.0-3.5) for those without depressive symptoms (P<0.001). For overall HF, the elevated risk became attenuated after controlling for covariates. When HFpEF was assessed separately, depressive symptoms were associated with incident hospitalization after controlling for all covariates (hazard ratio [HR] 1.48, 95% CI 1.00-2.18) among those without baseline CHD. In contrast, depressive symptoms were not associated with incident HFrEF hospitalizations. Conclusions Among individuals free of CHD at baseline, depressive symptoms were associated with incident hospitalization for HFpEF, but not for HFrEF, or among those with baseline CHD.

What is the association of renin-angiotensin-aldosterone system inhibitors with COVID-19 outcomes: retrospective study of racially diverse patients?

OBJECTIVE: To describe the clinical outcomes of COVID-19 in a racially diverse sample from the US Southeast and examine the association of renin-angiotensin-aldosterone system (RAAS) inhibitor use with COVID-19 outcome. DESIGN, SETTING, PARTICIPANTS: This study is a retrospective cohort of 1024 patients with reverse-transcriptase PCR-confirmed COVID-19 infection, admitted to a 1242-bed teaching hospital in Alabama. Data on RAAS inhibitors use, demographics and comorbidities were extracted from hospital medical records. PRIMARY OUTCOMES: In-hospital mortality, a need of intensive care unit, respiratory failure, defined as invasive mechanical ventilation (iMV) and 90-day same-hospital readmissions. RESULTS: Among 1024 patients (mean (SD) age, 57 (18.8) years), 532 (52.0%) were African Americans, 514 (50.2%) male, 493 (48.1%) had hypertension, 365 (36%) were taking RAAS inhibitors. During index hospitalisation (median length of stay of 7 (IQR (4-15) days) 137 (13.4%) patients died; 170 (19.2%) of survivors were readmitted. RAAS inhibitor use was associated with lower in-hospital mortality (adjusted HR, 95% CI (0.56, (0.36 to 0.88), p=0.01) and no effect modification by race was observed (p for interaction=0.81). Among patients with hypertension, baseline RAAS use was associated with reduced risk of iMV, adjusted OR, 95% CI (aOR 0.58, 95% CI 0.36 to 0.95, p=0.03). Patients with heart failure were twice as likely to die from COVID-19, compared with patients without heart failure. CONCLUSIONS: In a retrospespective study of racially diverse patients, hospitalised with COVID-19, prehospitalisation use of RAAS inhibitors was associated with 40% reduction in mortality irrespective of race.

Depressive symptoms, cognitive impairment, and all-cause mortality among REGARDS participants with heart failure.

Aims: To ascertain whether depressive symptoms and cognitive impairment (CI) are associated with mortality among patients with heart failure (HF), adjusting for sociodemographic, comorbidities, and biomarkers. Methods and results: We utilized Medicare-linked data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a biracial prospective ongoing cohort of 30 239 US community-dwelling adults, recruited in 2003-07. HF diagnosis was ascertained in claims analysis. Depressive symptoms were defined as a score ≥4 on the four-item Center for Epidemiological Studies-Depression scale. Cognitive impairment was defined as a score of ≤4 on the six-item screener that assessed three-item recall and orientation to year, month, and day of the week. Sequentially adjusted Cox proportional hazard models were used to estimate the risk of death. We analyzed 1059 REGARDS participants (mean age 73, 48%-African American) with HF; of those 146 (14%) reported depressive symptoms, 136 (13%) had CI and 31 (3%) had both. Over the median follow-up of 6.8 years (interquartile range, 3.4-10.3), 785 (74%) died. In the socio-demographics-adjusted model, CI was significantly associated with increased mortality, hazard ratio 1.24 (95% confidence interval 1.01-1.52), compared with persons with neither depressive symptoms nor CI, but this association was attenuated after further adjustment. Neither depressive symptoms alone nor their comorbidity with CI was associated with mortality. Risk factors of all-cause mortality included: low income, comorbidities, smoking, physical inactivity, and severity of HF. Conclusion: Depressive symptoms, CI, or their comorbidity was not associated with mortality in HF in this study. Treatment of HF in elderly needs to be tailored to cognitive status and includes focus on medical comorbidities.

Peer Support Intervention Improves Pain-Related Outcomes Among Rural Adults With Diabetes and Chronic Pain at 12-Month Follow-Up.

PURPOSE: Adults with diabetes mellitus (DM) suffer often from chronic pain, yet evidence-based interventions for comorbid pain and DM are scarce. We tested the effect of a peer-led cognitive behavioral training (CBT) intervention on pain self-efficacy (PSE), pain intensity, and pain-related functional limitations (PRFL) in adults with DM, 1 year after trial initiation. METHODS: The yearlong "Living Healthy" cluster-randomized trial included 230 residents of rural Alabama with DM, who reported pain in the past month; communities were treated as clusters. Intervention participants received a peer-delivered 8-session structured CBT intervention in the context of diabetes self-management; attention control arm participants received a peer-delivered 8-session general health education program. Outcomes included PSE (Arthritis Self-Efficacy Scale, range 10-100); pain intensity (McGill Pain Questionnaire, range 0-45); and PRFL (Western Ontario and McMaster Universities Osteoarthritis Index scale, range 0-100). We examined control-intervention differences in changes in outcome scores from baseline to 3-month and 12-month follow-up, adjusted for clustering. FINDINGS: The 195 participants with follow-up data were aged 59 ± 10.4 years, 96% were African American, 79% were women, and 80% reported pain on the day of baseline data collection. At 3-month follow-up, PSE increased more for intervention (21-point increase) than control (5-point increase) participants (P for control-intervention (C-I) difference in change < .001); pain intensity decreased for both groups; and PRFL decreased only for intervention participants (-11 score; P for C-I difference in change < .001). Results were sustained at 12 months, and pain intensity significantly improved in only the intervention arm (P for C-I difference in change = .01). CONCLUSIONS: This peer-delivered CBT intervention improved pain self-efficacy, pain-related functional limitations, and pain intensity over 12 months among rural participants with DM and chronic pain.

Depressive symptoms do not discriminate: racial and economic influences between time-varying depressive symptoms and mortality among REGARDS participants.

PURPOSE: Depressive symptoms relapse and remit over time, perhaps differentially by race and income. Few studies have examined whether time-varying depressive symptoms (TVDS) differentially predict mortality. We sought to determine whether race (white/black) and income (

Time-Varying Depressive Symptoms and Cardiovascular and All-Cause Mortality: Does the Risk Vary by Age or Sex?

Background Depressive symptoms are associated with mortality. Data regarding moderation of this effect by age and sex are inconsistent, however. We aimed to identify whether age and sex modify the association between depressive symptoms and all-cause and cardiovascular disease (CVD) mortality. Methods and Results The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study is a prospective cohort of Black and White individuals recruited between 2003 and 2007. Associations between time-varying depressive symptoms (Center for Epidemiologic Studies Depression scale score ≥4 versus <4) and all-cause and CVD mortality were measured using Cox proportional hazard models adjusting for demographic and clinical risk factors. All results were stratified by age or sex and by self-reported health status. Of 29 491 participants, 3253 (11%) had baseline elevated depressive symptoms. Mean age was 65 (9.4) years, with 55.1% of participants female, 41.1% Black, and 46.4% had excellent/very good health. Depressive symptoms were measured at baseline, on average 4.9 (SD, 1.5), then 2.1 (SD, 0.4) years later. Neither age nor sex moderated the association between elevated time-varying depressive symptoms and all-cause or CVD mortality (all-cause: age 45-64 years adjusted hazard ratio [aHR], 1.38; 95% CI, 1.18-1.61 versus age ≥65 years aHR,1.36; 95% CI, 1.23-1.50; P=0.05; CVD: age 45-64 years aHR, 1.17; 95% CI, 0.90-1.53 versus age ≥65 years aHR, 1.26; 95% CI, 1.06-1.50; P=0.54; all-cause: males aHR, 1.46; 95% CI, 1.29-1.64 versus female aHR, 1.34; 95% CI, 1.19-1.50; P=0.35; CVD: male aHR, 1.32; 95% CI, 1.08-1.62 versus female aHR, 1.22; 95% CI, 1.00-1.47; P=0.64). Similar results were observed when stratified by self-reported health status. Conclusions Depressive symptoms confer mortality risk regardless of age and sex, including individuals who report excellent/very good health.

Impact of Peer Support on Acute Care Visits and Hospitalizations for Individuals With Diabetes and Depressive Symptoms: A Cluster-Randomized Controlled Trial.

OBJECTIVE: Comorbid depression is associated with increased health care utilization and cost. We examined the effects of peer support on acute care (AC) and hospital utilization in individuals with diabetes with or without depressive symptoms. RESEARCH DESIGN AND METHODS: This was a cluster-randomized controlled trial conducted in 2010-2012, with the clusters being practices and their surrounding communities. Adults with type 2 diabetes who wanted help with self-management were eligible to participate. Those without a doctor, with limited life expectancy, with plans to move within the next year, and with an unwillingness to work with a peer advisor were excluded. Intervention participants received 1 year of peer support. Control participants received usual care. The Patient Health Questionnaire (PHQ-8) (range 0-24; 5 indicates mild and 10 indicates moderate depressive symptoms) assessed depressive symptoms. AC and hospital utilization were measured by self-report. Data were collected at baseline, 6 months, and 12 months. Quasi-Poisson regression using generalized estimating equations examined differences in utilization per year attributable to the intervention for those with and without mild depressive symptoms (and separately, moderate depressive symptoms), controlling for imbalance across treatment arms. RESULTS: At baseline, half of the sample reported mild depressive symptoms (52% intervention and 48% control, P = 0.37), a quarter reported moderate depressive symptoms (25% intervention and 26% control, P = 1.0), and there were no significant differences in utilization. A total of 168 intervention (six clusters) and 187 control (five clusters) participants had follow-up data. In individuals with mild depressive symptoms, the incident rate ratio (IRR) for hospitalization among intervention compared with control was 0.26 (95% CI 0.08-0.84) per 10 patient-years. The IRR for AC was 0.55 (95% CI 0.28-1.07) per 10 person-years. Findings were similar for individuals with moderate depressive symptoms. CONCLUSIONS: Peer support lowered AC visits and hospitalizations for individuals with depressive symptoms but not for those without depressive symptoms; these findings can guide resource allocation for population health management.