Childhood maltreatment and trajectories of cardiometabolic health across the reproductive life span among individuals with a first birth during the Coronary Artery Risk Development in Young Adults Study.

OBJECTIVE: Childhood adversity is associated with poor cardiometabolic health in adulthood; little is known about how this relationship evolves through childbearing years for parous individuals. The goal was to estimate differences in cardiometabolic health indicators before, during and after childbearing years by report of childhood maltreatment in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study. METHODS: Including 743 individuals nulliparous at baseline (1985-1986) with one or more pregnancies >20 weeks during follow-up (1986-2022), we fit segmented linear regression models to estimate mean differences between individuals reporting or not reporting childhood maltreatment (physical or emotional) in waist circumference, triglycerides, high-density lipoprotein cholesterol, systolic and diastolic blood pressure, fasting glucose, and body mass index (BMI) prior to, during, and following childbearing years using generalized estimating equations, allowing for interaction between maltreatment and time within each segment, and adjusting for total parity, parental education, and race (Black or white, self-reported). RESULTS: Individuals reporting maltreatment (19%; 141) had a greater waist circumference (post-childbearing: +2.9 cm, 95% CI (0.7, 5.0), higher triglycerides [post-childbearing: +8.1 mg/dL, 95% CI (0.7, 15.6)], and lower HDL cholesterol [post-childbearing: -2.1 mg/dL, 95% CI (-4.7, 0.5)] during all stages compared to those not reporting maltreatment. There were not meaningful differences in blood pressure, fasting glucose, or BMI. Individuals who reported maltreatment did not report faster changes over time. CONCLUSION: Differences in some aspects of cardiometabolic health between individuals reporting versus not reporting childhood maltreatment were sustained across reproductive life stages, suggesting potentially persistent impacts of childhood adversity.

Associations of Clinical and Social Risk Factors With Racial Differences in Premature Cardiovascular Disease.

BACKGROUND: Racial differences in cardiovascular disease (CVD) are likely related to differences in clinical and social factors. The relative contributions of these factors to Black-White differences in premature CVD have not been investigated. METHODS: In Black and White adults aged 18 to 30 years at baseline in the CARDIA study (Coronary Artery Risk Development in Young Adults), the associations of clinical, lifestyle, depression, socioeconomic, and neighborhood factors across young adulthood with racial differences in incident premature CVD were evaluated in sex-stratified, multivariable-adjusted Cox proportional hazards models using multiply imputed data assuming missing at random. Percent reduction in the ß estimate (log-hazard ratio [HR]) for race quantified the contribution of each factor group to racial differences in incident CVD. RESULTS: Among 2785 Black and 2327 White participants followed for a median 33.9 years (25th-75th percentile, 33.7-34.0), Black (versus White) adults had a higher risk of incident premature CVD (Black women: HR, 2.44 [95% CI, 1.71-3.49], Black men: HR, 1.59 [1.20-2.10] adjusted for age and center). Racial differences were not statistically significant after full adjustment (Black women: HR, 0.91 [0.55-1.52], Black men: HR 1.02 [0.70-1.49]). In women, the largest magnitude percent reduction in the ß estimate for race occurred with adjustment for clinical (87%), neighborhood (32%), and socioeconomic (23%) factors. In men, the largest magnitude percent reduction in the ß estimate for race occurred with an adjustment for clinical (64%), socioeconomic (50%), and lifestyle (34%) factors. CONCLUSIONS: In CARDIA, the significantly higher risk for premature CVD in Black versus White adults was statistically explained by adjustment for antecedent multilevel factors. The largest contributions to racial differences were from clinical and neighborhood factors in women, and clinical and socioeconomic factors in men.

Depressive Symptom Subgroups and Their Association with Prevalent and Incident Cardiovascular Risk Factors in the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

BACKGROUND: We sought to identify depressive symptom subgroups in a community sample of young adults, investigate their stability over time, and determine their association with prevalent and incident cardiovascular disease (CVD) risk factors. METHOD: Participants were 3377 adults from the Coronary Artery Risk Development in Young Adults study. Using latent class and latent transition analysis, we derived subgroups based on items of the 20-item version of the Center for Epidemiologic Studies Depression Scale in 1990, and examined patterns of change over a 10-year period (1990-2000). Cox regression models were used to examine associations between subgroup membership and prevalent (2000) and incident (2000 to 2016) obesity, hypertension, and diabetes. RESULTS: Three baseline subgroups were identified and labeled: "No Symptoms" (63.5%), "Lack of Positive Affect" (PA, 25.6%), and "Depressed Mood" (10.9%). At 10-year follow-up, individuals in "No Symptoms" subgroup had the highest probability (0.84) of being classified within the same subgroup. Participants classified as "Lack of PA" were likely (0.46) to remain in the same subgroup or be classified as "No Symptoms." Participants in the "Depressed Mood" were most likely to transition to the "Lack of PA" subgroup (0.38). Overall, 30.5% of participants transitioned between subgroups, with 11.4% classified as "Worsening" and 19.1% as "Improving." Relative to the "No Symptoms Stable," other subgroups ("Depressed Stable," "Worsening," and "Improving") were associated with prevalent obesity and hypertension. CONCLUSION: We identified distinct depressive symptom subgroups that are variably stable over time, and their change patterns were differentially associated with CVD risk factor prevalence.

Alcohol Use and Blood Pressure Among Adults with Hypertension: the Mediating Roles of Health Behaviors.

BACKGROUND: Alcohol use is associated with increased blood pressure among adults with hypertension, but it is unknown whether some of the observed relationship is explained by mediating behaviors related to alcohol use. OBJECTIVE: We assess the potential indirect role of smoking, physical inactivity, unhealthy diet, and poor medication adherence on the association between alcohol use and blood pressure among Black and White men and women with hypertension. DESIGN: Adjusted repeated-measures analyses using generalized estimating equations and mediation analyses using inverse odds ratio weighting. PARTICIPANTS: 1835 participants with hypertension based on ACC/AHA 2017 guidelines in three most recent follow-up exams of the longitudinal Coronary Artery Risk Development in Young Adults cohort study (2005-2016). MAIN MEASURES: Alcohol use was assessed using both self-reported average ethanol intake (drinks/day) and engagement in heavy episodic drinking (HED) in the past 30 days. Systolic and diastolic blood pressure (SBP, DBP) were measured by trained technicians (mmHg). Smoking, physical inactivity, and diet were self-reported and categorized according to American Heart Association criteria, and medication adherence was assessed using self-reported typical adherence to antihypertensive medications. KEY RESULTS: At baseline (2005-2006), 57.9% of participants were Black and 51.4% were women. Mean age (standard deviation) was 45.5 (3.6) years, mean SBP was 128.7 (15.5) mmHg, and mean DBP was 83.2 (10.1) mmHg. Each additional drink per day was significantly associated with higher SBP (ß = 0.713 mmHg, 95% confidence interval (CI): 0.398, 1.028) and DBP (ß = 0.398 mmHg, 95% CI: 0.160, 0.555), but there was no evidence of mediation by any of the behaviors. HED was not associated with blood pressure independent of average consumption. CONCLUSIONS: These findings support the direct nature of the association of alcohol use with blood pressure and the utility of advising patients with hypertension to limit consumption in addition to other behavioral and pharmacological interventions.

Presence of Geriatric Conditions Is Prognostic of Major Bleeding in Older Patients with Atrial Fibrillation: a Cohort Study.

BACKGROUND: In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. OBJECTIVE: To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. DESIGN: Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. PARTICIPANTS: Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. MAIN MEASURES: A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. KEY RESULTS: At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02-2.56) and frailty (HR 2.77, 95% CI 1.38-5.58) were significantly associated with the development of major bleeding. CONCLUSIONS: In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.

Psychosocial profiles and longitudinal achievement of optimal cardiovascular risk factor levels: the Coronary Artery Risk Development in Young Adults (CARDIA) study.

Psychosocial factors are associated with the achievement of optimal cardiovascular disease risk factor (CVDRF) levels. To date, little research has examined multiple psychosocial factors simultaneously to identify distinguishing psychosocial profiles among individuals with CVDRF. Further, it is unknown whether profiles are associated with achievement of CVDRF levels longitudinally. Therefore, we characterized psychosocial profiles of individuals with CVDRF and assessed whether they are associated with achievement of optimal CVDRF levels over 15 years. We included 1148 CARDIA participants with prevalent hypertension, hypercholesterolemia and/or diabetes mellitus in 2000-2001. Eleven psychosocial variables reflecting psychological health, personality traits, and social factors were included. Optimal levels were deemed achieved if: Hemoglobin A1c (HbA1c) < 7.0%, low-density lipoprotein (LDL) cholesterol < 100 mg/dl, and systolic blood pressure (SBP) < 140 mm Hg. Latent profile analysis revealed three psychosocial profile groups "Healthy", "Distressed and Disadvantaged" and "Discriminated Against". There were no significant differences in achievement of CVDRF levels of the 3 targets combined across profiles. Participants in the "Distressed and Disadvantaged" profile were less likely to meet optimal HbA1c levels compared to individuals in the "Healthy" profile after demographic adjustment. Associations were attenuated after full covariate adjustment. Distinct psychosocial profiles exist among individuals with CVDRF, representing meaningful differences. Implications for CVDRF management are discussed.

Racial differences in the association of accelerated aging with future cardiovascular events and all-cause mortality: the coronary artery risk development in young adults study, 2007-2018.

OBJECTIVE: Variability of Cardiovascular disease (CVD) risk, including racial difference, is not fully accounted for by the variability of traditional CVD risk factors. We used a multiple biomarker model as a framework to explore known racial differences in CVD burden. DESIGN: We measured associations between accelerated aging (AccA) measured by a combination of biomarkers, and cardiovascular morbidity and all-cause mortality using data from the Coronary Artery Risk Development in Young Adults study (CARDIA). AccA was defined as the difference between biological age, calculated using biomarkers with the Klemera and Doubal method, and chronological age. Using logistic regression, we assessed overall and race-specific associations between AccA, CVD, and all-cause mortality. RESULTS: Among our cohort of 2959 Black or White middle-aged adults, after adjustment, a one-year increase in AccA was associated with increased odds of CVD (Odds Ratio (OR) = 1.04; 95% CI: 1.02, 1.06), stroke (OR = 1.12; 95% CI: 1.07, 1.17), and all-cause mortality (OR = 1.05; 95% CI: 1.02, 1.08). We did not find significant overall racial differences, but we did find race by sex differences where Black men differed markedly from White men in the strength of association with CVD (OR = 1.06, 95% CI: 1.01, 1.12). CONCLUSIONS: We provide evidence that AccA is associated with future CVD.

Complex Patients Have More Emergency Visits: Don't Punish the Systems That Serve Them.

IMPORTANCE: Better patient management can reduce emergency department (ED) use. Performance measures should reward plans for reducing utilization by predictably high-use patients, rather than rewarding plans that shun them. OBJECTIVE: The objective of this study was to develop a quality measure for ED use for people diagnosed with serious mental illness or substance use disorder, accounting for both medical and social determinants of health (SDH) risks. DESIGN: Regression modeling to predict ED use rates using diagnosis-based and SDH-augmented models, to compare accuracy overall and for vulnerable populations. SETTING: MassHealth, Massachusetts' Medicaid and Children's Health Insurance Program. PARTICIPANTS: MassHealth members ages 18-64, continuously enrolled for the calendar year 2016, with a diagnosis of serious mental illness or substance use disorder. EXPOSURES: Diagnosis-based model predictors are diagnoses from medical encounters, age, and sex. Additional SDH predictors describe housing problems, behavioral health issues, disability, and neighborhood-level stress. MAIN OUTCOME AND MEASURES: We predicted ED use rates: (1) using age/sex and distinguishing between single or dual diagnoses; (2) adding summarized medical risk (DxCG); and (3) further adding social risk (SDH). RESULTS: Among 144,981 study subjects, 57% were women, 25% dually diagnosed, 67% White/non-Hispanic, 18% unstably housed, and 37% disabled. Utilization was higher by 77% for those dually diagnosed, 50% for members with housing problems, and 18% for members living in the highest-stress neighborhoods. SDH modeling predicted best for these high-use populations and was most accurate for plans with complex patients. CONCLUSION: To set appropriate benchmarks for comparing health plans, quality measures for ED visits should be adjusted for both medical and social risks.

Non-specific pain and 30-day readmission in acute coronary syndromes: findings from the TRACE-CORE prospective cohort.

BACKGROUND: Patients with acute coronary syndromes often experience non-specific (generic) pain after hospital discharge. However, evidence about the association between post-discharge non-specific pain and rehospitalization remains limited. METHODS: We analyzed data from the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) prospective cohort. TRACE-CORE followed patients with acute coronary syndromes for 24 months post-discharge from the index hospitalization, collected patient-reported generic pain (using SF-36) and chest pain (using the Seattle Angina Questionnaire) and rehospitalization events. We assessed the association between generic pain and 30-day rehospitalization using multivariable logistic regression (N = 787). We also examined the associations among patient-reported pain, pain documentation identified by natural language processing (NLP) from electronic health record (EHR) notes, and the outcome. RESULTS: Patients were 62 years old (SD = 11.4), with 5.1% Black or Hispanic individuals and 29.9% women. Within 30 days post-discharge, 87 (11.1%) patients were re-hospitalized. Patient-reported mild-to-moderate pain, without EHR documentation, was associated with 30-day rehospitalization (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.14-3.62, reference: no pain) after adjusting for baseline characteristics; while patient-reported mild-to-moderate pain with EHR documentation (presumably addressed) was not (OR: 1.23, 95% CI: 0.52-2.90). Severe pain was also associated with 30-day rehospitalization (OR: 3.16, 95% CI: 1.32-7.54), even after further adjusting for chest pain (OR: 2.59, 95% CI: 1.06-6.35). CONCLUSIONS: Patient-reported post-discharge generic pain was positively associated with 30-day rehospitalization. Future studies should further disentangle the impact of cardiac and non-cardiac pain on rehospitalization and develop strategies to support the timely management of post-discharge pain by healthcare providers.

Recurrence and Mortality of Melanoma In Situ of the Trunk or Extremities: A Surveillance, Epidemiology, and End Results Analysis.

BACKGROUND: Recent studies demonstrate comparable outcomes of Mohs micrographic surgery (MMS) versus local excision (LE) for melanoma in situ. These studies are limited by their focus on the head and neck. OBJECTIVE: The primary objective was to compare 5-year overall and melanoma-specific mortality among patients with melanoma in situ of the trunk or extremities who undergo MMS versus LE. The secondary objective was to compare 5-year local recurrence among the same cohort of patients who undergo MMS versus LE. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results (SEER) database (2000-2015) was queried to identify patients who underwent MMS versus LE for melanoma in situ of the trunk, upper extremities, or lower extremities. Outcomes were 5-year recurrence, melanoma-specific mortality, and overall mortality. Multivariable regression analyses were performed. RESULTS: Thirty three thousand nine hundred eighty-three patients underwent surgical treatment (MMS 3%; LE 97%). In adjusted analyses, there was no difference in local recurrence (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.56-1.78), melanoma-specific mortality (HR 0.89, 95% CI 0.12-6.47), nor overall mortality (HR 1.10, 95% CI 0.82-1.48) between MMS versus LE. CONCLUSION: There is no difference of 5-year local recurrence, melanoma-specific mortality, nor overall mortality associated with MMS versus LE for melanoma in situ of the trunk or extremities.

Association between incarceration and incident cardiovascular disease events: results from the CARDIA cohort study.

BACKGROUND: Incarceration has been associated with higher cardiovascular risk, yet data evaluating its association with cardiovascular disease events are limited. The study objective was to evaluate the association between incarceration and incident fatal and non-fatal cardiovascular disease (CVD) events. METHODS: Black and white adults from the community-based Coronary Artery Risk Development in Young Adult (CARDIA) study (baseline 1985-86, n = 5105) were followed through August 2017. Self-reported incarceration was measured at baseline (1985-1986) and Year 2 (1987-1988), and fatal and non-fatal cardiovascular disease events, including coronary heart disease, stroke, and heart failure, and all-cause mortality, were captured through 2017. Analyses were completed in September 2019. Cumulative CVD incidence rates and Cox proportional hazards were compared overall by incarceration status. An interaction between incarceration and race was identified, so results were also analyzed by sex-race groups. RESULTS: 351 (6.9%) CARDIA participants reported a history of incarceration. Over 29.0 years mean follow-up, CVD incidence rate was 3.52 per 1000 person-years in participants with a history of incarceration versus 2.12 per 1000 person-years in participants without a history of incarceration (adjusted HR = 1.33 [95% CI, 0.90-1.95]). Among white men, incarceration was associated with higher risk of incident cardiovascular disease (adjusted HR = 3.35 [95% CI, 1.54-7.29) and all-cause mortality (adjusted HR = 2.52 [95% CI, 1.32-4.83]), but these associations were not statistically significant among other sex-race groups after adjustment. CONCLUSIONS: Incarceration was associated with incident cardiovascular disease rates, but associations were only significant in one sex-race group after multivariable adjustment.

Associations of Income Volatility With Incident Cardiovascular Disease and All-Cause Mortality in a US Cohort.

BACKGROUND: Income volatility is on the rise and presents a growing public health problem. Because in many epidemiological studies income is measured at a single point in time, the association of long-term income volatility with incident cardiovascular disease (CVD) and mortality has not been adequately explored. The goal of this study was to examine associations of income volatility from 1990 to 2005 with incident CVD and all-cause mortality in the subsequent 10 years. METHODS: The Coronary Artery Risk Development in Young Adults Study is an ongoing prospective cohort study conducted within urban field centers in Birmingham, AL; Chicago, IL; Minneapolis, MN; and Oakland, CA. We studied 3937 black and white participants 23 to 35 years of age in 1990 (our study baseline). Income volatility was defined as the intraindividual SD of the percent change in income across 5 assessments from 1990 to 2005. An income drop was defined as a decrease of ≥25% from the previous visit and less than the participant's average income from 1990 to 2005. CVD events (fatal and nonfatal) and all-cause mortality between 2005 and 2015 were adjudicated with the use of medical records and death certificates. CVD included primarily acute events related to heart disease and stroke. RESULTS: A total of 106 CVD events and 164 deaths occurred between 2005 and 2015 (incident rate, 2.76 and 3.66 per 1000 person-years, respectively). From Cox models adjusted for sociodemographic, behavioral, and CVD risk factors, higher income volatility and more income drops were associated with greater CVD risk (high versus low volatility: hazard ratio, 2.07; 95% CI, 1.10-3.90; ≥2 versus 0 income drops: hazard ratio, 2.54; 95% CI, 1.24-5.19) and all-cause mortality (high versus low volatility: hazard ratio, 1.78; 95% CI,1.03-3.09; ≥2 versus 0 income drops: hazard ratio, 1.92; 95% CI, 1.07-3.44). CONCLUSIONS: In a cohort of relatively young adults, income volatility and drops during a 15-year period of formative earning years were independently associated with a nearly 2-fold risk of CVD and all-cause mortality.

Religiosity and Patient Activation Among Hospital Survivors of an Acute Coronary Syndrome.

BACKGROUND: Optimum management after an acute coronary syndrome (ACS) requires considerable patient engagement/activation. Religious practices permeate people's lives and may influence engagement in their healthcare. Little is known about the relationship between religiosity and patient activation. OBJECTIVE: To examine the association between religiosity and patient activation in hospital survivors of an ACS. DESIGN: Secondary analysis using baseline data from Transitions, Risks, and Actions in Coronary Events: Center for Outcomes Research and Education (TRACE-CORE) Study. PARTICIPANTS: A total of 2067 patients hospitalized for an ACS at six medical centers in Central Massachusetts and Georgia (2011-2013). MAIN MEASURES: Study participants self-reported three items assessing religiosity-strength and comfort from religion, making petition prayers, and awareness of intercessory prayers for health. Patient activation was assessed using the 6-item Patient Activation Measure (PAM-6). Participants were categorized as either having low (levels 1 and 2) or high (levels 3 and 4) activation. RESULTS: The mean age of study participants was 61 years, 33% were women, and 81% were non-Hispanic White. Approximately 85% derived strength and comfort from religion, 61% prayed for their health, and 89% received intercessory prayers for their health. Overall, 58% had low activation. Reports of a great deal (aOR, 2.02; 95% CI, 1.44-2.84), and little/some (aOR, 1.45; 95% CI, 1.07-1.98) strength and comfort from religion were associated with high activation, as were receipt of intercessions (aOR, 1.48; 95% CI, 1.07-2.05). Praying for one's health was associated with low activation (aOR, 0.78; 95% CI, 0.61-0.99). CONCLUSIONS: Most ACS survivors acknowledge religious practices toward their recovery. Strength and comfort from religion and intercessory prayers for health were associated with high patient activation. Petition prayers for health were associated with low activation. Healthcare providers should use knowledge about patient's religiosity to enhance patient engagement in their care.

Education, Race/Ethnicity, and Causes of Premature Mortality Among Middle-Aged Adults in 4 US Urban Communities: Results From CARDIA, 1985-2017.

Objectives. To assess causes of premature death and whether race/ethnicity or education is more strongly and independently associated with premature mortality in a diverse sample of middle-aged adults in the United States.Methods. The Coronary Artery Risk Development in Young Adults study (CARDIA) is a longitudinal cohort study of 5114 participants recruited in 1985 to 1986 and followed for up to 29 years, with rigorous ascertainment of all deaths; recruitment was balanced regarding sex, Black and White race/ethnicity, education level (high school or less vs. greater than high school), and age group (18-24 and 25-30 years). This analysis included all 349 deaths that had been fully reviewed through month 348. Our primary outcome was years of potential life lost (YPLL).Results. The age-adjusted mortality rate per 1000 persons was 45.17 among Black men, 25.20 among White men, 17.63 among Black women, and 10.10 among White women. Homicide and AIDS were associated with the most YPLL, but cancer and cardiovascular disease were the most common causes of death. In multivariable models, each level of education achieved was associated with 1.37 fewer YPLL (P = .007); race/ethnicity was not independently associated with YPLL.Conclusions. Lower education level was an independent predictor of greater YPLL.

Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach.

BACKGROUND: Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS: We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS: Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION: Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS: Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).

Impact of comorbid conditions on disease-specific quality of life in older men and women with atrial fibrillation.

BACKGROUND: Older persons with atrial fibrillation (AF) experience significant impairment in quality of life (QoL), which may be partly attributable to their comorbid diseases. A greater understanding of the impact of comorbidities on QoL could optimize patient-centered care among older persons with AF. OBJECTIVE: To assess impairment in disease-specific QoL due to comorbid conditions in older adults with AF. METHODS: Patients aged ≥ 65 years diagnosed with AF were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. At 1 year of follow-up, the Quality of Life Disease Impact Scale-for Multiple Chronic Conditions was used to provide standardized assessment of patient self-reported impairment in QoL attributable to 34 comorbid conditions grouped in 10 clusters. RESULTS: The mean age of study participants (n = 1097) was 75 years and 48% were women. Overall, cardiometabolic, musculoskeletal, and pulmonary conditions were the most prevalent comorbidity clusters. A high proportion of participants (82%) reported that musculoskeletal conditions exerted the greatest impact on their QoL. Men were more likely than women to report that osteoarthritis and stroke severely impacted their QoL. Patients aged < 75 years were more likely to report that obesity, hip/knee joint problems, and fibromyalgia extremely impacted their QoL than older participants. CONCLUSIONS: Among older persons with AF, while cardiometabolic diseases were highly prevalent, musculoskeletal conditions exerted the greatest impact on patients' disease-specific QoL. Understanding the extent of impairment in QoL due to underlying comorbidities provides an opportunity to develop interventions targeted at diseases that may cause significant impairment in QoL.

Multimorbidity, physical frailty, and self-rated health in older patients with atrial fibrillation.

BACKGROUND: Holistic care models emphasize management of comorbid conditions to improve patient-reported outcomes in treatment of atrial fibrillation (AF). We investigated relations between multimorbidity, physical frailty, and self-rated health (SRH) among older adults with AF. METHODS: Patients (n = 1235) with AF aged 65 years and older were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. Ten previously diagnosed cardiometabolic and 8 non-cardiometabolic conditions were assessed from medical records. Physical Frailty was assessed with the Cardiovascular Health Study frailty scale. SRH was categorized as either "excellent/very good", "good", and "fair/poor". Separate multivariable ordinal logistic models were used to examine the associations between multimorbidity and SRH, physical frailty and SRH, and multimorbidity and physical frailty. RESULTS: Overall, 16% of participants rated their health as fair/poor and 14% were frail. Hypertension (90%), dyslipidemia (80%), and heart failure (37%) were the most prevalent cardiometabolic conditions. Arthritis (51%), anemia (31%), and cancer (30%), the most common non-cardiometabolic diseases. After multivariable adjustment, patients with higher multimorbidity were more likely to report poorer health status (Odds Ratio (OR): 2.15 [95% CI: 1.53-3.03], ≥ 8 vs 1-4; OR: 1.37 [95% CI: 1.02-1.83], 5-7 vs 1-4), as did those with more prevalent cardiometabolic and non-cardiometabolic conditions. Patients who were pre-frail (OR: 1.73 [95% CI: 1.30-2.30]) or frail (OR: 6.81 [95% CI: 4.34-10.68]) reported poorer health status. Higher multimorbidity was associated with worse frailty status. CONCLUSIONS: Multimorbidity and physical frailty were common and related to SRH. Our findings suggest that holistic management approaches may influence SRH among older patients with AF.

Adherence to 20 Emergency General Surgery Best Practices: Results of a National Survey.

OBJECTIVE: To examine national adherence to emergency general surgery (EGS) best practices. BACKGROUND: There is a national crisis in access to high-quality care for general surgery emergencies. Acute care surgery (ACS), a specialty leveraging strengths of trauma systems, may ameliorate this crisis. A critical component of trauma care is adherence to clinical guidelines. We previously established best practices for EGS using RAND Appropriateness Methodology and pilot data. METHOD: A hybrid (postal/electronic) questionnaire measuring adherence to 20 EGS best practices was administered to respondents overseeing EGS at all eligible adult acute care general hospitals across the US (N = 2811). Questionnaire responses were analyzed using bivariate methods and multiple logistic regression. RESULTS: The response rate was 60.1%. Adherence ranged from 8.5% for having an EGS registry to 86.2% for auditing 30-day postoperative readmissions. Adherence was higher for practices not restricted to EGS (eg, auditing readmissions) compared to EGS-specific practices (eg, registry, activation system). Adopting an ACS model of care increased adherence to practices for deferring elective cases; tiering urgent operations; following National Comprehensive Cancer Network guidelines; reversing anticoagulants; auditing returns to intensive care, time to evaluation, time to operation, and time to source control; and having transfer agreements to receive patients, ICU admission protocols, as well as EGS-specific activation systems, outpatient clinics, morbidity and mortality conferences, and registries. CONCLUSIONS: There is substantial room for performance improvement, and adopting an ACS model predicts better performance. This novel overview of adherence to EGS best practices will enable surgeons and policymakers to address variations in EGS care nationally.

Twenty-five year trends (1986-2011) in hospital incidence and case-fatality rates of ventricular tachycardia and ventricular fibrillation complicating acute myocardial infarction.

BACKGROUND: Long-term trends in the incidence rates (IRs) and hospital case-fatality rates (CFRs) of ventricular tachycardia (VT) and ventricular fibrillation (VF) among patients hospitalized with acute myocardial infarction (AMI) have not been recently examined. METHODS: We used data from 11,825 patients hospitalized with AMI at all 11 medical centers in central Massachusetts on a biennial basis between 1986 and 2011. Multivariable adjusted logistic regression modeling was used to examine trends in hospital IRs and CFRs of VT and VF complicating AMI. RESULTS: The median age of the study population was 71 years, 57.9% were men, and 94.7% were white. The hospital IRs declined from 14.3% in 1986/1988 to 10.5% in 2009/2011 for VT and from 8.2% to 1.7% for VF. The in-hospital CFRs declined from 27.7% to 6.9% for VT and from 49.6% to 36.0% for VF between 1986/1988 and 2009/2011, respectively. The IRs of both early (<48 hours) and late VT and VF declined over time, with greater declines in those of late VT and VF. The incidence rates of VT declined similarly for patients with either an ST-segment elevation myocardial infarction (STEMI) or non-STEMI, whereas they only declined in those with VF and a STEMI. CONCLUSIONS: The hospital IRs and CHRs of VT and VF complicating AMI have declined over time, likely because of changes in acute monitoring and treatment practices. Despite these encouraging trends, efforts remain needed to identify patients at risk for these serious ventricular arrhythmias so that preventive and treatment strategies might be implemented as necessary.

Evaluating Longitudinal Associations Between Depressive Symptoms, Smoking, and Biomarkers of Cardiovascular Disease in the CARDIA Study.

OBJECTIVE: The aim of the study was to evaluate associations between 15-year trajectories of co-occurring depressive symptoms and smoking with biomarkers of cardiovascular disease at year 15. METHODS: In the Coronary Artery Risk Development in Young Adults study, we modeled trajectories of depressive symptoms (Center for Epidemiologic Studies-Depression scale [CES-D]) and smoking (cigarettes per day [CPD]) among 3614 adults followed from year 0 (ages 18-30 years) through year 15 (ages 33-45 years). Biomarkers of inflammation (high-sensitivity C-reactive protein), oxidative stress (superoxide dismutase, F2-isoprostanes), and endothelial dysfunction (soluble intercellular adhesion molecule 1, soluble P-selectin) were assessed at year 15. We conducted separate linear regression analyses with CES-D trajectory, CPD trajectory, and their interaction with each of the five biomarkers. RESULTS: The sample was 56% women, 47% black, and 40 years old on average at year 15. The CES-D trajectory by CPD trajectory interaction was not associated with any of the biomarkers (all p's > .01). Removing the interaction term, CES-D trajectory was associated with inflammation: higher levels of high-sensitivity C-reactive protein were observed in the subthreshold (ß = 0.57, p = .004) and increasing depressive symptoms (ß = 1.36, p < .001) trajectories compared with the no depression trajectory. CPD trajectory was associated with oxidative stress and endothelial dysfunction: compared with never smokers, heavy smokers had significantly higher levels of F2-isoprostanes (ß = 6.20, p = .001), soluble intercellular adhesion molecule 1 (ß = 24.98, p < .001), and soluble P-selectin (ß = 2.91, p < .001). CONCLUSIONS: Co-occurring depressive symptoms and smoking do not seem to synergistically convey risk for cardiovascular disease via processes of inflammation, oxidative stress, or endothelial dysfunction. Nonetheless, these results advance our understanding of the complex relationships between modifiable risk factors and chronic disease.