Preventable hospitalizations for hypertension: establishing a baseline for monitoring racial differences in rates.

INTRODUCTION: Preventable hospitalization for hypertension is an ambulatory care-sensitive condition believed to indicate the failure of outpatient and public health systems to prevent and control hypertension. Blacks have higher rates of such hospitalizations than whites. The 2010 Patient Protection and Affordable Care Act (PPACA) seeks to implement higher quality health care, which may help close the racial gap in these rates. The objective of this study was to analyze pre-PPACA baseline rates of preventable hypertension hospitalizations in the United States and racial differences over time. METHODS: We used data from the 1995-2010 National Hospital Discharge Survey, a stratified, probability-designed survey representing approximately 1% of hospitalizations in the United States. Rates were calculated using specifications published by the Agency for Healthcare Research and Quality requiring census data as denominators for the rates. We combined at least 3 years of data to obtain more precise estimates and conducted a trend analysis by using rates calculated for each of the resulting 5 periods. RESULTS: For both sexes, all age groups, and each period, blacks had higher crude rates than whites. Age- and sex-standardized rates confirmed this finding (eg, 2007-2010: blacks, 334 per 100,000; whites, 97.4 per 100,000). Rates were generally flat over time; however, white women aged 65 or older showed increasing rates. CONCLUSION: Using national data, we confirmed higher rates of preventable hypertension hospitalizations for blacks, showing little improvement in disparities over time. This pre-PPACA baseline for blacks and whites allows for ongoing monitoring of preventable hospitalizations for hypertension.

Preventable hospitalizations and emergency department visits for angina, United States, 1995-2010.

INTRODUCTION: Preventable hospitalizations for angina have been decreasing since the late 1980s - most likely because of changes in guidance, physician coding practices, and reimbursement. We asked whether this national decline has continued and whether preventable emergency department visits for angina show a similar decline. METHODS: We used National Hospital Discharge Survey data from 1995 through 2010 and National Hospital Ambulatory Medical Care Survey data from 1995 through 2009 to study preventable hospitalizations and emergency department visits, respectively. We calculated both crude and standardized rates for these visits according to technical specifications published by the Agency for Healthcare Research and Quality, which uses population estimates from the US Census Bureau as the denominator for the rates. RESULTS: Crude hospitalization rates for angina declined from 1995-1998 to 2007-2010 for men and women in all 3 age groups (18-44, 45-64, and ≥65) and age- and sex-standardized rates declined in a linear fashion (P = .02). Crude rates for preventable emergency department visits for angina declined for men and women aged 65 or older from 1995-1998 to 2007-2009. Age- and sex-standardized rates for these visits showed a linear decline (P = .05). CONCLUSION: We extend previous research by showing that preventable hospitalization rates for angina have continued to decline beyond the time studied previously. We also show that emergency department visits for the same condition have also declined during the past 15 years. Although these declines are probably due to changes in diagnostic practices in the hospitals and emergency departments, more studies are needed to fully understand the reasons behind this phenomenon.

Preventable hospitalizations for congestive heart failure: establishing a baseline to monitor trends and disparities.

INTRODUCTION: Preventable hospitalization for congestive heart failure (CHF) is believed to capture the failure of the outpatient health care system to properly manage and treat CHF. In anticipation of changes in the national health care system, we report baseline rates of these hospitalizations and describe trends by race over 15 years. METHODS: We used National Hospital Discharge Survey data from 1995 through 2009, which represent approximately 1% of hospitalizations in the United States each year. We calculated age-, sex-, and race-stratified rates and age- and sex-standardized rates for preventable CHF hospitalizations on the basis of the Agency for Healthcare Research and Quality's specifications, which use civilian population estimates from the US Census Bureau as the denominator for rates. RESULTS: Approximately three-fourths of the hospitalizations occurred among people aged 65 years or older. In each subgroup and period, rates were significantly higher (P < .05) for blacks than whites. Only black men aged 18 to 44 showed a linear increase (P = .004) in crude rates across time. Subpopulations aged 65 or older, except black men, showed a linear decrease (P < .05) in crude rates over time. Age- and sex-standardized rates showed a significant linear decrease in rates for whites (P = .01) and a borderline decrease for blacks (P = .06) CONCLUSION: Before implementation of the Patient Protection and Affordable Care Act, we found that blacks were disproportionately affected by preventable CHF hospitalizations compared with whites. Our results confirm recent findings that preventable CHF hospitalization rates are declining in whites more than blacks. Alarmingly, rates for younger black men are on the rise.

Association Between Self-Reported Hypertension and Antihypertensive Medication Use and Cardiovascular Disease-Related Events and Expenditures Among Patients Diagnosed With Hypertension.

OBJECTIVES: Research suggests that persons who are aware of the risk factors for cardiovascular disease (CVD) are more likely to engage in healthy behaviors than persons who are not aware of the risk factors. We examined whether patients whose insurance claims included an International Classification of Diseases, Ninth Revision (ICD-9) code associated with hypertension who self-reported high blood pressure were more likely to fill antihypertensive medication prescriptions and less likely to have CVD-related emergency department visits and hospitalizations (hereinafter, CVD-related events) and related medical expenditures than patients with these codes who did not self-report high blood pressure. METHODS: We used a large convenience sample from the MarketScan Commercial Database linked with the MarketScan Health Risk Assessment (HRA) Database to identify patients aged 18-64 in the United States whose insurance claims included an ICD-9 code associated with hypertension and who completed an HRA from 2008 through 2012 (n = 111 655). We used multivariate logistic regression analysis to examine the association between self-reported high blood pressure and (1) filling prescriptions for antihypertensive medications and (2) CVD-related events. Because most patients with hypertension will not have a CVD-related event, we used a 2-part model to analyze medical expenditures. The first part estimated the likelihood of a CVD-related event, and the second part estimated expenditures. RESULTS: Patients with an ICD-9 code of hypertension who self-reported high blood pressure had a significantly higher predicted probability of filling antihypertensive medication prescriptions (26.5%; 95% confidence interval, 25.7-27.3; P < .001), had a significantly lower predicted probability of a CVD-related event (0.6%, P < .001), and on average spent significantly less on CVD-related events ($251, P = .01) than patients who did not self-report high blood pressure. CONCLUSION: This study affirms that self-knowledge of high blood pressure, even among patients who are diagnosed and treated for hypertension, can be improved. Interventions that improve patients' awareness of their hypertension may improve antihypertensive medication use and reduce adverse CVD-related events.

The WISEWOMAN program: reflection and forecast.

The WISEWOMAN program targets low-income under- and uninsured women aged 40-64 years for screening and interventions aimed at reducing the risk of heart disease, stroke, and other chronic diseases. The program enters its third phase on June 30, 2008. Design issues and results from Phase I and Phase II have been published in a series of papers. We summarize remaining challenges, which were identified through systematic research and evaluation. Phase III will address these challenges through a number of new initiatives such as allowing interventions of different intensities, taking advantage of resources for promoting community health, and providing evidence-based interventions through the program's Center of Excellence. Finally, we provide a framework and vision so that organizational, community, and other partners can make the case for the importance of the program to their communities and for what is needed to make it work.

Beyond effectiveness: evaluating the public health impact of the WISEWOMAN program.

Interventions that are effective are often improperly or only partially implemented when put into practice. When intervention programs are evaluated, feasibility of implementation and effectiveness need to be examined. Reach, effectiveness, adoption, implementation, and maintenance make up the RE-AIM framework used to assess such programs. To examine the usefulness of this metric, we addressed 2 key research questions. Is it feasible to operationalize the RE-AIM framework using women's health program data? How does the determination of a successful program differ if the criterion is (1) effectiveness alone, (2) reach and effectiveness, or (3) the 5 dimensions of the RE-AIM framework? Findings indicate that it is feasible to operationalize the RE-AIM concepts and that RE-AIM may provide a richer measure of contextual factors for program success compared with other evaluation approaches.

Ethnicity and nutrient intake among Arizona WISEWOMAN participants.

BACKGROUND: Diet quality and risks of chronic disease have been identified, yet nutrient intakes from older uninsured populations have been scarcely described. METHODS: Using the dietary intake profiles of an older, uninsured, and mostly Hispanic sample of Arizona WISEWOMAN participants, two ethnic groups were compared: Mexican American and non-Hispanic white women. Sociodemographic data related to nutrient intakes were identified. Estimated mean nutrient intakes of Mexican Americans (n = 260) and non-Hispanic white (n = 88) women were compared based on ethnicity and acculturation levels. Using linear regression models, associations of individual characteristics were made on nutrients for which reported intakes were less than the estimated average requirement (EAR). RESULTS: Mexican Americans had energy, vitamin E, and niacin intakes that were significantly lower than those of non-Hispanic whites, whereas vitamin A intake was significantly higher among Mexican Americans. Less acculturated Mexican American women had significantly higher intakes of vitamin E and folate than their more acculturated counterparts. For both ethnic and acculturation groups, intakes of vitamin E, calcium, and potassium were lower than the established standards in more than 70% of this population. Having a high body mass index (BMI) was associated with lower reported energy intake and higher protein and potassium intakes, and smoking was associated with lower intakes of vitamin E and folate. CONCLUSIONS: Mexican American women had overall lower micronutrient intakes compared with uninsured non-Hispanic white older women; this difference may be attributed to their underreporting intake.

A captive audience: bringing the WISEWOMAN program to South Dakota prisoners.

PURPOSE: This analysis compares the baseline heart disease risk profile of WISEWOMAN participants screened in the South Dakota Women's Prison with the general WISEWOMAN population in South Dakota and explores the potential benefits of lifestyle intervention programs to reduce heart disease risk factors among women during incarceration. METHODS: Using baseline data for WISEWOMAN participants in South Dakota, we compared participants who were enrolled in prison (n = 261) with nonincarcerated participants enrolled throughout the state (n = 1,427). Using regression analysis and adjusting for demographics, we assessed differences in baseline prevalence of risk factors (hypertension, high cholesterol, smoking, and obesity), awareness and treatment of hypertension and high cholesterol, and attendance at lifestyle intervention sessions. RESULTS: Incarcerated participants had significantly lower (p < .01) total cholesterol (183 mg/dL) than nonincarcerated participants (199 mg/dL). However, a significantly higher (p < .03) percentage of incarcerated women (85%) than nonincarcerated women (54%) with high cholesterol were unaware of their condition. Despite the smoke-free status of the prison, 24% of incarcerated participants reported smoking. Attendance at lifestyle intervention sessions was significantly higher among incarcerated participants than among nonincarcerated participants with intervention take-up rates of 53% among incarcerated versus 23% among nonincarcerated women (p < .01) and intervention completion rates of 43% and 4% (p < .01). CONCLUSIONS: The results illustrate the need for screening and education programs in prisons. WISEWOMAN screenings helped identify undiagnosed cases of abnormal blood pressure and cholesterol, and educational interventions provided women with opportunities to improve their health. Such programs may also improve discharge planning and linkages between released women and community health providers.

The impact of medication use in a multicomponent intervention: results from the WISEWOMAN program.

PURPOSE: To assess the impact of medication use on improvements in coronary heart disease (CHD) risk among WISEWOMAN participants. DESIGN: Pre-post analysis. SETTING: WISEWOMAN projects operating at the local level in 8 states. SUBJECTS: WISEWOMAN participants with baseline and one-year follow-up data with at least one abnormal risk factor at baseline (N=2385; 24% of women with baseline visits). INTERVENTION: WISEWOMAN provides low-income uninsured women with CHD risk factor screenings, lifestyle interventions, access to medications, and referral services. MEASURES: One-year changes in blood pressure, cholesterol, and 10-year CHD risk by medication status. ANALYSIS: Regression analysis was used to estimate risk factor changes by medication status (newly medicated women, women medicated at baseline, or not medicated women) and quantify the percentage of improvements in risk factors attributed to medication use. RESULTS: Participants experienced statistically significant improvements in systolic (12.6 mm Hg) and diastolic (9.7 mm Hg) blood pressure, total (25.7 mg/dl) and HDL (4.9 mg/dl) cholesterol, and 10-year CHD risk (11.6%). Medication use was responsible for 4% to 5% of the reduction in blood pressure, 32% of the reduction in total cholesterol, 3% of the increase in HDL cholesterol, and 31 % of the reduction in 10-year CHD risk. CONCLUSIONS: Some of the improvements in CHD risk factors can be attributed to medication use; however, the majority of improvements are likely driven by a combination of other factors, including screenings, risk factor counseling, and lifestyle interventions.

Cardiovascular disease risk factor screening among Alaska Native women: the traditions of the heart project.

OBJECTIVES: To describe tobacco use, obesity and overweight, high blood pressure, high blood cholesterol and impaired glucose tolerance in Alaska Native and American Indian women living in the Anchorage area. STUDY DESIGN: Cross-sectional evaluation of women enrolled in the Traditions of the Heart program. METHODS: Traditions of the Heart was a randomized controlled trial of an intervention to reduce risk factors for cardiovascular disease. Starting in October 2000, Southcentral Foundation provided a 12-week group lifestyle intervention to eligible Alaska Native and American Indian women aged 40 to 64 residing in the Anchorage area. The study included assessment of biochemical and behavioral risk factors for cardiovascular disease. RESULTS: Of the 1334 women who enrolled between October 2000 and July 2005, 33.5% were current smokers, 78.8% were overweight or obese, 10.9% were hypertensive, 21.4% had elevated total cholesterol, and 5.6% had fasting glucose concentrations > or = 126 mg/dL. CONCLUSIONS: The women in this study had many risk factors for cardiovascular disease. Interventions are needed to reduce these risk factors among Alaska Native women.

Environment, obesity, and cardiovascular disease risk in low-income women.

BACKGROUND: Financially disadvantaged populations are more likely to live in communities that do not support healthy choices. This paper investigates whether certain characteristics of the built environment are associated with obesity or coronary heart disease (CHD) risk among uninsured low-income women. METHODS: Using a sample of 2001-2002 data from 2692 women enrolled in the WISEWOMAN program of the Centers for Disease Control and Prevention, the study team performed regression analysis (conducted in January-April 2005) to estimate body mass index (BMI) and the log of 10-year CHD risk as a function of the built environment and socioecologic measures. RESULTS: For women living in an environment of maximum mixed land use (i.e., an environment more conducive to healthy living), BMI was lower by 2.60 kg/m2 and CHD risk was lower by 20% than for women living in single-use uniform environments (i.e., environments less conducive to healthy living). An additional fitness facility per 1000 residents was associated with BMI and CHD risk that were lower by 1.39 kg/m2 and 15.1%, respectively. Crime was positively associated with BMI and CHD risk, whereas neighborhood affluence was negatively associated. Living in more racially segregated areas was negatively associated with CHD risk among black, Hispanic, and Asian women and positively associated with CHD risk among American Indian women. CONCLUSIONS: The built environment and socioecologic characteristics of financially disadvantaged women were associated with BMI and CHD risk. More research is needed to understand the effects of racial segregation or acculturation on health for specific subpopulations.

Cost-effectiveness of WISEWOMAN, a program aimed at reducing heart disease risk among low-income women.

OBJECTIVE: To quantify the cost-effectiveness of the WISEWOMAN program. WISEWOMAN is a Centers for Disease Control and Prevention (CDC)-funded lifestyle intervention program that provides low-income uninsured women aged 40-64 with chronic disease risk factor screenings, lifestyle interventions, and referral services in an effort to prevent coronary heart disease (CHD) and improve health. METHODS: We used data for 3015 WISEWOMAN participants who completed baseline and 1-year follow-up screenings. We quantified the average per capita cost of providing WISEWOMAN over the last 6 months of the reporting period. We assessed 1-year reductions in select CHD risk factors. We calculated the cost-effectiveness ratio by dividing the average per capita cost by average predicted life-years gained. RESULTS: The cost of providing WISEWOMAN services to each additional participant averaged 270 US dollars per participant. Participants significantly improved their systolic (1.3%) and diastolic (1.7%) blood pressure, total (2%) and high-density lipoprotein (HDL) (0.7%) cholesterol, and 10-year risk of CHD (8.7%). There were also significant reductions in percent of women who smoked (11.7%) or had high blood pressure (15.8%) or high cholesterol (13.1%). The bestcase cost-effectiveness ratio was 470 US dollars per percentage point reduction in CHD risk, or 4400 US dollars per discounted life-year gained; however, sensitivity analysis revealed substantial uncertainty around this estimate. CONCLUSIONS: Although more research is needed to confirm the assumptions used in the model, results of our analysis suggest that the WISEWOMAN program is a cost-effective approach for reducing CVD risk among low-income, uninsured women aged 40-64, especially if improvements in risk factors are sustainable when program participation concludes.

Linking clinical care to community resources for cardiovascular disease prevention: the North Carolina Enhanced WISEWOMAN project.

BACKGROUND: The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) project addresses the need for effective cardiovascular disease (CVD) prevention among underserved, midlife women. We describe an Enhanced Intervention that addressed environmental and individual factors within the context of a clinic-based intervention. We also present the study design and baseline results of the randomized trial to evaluate the enhanced intervention. METHODS: The multicomponent behavior change intervention addressed many elements of the Chronic Care Model (CCM), including the community resources and policy element, wherein Enhanced Intervention participants were encouraged to overcome environmental barriers to a healthy lifestyle by using community resources. Study participants were enrolled at one community health center; all were low-income, underinsured, midlife (40-64 years) women. RESULTS: A total of 236 participants were randomized to receive the Enhanced Intervention or the Minimum Intervention. At baseline, over three fourths of the participants were overweight or obese. Participants reported a variety of problematic neighborhood characteristics, including a paucity of restaurants with healthy food choices (41% reported as a problem); not enough farmer's markets or produce stands (50%), not enough affordable exercise places (52%), not enough physical activity programs that met women's needs (42%), heavy traffic (47%), and speeding drivers (53%). Overall, women knew little about affordable exercise venues and nutrition classes. CONCLUSIONS: In this clinic-based intervention, we addressed environmental factors related to a healthy lifestyle. Results indicate the need for effective and feasible intervention strategies to address the environments in which individuals are making behavior changes. The effectiveness of the WISEWOMAN Enhanced Intervention will be assessed in a randomized trial.

Fruit and vegetable consumption of older Mexican-American women is associated with their acculturation level.

Little is known about the association between acculturation and fruit and vegetable (FV) consumption among older Mexican-American (MA) women. Environmental and lifestyles changes experienced by immigrants to the United States may markedly affect their diet and health and increase their risk for chronic diseases. Our objectives were to: 1) describe FV consumption by ethnicity, acculturation, and sociodemographic characteristics, and 2) compare effects of acculturation and sociodemographic variables on FV intake in a population of older MA and non-Hispanic White (NHW) women from the Well-Integrat-ed Screening and Evaluation for Women Across the Nation (WISEWOMAN) Study. This report examines baseline FV intake of 346 underinsured women aged 50-76 years, assessed through 24-hour dietary recalls. Acculturation was measured with a five-item Likert-type scale. Twenty percent of more acculturated MA women, 24% of less acculturated MA women, and 36% of White women consumed > or = 5 servings of FV servings per day. Fruit and vegetable (FV) intake was associated with acculturation, education, and smoking status. Being more acculturated was associated with lower consumption of FVs among MAs, while having a higher education and no smoking was associated with higher intakes of FV servings among NHWs. Public health efforts to improve the intake of FVs among MA women should be sensitive to their acculturation status.

Medication Adherence and Incident Preventable Hospitalizations for Hypertension.

INTRODUCTION: Potentially preventable hospitalizations (PPHs) for hypertension (HTN) is one indicator of possible failed ambulatory care. Rates of PPHs for HTN have remained fairly level since the late 1980s, which may reflect a lack of understanding of the drivers of these hospitalizations. Anti-HTN medication non-adherence has been studied as a potential risk factor for other cardiovascular disease outcomes but not for PPHs for HTN. METHODS: A cohort analysis was conducted during 2005-2012 of people with HTN enrolled in commercial and employee health plans with claims in the MarketScan database. PPH for HTN was defined according to specifications published by the Agency for Healthcare Research and Quality. The proportion of days covered (PDC) algorithm was used to assess adherence to antihypertensives. Crude- and multivariate-adjusted incident PPHs for HTN rates were calculated, as well as third-party payments for selected PPH for HTN-related expenses. RESULTS: During 9,344,528 person-years of follow-up (mean=3 years), 6,008 incident PPHs for HTN were identified among 3,099,291 people. The crude rate for good adherence (PDC ≥80%) was 23.2 per 100,000 person-years compared with 102.6 per 100,000 person-years for poor adherence (PDC <40%). Over the 8-year study, PPH for HTN-associated payments equaled $41 million. Payments for those with poor adherence were four times higher than for those with good adherence. CONCLUSIONS: Poor anti-HTN medication adherence is strongly associated with PPHs for HTN. Improving the percentage of people who achieve good medication adherence is one possible approach to reducing the burden of PPHs for HTN in the U.S.

Modeled Health and Economic Impact of Team-Based Care for Hypertension.

INTRODUCTION: Team-based interventions for hypertension care have been widely studied and shown effective in improving hypertension outcomes. Few studies have evaluated long-term effects of these interventions; none have assessed broad-scale implementation. This study estimates the prospective health, economic, and budgetary impact of universal adoption of a team-based care intervention model that targets people with treated but uncontrolled hypertension in the U.S. METHODS: Analysis was conducted in 2014-2015 using a microsimulation model, constructed with various data sources from 1948 to 2014, designed to evaluate prospective cardiovascular disease (CVD)-related interventions in the U.S. POPULATION: Ten-year primary outcomes included prevalence of uncontrolled hypertension; incident myocardial infarction, stroke, CVD events, and CVD-related mortality; intervention and net medical costs by payer; productivity; and quality-adjusted life years. RESULTS: About 4.7 million (13%) fewer people with uncontrolled hypertension and 638,000 prevented cardiovascular events would be expected over 10 years. Assuming $525 per enrollee, implementation would cost payers $22.9 billion, but $25.3 billion would be saved in averted medical costs. Estimated net cost savings for Medicare approached $5.8 billion. Net costs were especially sensitive to intervention costs, with break-even thresholds of $300 (private), $450 (Medicaid), and $750 (Medicare). CONCLUSIONS: Nationwide adoption of team-based care for uncontrolled hypertension could have sizable effects in reducing CVD burden. Based on the study's assumptions, the policy would be cost saving from the perspective of Medicare and may prove to be cost effective from other payers' perspectives. Expected net cost savings for Medicare would more than offset expected net costs for all other insurers.

The WISEWOMAN projects: lessons learned from three states.

BACKGROUND: The WISEWOMAN program provides chronic disease risk factor screening, lifestyle interventions, and referrals to financially disadvantaged women who participate in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Three states (Arizona, Massachusetts, and North Carolina) participated in Phase One (1995-1998). METHODS: Using a case study approach, we reviewed documents and conducted telephone interviews to compare the three projects' design and execution. The interviews, carried out in mid-2002, involved a convenience sample of project coordinators, project directors, researchers, and one CDC project officer (n = 9). RESULTS: Many providers were overwhelmed by WISEWOMAN's research component and disliked its lack of flexibility. Researchers emphasized that high-quality evaluation requires resources and attention. Informants described the challenges of integrating WISEWOMAN with state BCCEDP programs that are in varying development stages and recommended changes in organizational culture and provider practices. Regarding implementation, informants emphasized the need for adequate and appropriate planning, buy-in, training, professional support, and outreach. Our sample also noted that WISEWOMAN projects tend to be labor intensive. CONCLUSIONS: WISEWOMAN projects face challenges of integrating clinical and lifestyle interventions, reaching beyond a focus on individuals, marshaling substantial resources, and introducing complex interventions into stretched healthcare environments. The three Phase One projects were deemed successful in reaching underserved women, developing a more comprehensive women's health model, strengthening linkages to primary healthcare, experimenting with innovative behavioral interventions, and tapping into women's roles as social support providers and family/community gatekeepers.

Spatial analysis of body mass index and smoking behavior among WISEWOMAN participants.

BACKGROUND: The WISEWOMAN program focuses on reducing cardiovascular disease (CVD) risk factors by providing screening and lifestyle interventions for many low-income and uninsured women. To provide the most effective interventions possible, it is important to understand the characteristics of WISEWOMAN participants and their communities. METHODS: We used baseline data collected for WISEWOMAN participants from five states (Connecticut, Michigan, Nebraska, North Carolina, and South Dakota) who had enrolled in WISEWOMAN between January 2001 and December 2002 in order to examine body mass index (BMI) and smoking behavior for evidence of spatial clustering. We then examined whether neighborhood characteristics in clusters of high-risk factors differed from neighborhood characteristics in other locations. RESULTS: Six percent of the WISEWOMAN participants lived in ZIP codes with high-BMI clusters, and 4% lived in ZIP codes with high-smoking clusters. High-BMI and high-smoking clusters occurred, however, in different locations from each other. The high-BMI-clustered ZIP codes were, on average, located in more disadvantaged areas. Most of the differences between the high-smoking-clustered ZIP codes and the remaining ZIP codes were not statistically significant. CONCLUSIONS: Our analysis revealed spatial clustering in CVD risk factors among WISE-WOMAN participants. We also found evidence of a correlation between high-BMI clusters and low socioeconomic status of the surrounding community. A more in-depth analysis of the relationship between risk factors (e.g., BMI) and community characteristics in clustered locations will provide further information concerning the role of the community in affecting individual behavior and should allow for tailoring interventions to reduce these risk factors more effectively.

Health promotion interventions for disadvantaged women: overview of the WISEWOMAN projects.

BACKGROUND: The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program aims to remove racial and ethnic disparities in health by addressing the screening and intervention needs of midlife uninsured women. This paper describes the WISEWOMAN program requirements, the design of the 12 projects funded in 2002, the use of a standardized data reporting and analysis system, risk factors among participants, effective behavioral strategies, and plans for the future. METHODS: The WISEWOMAN demonstration projects are examining the feasibility and effectiveness of adding a cardiovascular disease (CVD) prevention component to the early detection of breast and cervical cancer. Women aged 40-64 are eligible if they are enrolled in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in selected U. S. states and are financially disadvantaged and lack health insurance. The primary outcome measures are blood pressure, lipid levels, and tobacco use. Intermediate measures include self-reported diet and physical activity, measures of readiness for change, and barriers to behavior change. RESULTS: During 2002, the 10 projects that were fully operational screened 8164 financially disadvantaged women and developed culturally and regionally appropriate nutrition and physical activity interventions for a variety of racial and ethnic backgrounds. Twenty-three percent of the women screened had high total cholesterol, with 48% of these being newly diagnosed. Thirty-eight percent of the women had high blood pressure, with 24% being newly diagnosed. Approximately, 75% of participants were either overweight or obese, and in some sites up to 42% were smokers. CONCLUSIONS: The WISEWOMAN demonstration projects have been successful at reaching financially disadvantaged and minority women who are at high risk for chronic diseases. These projects face challenges because they are generally implemented by safety net providers who have limited resources and staff to conduct research and evaluation. On the other hand, the findings from these projects will be especially informative in reducing health disparities because they are conducted in those settings where the most socially and medically vulnerable women receive care.

Racial/ethnic disparities in coronary heart disease risk factors among WISEWOMAN enrollees.

BACKGROUND: We used the baseline data collected for the Well-integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) participants to provide a snapshot of cardiovascular disease (CVD) risk on enrollment and to address racial/ethnic disparities in the following CVD risk factors: body mass index (BMI), systolic and diastolic blood pressure, high-density lipoprotein (HDL) and total cholesterol, diabetes and smoking prevalence, 10-year coronary heart disease (CHD) risk, and treatment and awareness of high cholesterol, hypertension, and diabetes. METHODS: We used linear regression analysis to (1) assess the presence of racial/ethnic disparities and test whether existing disparities can be explained by (2) differences in individual characteristics or by (3) differences in individual and community characteristics. RESULTS: Our results reveal a high degree of CVD risk among the WISEWOMAN participants and statistically significant racial/ethnic disparities in risk factors. Black participants were at the greatest risk of CVD, and Hispanic and Alaska Native participants were healthier in terms of CVD risk than white participants. Some racial/ethnic disparities were explained by differences in individual and community characteristics, but other disparities persisted even after controlling for these factors. CONCLUSIONS: Because differences in community characteristics explain many of the racial/ethnic disparities in CVD risk factors, eliminating disparities may require community-wide interventions. Successful WISEWOMAN projects are likely to not only reduce CVD risk factors overall but also to lessen racial/ethnic disparities in these risk factors.