The National Heart Lung and Blood Institute Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Alliance.

OBJECTIVE: To describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) Alliance to support late-stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease. STUDY SETTING: NHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high-risk diverse populations including racial and ethnic minorities, urban, rural, and low-income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma. STUDY DESIGN: The initial phase supports planning activities for sustainable uptake of evidence-based interventions in targeted communities. The second phase tests late-stage evidence-based implementation strategies. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: We provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross-center partnership and collaboration. CONCLUSIONS: The DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.

Signet Ring Cell Gastric Carcinoma: Clinical Epidemiology and Outcomes in a Predominantly Latino County Hospital Population.

BACKGROUND: Gastric signet ring cell carcinoma (GSRC) is a rare but increasingly prevalent tumor histotype whose clinical features and natural history are poorly understood, particularly in the USA and minorities. AIMS: To examine the occurrence, clinico-demographic characteristics, oncologic features, treatment, and outcomes of GSRC in a predominantly minority county hospital setting and benchmark them against data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. METHODS: We queried biopsy-proven GSRC cases at a Los Angeles County hospital, from 2004 to 2017. Clinical characteristics, treatment, and survival data were collected and compared to SEER data. RESULTS: We identified 63 patients with GSRC. Compared to SEER, our cohort was significantly younger (52.6 vs. 63.5 years, p < 0.01), Hispanic/Latino predominant (81% vs. 20%, p < 0.01), had higher overall stage (86% vs. 69% with stage III/IV, p < 0.01), and more frequent node involvement (89% vs. 49%, p < 0.01). Lower tumor stage, Helicobacter pylori positivity, and surgical intervention were associated with significantly longer median survival (all p < 0.05), which was similar in our study compared to SEER (median 12.6 vs. 9.0 months, p = 0.26). CONCLUSIONS: Patients with GSRC within the Los Angeles County population have different clinical characteristics compared to what has been reported in SEER. Our cohort was younger, and despite having more advanced disease, did not have shorter survival. Further study is needed to better identify protective and risk factors in this population and improve understanding of the etiopathogenesis and natural history of this malignancy.

Derivation and Application of a Tool to Estimate Benefits From Multiple Therapies That Reduce Recurrent Stroke Risk.

Background and Purpose- Lowering blood pressure and cholesterol, antiplatelet/antithrombotic use, and smoking cessation reduce risk of recurrent stroke. However, gaps in risk factor control among stroke survivors warrant development and evaluation of alternative care delivery models that aim to simultaneously improve multiple risk factors. Randomized trials of care delivery models are rarely of sufficient duration or size to be powered for low-frequency outcomes such as observed recurrent stroke. This creates a need for tools to estimate how changes across multiple stroke risk factors reduce risk of recurrent stroke. Methods- We reviewed existing evidence of the efficacy of interventions addressing blood pressure reduction, cholesterol lowering, antiplatelet/antithrombotic use, and smoking cessation and extracted relative risks for each intervention. From this, we developed a tool to estimate reductions in recurrent stroke risk, using bootstrapping and simulation methods. We also calculated a modified Global Outcome Score representing the proportion of potential benefit (relative risk reduction) achieved if all 4 individual risk factors were optimally controlled. We applied the tool to estimate stroke risk reduction among 275 participants with complete 12-month follow-up data from a recently published randomized trial of a healthcare delivery model that targeted multiple stroke risk factors. Results- The recurrent stroke risk tool was feasible to apply, yielding an estimated reduction in the relative risk of ischemic stroke of 0.36 in both the experimental and usual care trial arms. Global Outcome Score results suggest that participants in both arms likely averted, on average, 45% of recurrent stroke events that could possibly have been prevented through maximal implementation of interventions for all 4 individual risk factors. Conclusions- A stroke risk reduction tool facilitates estimation of the combined impact on vascular risk of improvements in multiple stroke risk factors and provides a summary outcome for studies testing alternative care models to prevent recurrent stroke. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00861081.

Trends in Racial/Ethnic and Nativity Disparities in Cardiovascular Health Among Adults Without Prevalent Cardiovascular Disease in the United States, 1988 to 2014.

Background: Trends in cardiovascular disparities are poorly understood, even as diversity increases in the United States. Objective: To examine U.S. trends in racial/ethnic and nativity disparities in cardiovascular health. Design: Repeated cross-sectional study. Setting: NHANES (National Health and Nutrition Examination Survey), 1988 to 2014. Participants: Adults aged 25 years or older who did not report cardiovascular disease. Measurements: Racial/ethnic, nativity, and period differences in Life's Simple 7 (LS7) health factors and behaviors (blood pressure, cholesterol, hemoglobin A1c, body mass index, physical activity, diet, and smoking) and optimal composite scores for cardiovascular health (LS7 score ≥10). Results: Rates of optimal cardiovascular health remain below 40% among whites, 25% among Mexican Americans, and 15% among African Americans. Disparities in optimal cardiovascular health between whites and African Americans persisted but decreased over time. In 1988 to 1994, the percentage of African Americans with optimal LS7 scores was 22.8 percentage points (95% CI, 19.3 to 26.4 percentage points) lower than that of whites in persons aged 25 to 44 years and 8.0 percentage points (CI, 6.4 to 9.7 percentage points) lower in those aged 65 years or older. By 2011 to 2014, differences decreased to 10.6 percentage points (CI, 7.4 to 13.9 percentage points) and 3.8 percentage points (CI, 2.5 to 5.0 percentage points), respectively. Disparities in optimal LS7 scores between whites and Mexican Americans were smaller but also decreased. These decreases were due to reductions in optimal cardiovascular health among whites over all age groups and periods: Between 1988 to 1994 and 2011 to 2014, the percentage of whites with optimal cardiovascular health decreased 15.3 percentage points (CI, 11.1 to 19.4 percentage points) for those aged 25 to 44 years and 4.6 percentage points (CI, 2.7 to 6.5 percentage points) for those aged 65 years or older. Limitation: Only whites, African Americans, and Mexican Americans were studied. Conclusion: Cardiovascular health has declined in the United States, racial/ethnic and nativity disparities persist, and decreased disparities seem to be due to worsening cardiovascular health among whites rather than gains among African Americans and Mexican Americans. Multifaceted interventions are needed to address declining population health and persistent health disparities. Primary Funding Source: National Institute of Neurological Disorders and Stroke and National Center for Advancing Translational Sciences of the National Institutes of Health.

Successful schools and risky behaviors among low-income adolescents.

OBJECTIVES: We examined whether exposure to high-performing schools reduces the rates of risky health behaviors among low-income minority adolescents and whether this is due to better academic performance, peer influence, or other factors. METHODS: By using a natural experimental study design, we used the random admissions lottery into high-performing public charter high schools in low-income Los Angeles neighborhoods to determine whether exposure to successful school environments leads to fewer risky (eg, alcohol, tobacco, drug use, unprotected sex) and very risky health behaviors (e.g., binge drinking, substance use at school, risky sex, gang participation). We surveyed 521 ninth- through twelfth-grade students who were offered admission through a random lottery (intervention group) and 409 students who were not offered admission (control group) about their health behaviors and obtained their state-standardized test scores. RESULTS: The intervention and control groups had similar demographic characteristics and eighth-grade test scores. Being offered admission to a high-performing school (intervention effect) led to improved math (P < .001) and English (P = .04) standard test scores, greater school retention (91% vs. 76%; P < .001), and lower rates of engaging in ≥1 very risky behaviors (odds ratio = 0.73, P < .05) but no difference in risky behaviors, such as any recent use of alcohol, tobacco, or drugs. School retention and test scores explained 58.0% and 16.2% of the intervention effect on engagement in very risky behaviors, respectively. CONCLUSIONS: Increasing performance of public schools in low-income communities may be a powerful mechanism to decrease very risky health behaviors among low-income adolescents and to decrease health disparities across the life span.

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement.

OBJECTIVE: The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement. EVIDENCE: The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society. CONCLUSIONS: Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

The vulnerability of middle-aged and older adults in a multiethnic, low-income area: contributions of age, ethnicity, and health insurance.

This community-partnered study was developed and fielded in partnership with key community stakeholders and describes age- and race-related variation in delays in care and preventive service utilization between middle-aged and older adults living in South Los Angeles. The survey sample included adults aged 50 and older who self-identified as African American or Latino and lived in ZIP codes of South Los Angeles (N=708). Dependent variables were self-reported delays in care and use of preventive services. Insured participants aged 50 to 64 were more likely to report any delay in care (adjusted predicted percentage (APP)=18%, 95% confidence interval (CI)=14-23) and problems obtaining needed medical care (APP=15%, 95% CI=12-20) than those aged 65 and older. Uninsured participants aged 50 to 64 reported even greater delays in care (APP=45%, 95% CI=33-56) and problems obtaining needed medical (APP=33%, 95% CI=22-45) and specialty care (APP=26%, 95% CI=16-39) than those aged 65 and older. Participants aged 50 to 64 were generally less likely to receive preventive services, including influenza and pneumococcal vaccines and colonoscopy than older participants, but women were more likely to receive mammograms. Participants aged 50 to 64 had more problems obtaining recommended preventive care and faced more delays in care than those aged 65 and older, particularly if they were uninsured. Providing insurance coverage for this group may improve access to preventive care and promote wellness.

Neighborhood and weight-related health behaviors in the Look AHEAD (Action for Health in Diabetes) study.

BACKGROUND: Previous studies have shown that neighborhood factors are associated with obesity, but few studies have evaluated the association with weight control behaviors. This study aims to conduct a multi-level analysis to examine the relationship between neighborhood SES and weight-related health behaviors. METHODS: In this ancillary study to Look AHEAD (Action for Health in Diabetes) a trial of long-term weight loss among individuals with type 2 diabetes, individual-level data on 1219 participants from 4 clinic sites at baseline were linked to neighborhood-level data at the tract level from the 2000 US Census and other databases. Neighborhood variables included SES (% living below the federal poverty level) and the availability of food stores, convenience stores, and restaurants. Dependent variables included BMI, eating patterns, weight control behaviors and resource use related to food and physical activity. Multi-level models were used to account for individual-level SES and potential confounders. RESULTS: The availability of restaurants was related to several eating and weight control behaviors. Compared to their counterparts in neighborhoods with fewer restaurants, participants in neighborhoods with more restaurants were more likely to eat breakfast (prevalence Ratio [PR] 1.29 95% CI: 1.01-1.62) and lunch (PR = 1.19, 1.04-1.36) at non-fast food restaurants. They were less likely to be attempting weight loss (OR = 0.93, 0.89-0.97) but more likely to engage in weight control behaviors for food and physical activity, respectively, than those who lived in neighborhoods with fewer restaurants. In contrast, neighborhood SES had little association with weight control behaviors. CONCLUSION: In this selected group of weight loss trial participants, restaurant availability was associated with some weight control practices, but neighborhood SES was not. Future studies should give attention to other populations and to evaluating various aspects of the physical and social environment with weight control practices.

Characteristics of insured patients with persistent gaps in diabetes care services: the Translating Research into Action for Diabetes (TRIAD) study.

BACKGROUND: Although preventing diabetes complications requires long-term management, little is known about which patients persistently fail to get recommended care. OBJECTIVE: To determine the frequency and correlates of persistent, long-term gaps in diabetes care. METHOD: : The study population included 8392 patients with diabetes. Patient surveys and medical records from 10 health plans over 3 years provided data on socioeconomic characteristics, access to care, social support, and mental and physical health, and diabetes preventive care services. We defined a "persistent gap" as a participant's missing a preventive care service for the entire 3 years. Services considered included hemoglobin A1c, cholesterol, and albuminuria tests, and foot and dilated eye examinations. RESULTS: Thirty percent of participants had at least 1 persistent gap. The most common gaps were lipid testing (11.6%), microalbuminuria testing (9.7%), and eye examinations (9.0%). Persistent gaps were 18% to 42% higher for young patients, lean persons, those with low income, employed persons, smokers, those with diabetes less than 5 years, and patients with none or 1 comorbid conditions. Sex, education, marital status, family demands, transportation, trust in physicians, and mental health were not associated with gaps in care. CONCLUSIONS: Persistent gaps in diabetes care are common even among insured patients. Patients with lower income, younger age, fewer years of diabetes, having fewer comorbidities, taking fewer medications, and poor health behaviors are vulnerable to persistent gaps in care and a group who warrant targeted interventions to improve preventive diabetes care.

Educational disparities in rates of smoking among diabetic adults: the translating research into action for diabetes study.

OBJECTIVES: We assessed educational disparities in smoking rates among adults with diabetes in managed care settings. METHODS: We used a cross-sectional, survey-based (2002-2003) observational study among 6538 diabetic patients older than 25 years across multiple managed care health plans and states. For smoking at each level of self-reported educational attainment, predicted probabilities were estimated by means of hierarchical logistic regression models with random intercepts for health plan, adjusted for potential confounders. RESULTS: Overall, 15% the participants reported current smoking. An educational gradient in smoking was observed that varied significantly (P<.003) across age groups, with the educational gradient being strong in those aged 25 to 44 years, modest in those aged 45 to 64 years, and nonexistent in those aged 65 years or older. Of particular note, the prevalence of smoking observed in adults aged 25-44 years with less than a high school education was 50% (95% confidence interval: 36% to 63%). CONCLUSIONS: Approximately half of poorly educated young adults with diabetes smoke, magnifying the health risk associated with early-onset diabetes. Targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes are needed.

Perception of neighborhood problems, health behaviors, and diabetes outcomes among adults with diabetes in managed care: the Translating Research Into Action for Diabetes (TRIAD) study.

OBJECTIVE: Recent data suggest that residential environment may influence health behaviors and outcomes. We assessed whether perception of neighborhood problems was associated with diabetes behaviors and outcomes. RESEARCH DESIGN AND METHODS: This cross-sectional analysis included 7,830 diabetic adults enrolled in Translating Research Into Action for Diabetes, a study of diabetes care and outcomes in managed care settings. Perception of neighborhood problems was measured using a summary score of participants' ratings of crime, trash, litter, lighting at night, and access to exercise facilities, transportation, and supermarkets. Outcomes included health behaviors and clinical outcomes. Hierarchical regression models were used to account for clustering of patients within neighborhoods and to adjust for objective neighborhood socioeconomic status (percentage living in poverty) and potential individual-level confounders (age, sex, race/ethnicity, education, income, comorbidity index, and duration of diabetes). RESULTS: After adjustment, residents of neighborhoods in the lowest tertile (most perceived problems) reported higher rates of current smoking (15 vs. 11%) than those in the highest tertile and had slightly lower participation in any weekly physical activity (95 vs. 96%). In addition, their blood pressure control was worse (25 vs. 31% <130/80 mmHg), and their Short Form 12 scores were slightly lower (44 vs. 46 units for emotional well-being and 43 vs. 44 units for physical well-being); all P < 0.01. CONCLUSIONS: Neighborhood problems were most strongly associated with more smoking and higher blood pressure, both of which have significant implications for cardiovascular risk. Potential mechanisms that explain these associations should be further explored in longitudinal studies.

Understanding the gap between good processes of diabetes care and poor intermediate outcomes: Translating Research into Action for Diabetes (TRIAD).

BACKGROUND: Performance of diabetes clinical care processes has improved recently, but control of hemoglobin A1c (A1c) and other vascular disease risk factors has improved more slowly. OBJECTIVES: To identify patient factors associated with control of vascular disease risk factors among diabetes patients receiving recommended care processes. POPULATION: Managed care enrollees who participated in the TRIAD (Translating Research into Action for Diabetes) Study and received at least 5 of 7 recommended care processes during the 12 months before the second survey (2002-2003). METHODS: Comparison of 1003 patients with good control of A1c (<8%), systolic blood pressure (<140 mm Hg) and LDL-cholesterol (<130 mg/dL) versus 812 patients with poor control for at least 2 of these factors. RESULTS: Poorly controlled patients were younger, more frequently female, African American, with lower education and income (P < 0.001 for each). General health status was lower, body mass index higher, and insulin treatment more frequent; history of prior coronary heart disease was less frequent. They were more likely to indicate depression and hopelessness and to identify costs as a barrier to self-care; less likely to report trust in their regular physician; and more likely to smoke cigarettes and be physically inactive. Adjusting for demographic and clinical variables, concerns about costs, low trust in one's physician, current smoking, and physical inactivity remained associated with poor control. However, inclusion of these 4 variables in a single model did not diminish associations of race/ethnicity or education with control. CONCLUSIONS: Clinical, socioeconomic, psychosocial, and behavioral factors were independently associated with poor control. However, these factors did not fully explain observed racial and socioeconomic disparities in control.

Educational disparities in health behaviors among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study.

BACKGROUND: Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors. METHODS: This observational study was based on a cohort of 8,763 survey respondents drawn from ~180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans. RESULTS: Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25-44, modest for those ages 45-64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings. CONCLUSION: The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

Who is tested for diabetic kidney disease and who initiates treatment? The Translating Research Into Action For Diabetes (TRIAD) Study.

OBJECTIVE: We examined factors associated with screening for albuminuria and initiation of ACE inhibitor or angiotensin receptor blocker (ARB) treatment in diabetic patients. RESEARCH DESIGN AND METHODS: We conducted surveys and medical record reviews for 5,378 patients participating in a study of diabetes care in managed care at baseline (2000-2001) and follow-up (2002-2003). Factors associated with testing for albuminuria were examined in cross-sectional analysis at baseline. Factors associated with initiating ACE inhibitor/ARB therapy were determined prospectively. RESULTS: At baseline, 52% of patients not receiving ACE inhibitor/ARB therapy and without known diabetic kidney disease (DKD) were screened for albuminuria. Patients > or =65 years of age, those with higher HbA(1c), those with cardiovascular disease (CVD), and those without hyperlipidemia were less likely to be screened. Of the patients with positive screening tests, 47% began ACE inhibitor/ARB therapy. Initiation of therapy was associated with positive screening test results, BMI > or =25 kg/m(2), treatment with insulin or oral antidiabetic agents, peripheral neuropathy, systolic blood pressure > or =140 mmHg, and CVD. Of the patients receiving ACE inhibitor/ARB therapy or with known DKD, 63% were tested for albuminuria. CONCLUSIONS: Screening for albuminuria was inadequate, especially in older patients or those with competing medical concerns. The value of screening could be increased if more patients with positive screening tests initiated ACE inhibitor/ARB therapy. The efficiency of screening could be improved by limiting screening to diabetic patients not receiving ACE inhibitor/ARB therapy and without known DKD.