Ex vivo lung perfusion in donation after circulatory death: A post hoc analysis of the Normothermic Ex Vivo Lung Perfusion as an Assessment of Extended/Marginal Donors Lungs trial.

OBJECTIVE: Donation after circulatory death (DCD) donors offer the ability to expand the lung donor pool and ex vivo lung perfusion (EVLP) further contributes to this ability by allowing for additional evaluation and resuscitation of these extended criteria donors. We sought to determine the outcomes of recipients receiving organs from DCD EVLP donors in a multicenter setting. METHODS: This was an unplanned post hoc analysis of a multicenter, prospective, nonrandomized trial that took place during 2011 to 2017 with 3 years of follow-up. Patients were placed into 3 groups based off procurement strategy: brain-dead donor (control), brain-dead donor evaluated by EVLP, and DCD donors evaluated by EVLP. The primary outcomes were severe primary graft dysfunction at 72 hours and survival. Secondary outcomes included select perioperative outcomes, and 1-year and 3-years allograft function and quality of life measures. RESULTS: The DCD EVLP group had significantly higher incidence of severe primary graft dysfunction at 72 hours (P = .03), longer days on mechanical ventilation (P < .001) and in-hospital length of stay (P = .045). Survival at 3 years was 76.5% (95% CI, 69.2%-84.7%) for the control group, 68.3% (95% CI, 58.9%-79.1%) for the brain-dead donor group, and 60.7% (95% CI, 45.1%-81.8%) for the DCD group (P = .36). At 3-year follow-up, presence observed bronchiolitis obliterans syndrome or quality of life metrics did not differ among the groups. CONCLUSIONS: Although DCD EVLP allografts might not be appropriate to transplant in every candidate recipient, the expansion of their use might afford recipients stagnant on the waitlist a viable therapy.

Use of trajectory models to track air pollution from source to exposure: A methodological approach for identifying communities at risk.

OBJECTIVE: Ongoing environmental changes increasingly require public health nurses to understand how environmental factors impact the health of populations. One approach to researching these impacts is incorporating environmental research methods to determine associations between harmful exposures and health. We use the Salton Sea in Southern California as a demonstration of how environmental exposure can be examined using air parcel trajectory analysis. DESIGN: We demonstrate a methodology for public health nurses to better understand and apply data from the Hybrid Single-Particle Lagrangian Integrated Trajectory meteorological model to estimate the effect of airborne particulate matter from a single source. MEASUREMENTS: We explain a method for tracking air parcel trajectories to populations: selection of meterological data to identify air parcels, geographic identification of population centers, generation of trajectories, classification of trajectory dispersions, adjusting for atmospheric stability, and merging environmental variables with health data. CONCLUSIONS: Climate change-related environmental events are expected to become more commonplace and disproportionately affect those populations impacted by health disparities. Public health nurses can identify communities at risk so that public health nursing researchers can use these techniques in collaboration with environmental science to robustly examine health effects of proximal air pollution sources for communities at risk.

A mid-South chronic disease registry and practice-based research network to address disparities.

OBJECTIVES: To describe an innovative health information technology (HIT) model for supporting community-wide health improvement through multiprovider collaboration in a regional population health registry and practice-based research network (PBRN). STUDY DESIGN: Case study. METHODS: We describe the HIT data structure and governance of the Diabetes Wellness and Prevention Coalition (DWPC) Registry and PBRN based in Memphis, Tennessee. The population served and their characteristics were assessed for all adult patients with at least 1 encounter in a participating health care delivery system from January 1, 2013, to March 31, 2019. Disparities in access and health care utilization were assessed by residential zip code. RESULTS: The DWPC Registry is a chronic disease and population health data warehouse designed to facilitate chronic disease surveillance and tracking of processes and outcomes of care in medically underserved areas of the mid-South. The Registry primarily focuses on obesity-associated chronic conditions such as diabetes, hypertension, hyperlipidemia, and chronic kidney disease. It combines patient data from 7 regional health systems, which include 6 adult hospitals and more than 50 outpatient practices, covering 462,223 adults with 2,032,425 clinic visits and 602,679 hospitalizations and/or emergency department visits from January 1, 2013, to March 31, 2019. The most prevalent chronic conditions include obesity (37.2%), hypertension (34.4%), overweight (26.4%), hyperlipidemia (18.0%), and type 2 diabetes (14.0%). The Registry provides quarterly practice improvement reports to participating clinics, facilitates surveillance of and outreach to patients with unmet health needs, and supports a pragmatic clinical trial and multiple cohort studies. CONCLUSIONS: Regional registries and PBRNs are powerful tools that can support real-world quality improvement and population health efforts to reduce disparities and improve equity in chronic disease care in medically underserved communities across the United States.

Sensitivity of Clinical Pediatric Obesity Diagnosis Documented in Electronic Health Records.

Objective. This study tested the sensitivity of obesity diagnosis in electronic health records (EHRs) using body mass index (BMI) classification and identified variables associated with obesity diagnosis. Methods. Eligible children aged 2 to 18 years had a calculable BMI in 2017 and had at least 1 visit in 2016 and 2017. Sensitivity of clinical obesity diagnosis compared with children's BMI percentile was calculated. Logistic regression was performed to determine variables associated with obesity diagnosis. Results. Analyses included 31 059 children with BMI at or above 95th percentile. Sensitivity of clinical obesity diagnosis was 35.81%. Clinical obesity diagnosis was more likely if the child had a well visit, had Medicaid insurance, was female, Hispanic or Black, had a chronic disease diagnosis, and saw a provider in a practice in an urban area or with academic affiliation. Conclusion. Sensitivity of clinical obesity diagnosis in EHR is low. Clinical obesity diagnosis is associated with nonmodifiable child-specific factors but also modifiable practice-specific factors.

Racial and Regional Disparities in Outcomes Among Veterans Initially Adherent to Oral Antidiabetic Therapies: an Observational Cohort Study.

BACKGROUND: Adherence to prescribed medications is connected with, but is not a guarantee of, improved disease management and health outcomes. It remains unclear whether underlying health disparities exist among patients adherent to therapy and whether differences in outcomes vary by race and residential areas of the country. OBJECTIVE: To determine the extent of racial and regional variation in outcomes within 5 years of oral antidiabetic drug initiation among veterans adherent to therapy. DESIGN: Retrospective cohort study of 83,265 US Veterans Health Administration data, 2002-2014 PATIENTS: US veterans with uncomplicated diabetes and taking oral antidiabetic agents MAIN MEASURES: Veterans initially adherent to oral antidiabetic therapy were followed for up to 5 years, and comparisons focused on differences between non-Hispanic White and non-Hispanic Black veterans across geographic region and residential type (urban or rural). Outcomes included composite cardiovascular events, composite cerebrovascular events, or all-cause mortality using Poisson and adjusted Cox proportional hazards models. KEY RESULTS: Cardiovascular event and all-cause mortality rates differed by race and region, while urban/rural differences were evident for cerebrovascular events and all-cause mortality. For non-Hispanic Blacks, the mortality rate was half that compared to non-Hispanic Whites (6.5 [95% CI 5.8-7.2] versus 13.3 [95% CI 12.9-13.8], p < 0.0001). Compared to the Northeast, all other regions had higher adjusted hazards for cardiovascular or cerebrovascular events (with a single exception), but no regional differences in all-cause mortality were observed. Models with interactions demonstrated that racial differences in cardiovascular events and all-cause mortality were isolated to the Midwest (HR 1.99 [95% CI 1.301-3.06; HR 1.64 [95% CI 1.210-2.215]) and South (HR 1.69 [85% CI 1.347-2.131]; HR 1.27 [95% CI 1.095-1.470]). CONCLUSIONS: Despite adherence to therapy, differences in outcomes are likely among veterans with diabetes based on race and geography. Localized analyses may uncover specific social determinants contributing to differences in outcomes.

The prevalence and demographic correlates of stress, anxiety, and depression among veterinary students in the Southeastern United States.

It is no secret that the rigors of professional medical programs are creating an immense strain on mental health, and studies show that students are coping poorly. It is becoming more widely known that this problem especially exists in veterinary medicine. Veterinary colleges are starting to make changes to address the mental health crisis among their student (and practitioner) population, however, in order to solve a problem you must first understand your audience. There are still questions regarding who is more often affected and why? In this study, the prevalence and correlates of stress, anxiety, and depression among veterinary students in the Southeastern US is the primary focus. Three hundred and forty two participants answered survey questions addressing socio-demographics, as well as, completed a perceived stress scale and patient health questionnaire (PHQ-4) to measure anxiety and depression. Chi-square, independent samples t-test, and ANOVA were conducted to assess demographic correlates of stress, anxiety, and depression. High levels of stress, anxiety, and depression were identified among veterinary students participating in the study. Stress level was significantly associated with sex and Grade Point Average (GPA): females and those with GPA <3.0 exhibited higher levels of stress. While it is good that veterinary colleges are already making changes, the question remains if these changes are significant enough. Based on this study's results, transitioning to a pass/fail grading system and implementing regular mindfulness practice are proposed changes that may aid in promoting a positive mental health culture for students and future veterinary professionals.

A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions.

BACKGROUND: Approximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress. METHODS AND FINDINGS: To determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, 'other'). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R2 = 0.36) in claims paid/beneficiary. CONCLUSIONS: Identifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.

The Impact of the Revised WIC Food Package on Maternal Nutrition During Pregnancy and Postpartum.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritional support for pregnant and postpartum women and young children. The typical food package provided to recipient families was revised in October 2009 to include more whole grains, fruits, vegetables, and low-fat milk. Little is known about whether these revisions improved nutrition among women during this critical period of the life course. We conducted a quasiexperimental difference-in-differences analysis, comparing WIC recipients ("treatment" group) before and after the WIC policy change, while accounting for temporal trends among nonrecipients ("control" group). We examined nutritional outcomes among a cohort of 1,454 women recruited during pregnancy in 2006-2011 in Memphis and surrounding Shelby County, Tennessee. We found improvements in several measures of dietary quality and nutrient intake during pregnancy, although these did not persist into the postpartum period. Results were robust to numerous sensitivity analyses. At a time when federal WIC funding is threatened, this study provides some of the first evidence of the benefits of recent WIC revisions among low-income women.

DNA testing in sexual assault cases: When do the benefits outweigh the costs?

OBJECTIVES: We examined 1200 sexual assault cold cases from Denver, Colorado to ascertain the rate of successful prosecution in which there was a DNA suspect match and the cost per conviction. RESULTS: Nearly 40% of the cases in which there was a DNA match failed to result in an arrest or prosecution primarily because victims were uncooperative or their testimony was judged to be unreliable. Other factors affecting conviction included crime context, victim availability, and the ability of the defendant to mount a consensual sex defense. Once an arrest had been made, however, the conviction rate exceeded 90%. We estimate that Denver's sexual assault DNA testing program cost roughly $16,000 per conviction. CONCLUSION: Our results lend strong support to the value of testing sexual assault kits (SAKs) even in cold cases. This suggests that programs such as Federal Solving Cold Cases with DNA Program are well worth the investment.

Measuring socioeconomic adversity in early life.

AIM: Early life adversity leads to enduring effects on physical and mental health, school performance and other outcomes. We sought to identify potentially modifiable factors associated with socioeconomic adversity in early life. METHODS: We enrolled 1503 pregnant women aged 16-40 years, without pregnancy complications or pre-existing conditions from Shelby County, Tennessee. Social, familial and economic variables were analysed using principal components (PCs) analyses to generate the Socioeconomic Adversity Index (SAI). This was replicated using the National Survey of Children's Health (NSCH). Health and social outcomes were compared across the quintile groups defined by SAI values at the county, state and national levels. RESULTS: Significant differences occurred across the SAI Quintile-1 to Quintile-5 groups in marital status, household structure, annual income, education and health insurance. Significantly worse health and social outcomes occurred in the lower versus higher SAI quintiles, including maternal depression, parental incarceration, child's birthweight and potential for child abuse. Maternal age and race also differed significantly across the SAI quintiles. CONCLUSION: Modifiable factors contributing to socioeconomic adversity in early life included marital status, household structure, annual income, education and health insurance. Those exposed to greater socioeconomic adversity as defined by SAI values had significantly worse maternal and child outcomes.

A sustainable business model for comprehensive medication management in a patient-centered medical home.

OBJECTIVES: To develop a sustainable business model for pharmacist-provided comprehensive medication management services in a patient-centered medical home. Secondarily, to evaluate the impact that the pharmacist had on clinical (glycosylated hemoglobin [A1C], low-density lipoprotein [LDL], and blood pressure) and economic (physician productivity and cost avoidance) outcomes. PRACTICE DESCRIPTION: This pilot project took place at the Palmetto Primary Care Physicians Trident office in North Charleston, South Carolina, from October 2013 to September 2014. At the time, the practice employed 5 physicians and 2 nurse practitioners and served more than 20,000 patients. PRACTICE INNOVATION: The pharmacist targeted patients with diabetes, lipid disorders, hypertension, congestive heart failure, obesity, polypharmacy, and treatment regimen nonadherence for his comprehensive medication management services. The pharmacist was available for immediate consultation or referrals by appointment 5 days per week. Services provided by the pharmacist were billed as medication therapy management or "incident to" physician evaluation and management services codes. EVALUATION: Number of patients seen per day, revenue collected from services rendered by the pharmacist, physician productivity and payment, cost avoidance, and health quality metrics (A1C, LDL, and blood pressure) were measured to determine the financial sustainability and clinical impact of the project. RESULTS AND IMPLICATIONS: The pharmacist was able to see an average of 11 patients per day, which was 72% of his capacity. The practice collected about $7400 per month for services rendered by the pharmacist. The average daily payment for services rendered by the physicians in the practice increased by 20.6%. More than 70% of uncontrolled patients had an improvement in clinical outcomes, such as A1C, LDL, and blood pressure. CONCLUSION: This project demonstrates the sustainable business model for embedding a pharmacist into a patient-centered medical home.

A Cost-Benefit Analysis of Automated Physiological Data Acquisition Systems Using Data-Driven Modeling.

Precision medicine and the continuous analysis of "Big data" promises to improve patient outcomes dramatically in the near future. Very recently, healthcare facilities have started to explore automatic collection of patient-specific physiological data with the aim of reducing nursing workload and decreasing manual data entry errors. In addition to those purposes, continuous physiological data can be used for the early detection and prevention of common, and possibly fatal, diseases. For instance, poor patient outcomes from sepsis, a leading cause of mortality in healthcare facilities and a major driver of hospital costs in the USA, can be mitigated when detected early using screening tools that monitor the changing dynamics of physiological data. However, the potential cost of collecting continuous physiological data remains a barrier to the widespread adoption of automated high-frequency data collection systems. In this paper, we perform cost-benefit analysis (CBA) of machine learning applied to various types of acquisition systems (with different collection intervals) to determine if the benefits of such systems will outweigh their implementation costs. Although such systems can be used in the detection of various complications, in order to showcase the immediate benefits, we focus on the early detection of sepsis, one of the major challenges of hospital systems. We present a general approach to conduct such analysis for a wide range of hospitals and highlight its applicability using a case study for a small hospital with 150 beds and 3000 annual patients where the acquisition system would collect data at 1-min intervals. Lastly, we discuss how the analysis may help guide incentives/policies with regard to adopting automated data acquisition systems.

Correction to: A Cost-Benefit Analysis of Automated Physiological Data Acquisition Systems Using Data-Driven Modeling.

[This corrects the article DOI: 10.1007/s41666-018-0040-y.].

Disparities in Population-Level Socio-Economic Factors Are Associated with Disparities in Preoperative Clinical Risk Factors in Children.

African American children are more than twice as likely as white American children to die after surgery, and have increased risk for longer hospital stays, post-surgical complications, and higher hospital costs. Prior research into disparities in pediatric surgery outcomes has not considered interactions between patient-level Clinical Risk Factors (CRFs) and population-level Social, Economic, and Environmental Factors (SEEFs) primarily due to the lack of integrated data sets. In this study, we analyze correlations between SEEFs and CRFs and correlations between CRFs and surgery outcomes. We used a dataset from a cohort of 460 surgical cases who underwent surgery at a children's hospital in Memphis, Tennessee in the United States. The analysis was conducted on 23 CRFs, 9 surgery outcomes, and 10 SEEFs and demographic variables. Our results show that population-level SEEFs are significantly associated with both patient-level CRFs and surgery outcomes. These findings may be important in the improved understanding of health disparities in pediatric surgery outcomes.

Day-flying moths are smaller: evidence for ecological costs of being large.

Research on evolutionary forces determining optimal body sizes has primarily relied on experimental evaluation of respective selective pressures. Accounting for among-species variation through application of phylogenetic comparative methods is a complementary although little used approach. It enables the direct association of body size values with particular environments. Using phylogenetically explicit comparative analyses, we show that small body size is associated with diurnal (rather than nocturnal) activity of adults among temperate species of the moth family Geometridae. The association of an exclusively adult trait with species-specific body size suggests that optimal body sizes are at least partly determined by the costs being a large adult, as opposed to the more frequently considered costs of attaining large size. It appears likely that size-selective predation by insectivorous birds is the primary factor responsible for selection against large body size in day-flying moths.

Disparities in Initial Oral Antidiabetic Medication Adherence Among Veterans with Incident Diabetes.

BACKGROUND: Medication nonadherence is a prevalent public health issue, particularly among patients with diabetes mellitus (DM), and negatively affects health outcomes. Because of the prevalence of DM among U.S. veterans, it is crucial to understand how well these patients adhere to oral antidiabetic (OAD) medication and whether certain subgroups are more likely to be nonadherent. OBJECTIVE: To assess initial OAD medication use among veterans with uncomplicated DM and determine factors associated with adherence in the first 2 years of treatment. METHODS: This was a retrospective cohort study using data from the Veterans Affairs (VA) Corporate Data Warehouse from 2002 through 2014. The first diagnosis for uncomplicated DM was determined, and then medication use was assessed following OAD initiation. OAD use was assessed by proportion of days covered (PDC) for the first 2 years of therapy using outpatient VA pharmacy records. Adherence was determined both continuously and categorically, with a PDC of ≥ 80% used to indicate adherence. Logistic regression was used to determine if certain patient characteristics were associated with being adherent to OADs. RESULTS: A total of 148,544 veterans with uncomplicated DM were assessed, most of whom were white, aged ≥ 55 years, and initiated OAD therapy on metformin. A large portion resided in the southern part of the United States. In the first year, PDC averaged 79.2% (SD = 25.9), and 63.2% were adherent to OAD therapy; however, these numbers declined in the second year, when the average PDC was 71.3% (SD = 35.8), and only 59.1% were adherent. Over the course of both years, PDC averaged 75.3% (SD = 28.4), and 50.9% were adherent. The odds of being adherent were higher among older adults and significantly lower among veterans self-identifying as either African American (OR = 0.61; 95% CI = 0.59-0.63), Native American (OR = 0.67; 95% CI = 0.61-0.75), or Hawaiian/Pacific Islander (OR = 0.84; 95% CI = 0.76-0.92) when compared with whites. Veterans who were either divorced/separated (OR = 0.86; 95% CI = 0.83-0.88) or never married (OR = 0.89; 95% CI = 0.86-0.93) also had lower odds of being initially adherent to OAD therapy compared with those who reported being married. Being nonadherent in year 1 was highly predictive of remaining nonadherent in year 2 (OR = 12.8; 95% CI = 12.23-12.94), with only 22.2% nonadherent in the first year (8.2% overall) becoming adherent in the second year of therapy. Across both years, all minorities were less likely to be adherent (compared with whites), and average adherence differed among all geographic regions of the country. CONCLUSIONS: Within the first year of OAD therapy, medication adherence was suboptimal among veterans with DM, and second-year results indicate that adherence is likely to decline over time. Future studies should consider deeper regional and subgroup analysis to determine what contributes to variation in medication use in communities across the country. DISCLOSURES: This study was supported by a KL2 Career Development Grant from the University of Tennessee Health Science Center's Institute for Research, Innovation, Synergy and Health Equity and by resources from the U.S. Department of Veterans Affairs. Hung and Kovesdy are employees of the Department of Veterans Affairs. Opinions expressed are those of the study authors and do not necessarily reflect the views of the Department of Veterans Affairs. None of the authors declared significant relevant financial conflicts of interest. Results of this study were presented as a poster at the Academy of Managed Care Pharmacy Nexus Conference on October 3-6, 2016, in National Harbor, Maryland.

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) improves hypertension control in medically underserved patients: Care Coordination Institute and American Medical Association Hypertension Control Project Pilot Study results.

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) is an evidence-based protocol implemented to improve hypertension control in a clinic for underserved patients (49.9% Medicaid and 50.2% black). Patients with hypertension seen during the year before intervention and with at least one visit during the 6-month intervention (N = 714) were included. If initial attended blood pressure (BP; standard aneroid manometer) was ≥140/≥90 mm Hg, unattended automated office BP was measured in triplicate and averaged (Measure Accurately) using an Omron HEM-907XL. When automated office BP was ≥140/≥90 mm Hg, Act Rapidly included intensification of antihypertensive medications, assessed by therapeutic inertia. Partner With Patients included BP self-monitoring, reducing pill burden, and minimizing medication costs, which was assessed by systolic BP change per therapeutic intensification. Between baseline and the last study visit, BP control to <140/<90 mm Hg increased from 61.2% to 89.9% (P < .0001). MAP rapidly and significantly improved hypertension control in medically underserved patients, largely as a result of measuring BP accurately and partnering with patients.

Socioecological Risk Predictors of Physical Activity and Associated Mortality.

PURPOSE: To assess (1) the cumulative effect of socioecological factors (social risk) on objectively measured physical activity, (2) the cumulative socioecological risk on all-cause mortality, (3) the potential interaction effects of social risk factors on physical activity and mortality, and (4) whether physical activity mediates the relationship between social risk and mortality. DESIGN: Cross-sectional and prospective. SETTING: Laboratory- and survey-based testing of the general US population. PARTICIPANTS: Five thousand five hundred seventy-four adult participants of the National Health and Nutrition Examination Survey 2003 to 2006. MEASURES: Social risk was assessed from 4 variables, namely poverty level, education, minority status, and social living status. Moderate-to-vigorous physical activity (MVPA) was assessed via accelerometry. Mortality was assessed via linkage with the National Death Index, with follow-up through 2011. ANALYSIS: Negative binomial regression and Cox proportional hazard model. RESULTS: Compared to those with 0 social risk factors, those with 1 and 2+ social risk factors engaged in 11% and 10% less MVPA, respectively. Those with 1 (vs 0) social risk factor had a 2.0-fold increase in mortality risk, and those with 2+ (vs 0) social risk factors had a 2.3-fold increase in mortality risk. Interaction effects for various socioecological factors on both MVPA and mortality were observable. CONCLUSION: Cumulative social risk is associated with less MVPA and increased all-cause mortality risk. Given the interaction effects of socioecological factors, targeted interventions in identified populations may be needed.

Cholesterol Control Among Uninsured Adults Did Not Improve From 2001-2004 to 2009-2012 as Disparities With Both Publicly and Privately Insured Adults Doubled.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C) control is higher among insured than uninsured adults, but data on time trends and contributing factors are incomplete and important for improving health equity. METHODS AND RESULTS: Awareness, treatment, and control of elevated LDL-C were compared among insured versus uninsured and publicly versus privately insured adults, aged 21 to 64 years, in National Health and Nutrition Examination Surveys from 2001 to 2004, 2005 to 2008, and 2009 to 2012 using Adult Treatment Panel-3 criteria. Compared with insured adults, uninsured adults were younger; were more often minority; reported lower incomes, less education, and fewer healthcare encounters; and had lower awareness and treatment of elevated LDL-C (P<0.0001). LDL-C control was higher among insured than uninsured adults in 2001 to 2004 (mean±SEM, 21.4±1.6% versus 10.5±2.6%; P<0.01), and the gap widened by 2009 to 2012 (35.1±1.9% versus 11.3±2.2%; P<0.0001). Despite more minorities (P<0.01), greater poverty, and less education (P<0.001), publicly insured adults had more healthcare visits/year than privately insured adults (P<0.001) and similar awareness, treatment, and control of LDL-C from 2001 to 2012. In multivariable logistic regression, significant positive predictors of cholesterol awareness, treatment, and control included more frequent health care (strongest), increasing age, private healthcare insurance versus uninsured, and hypertension. Public insurance (versus uninsured) was a significant positive predictor of LDL-C control, whereas income <200% versus ≥200% of federal poverty was a significant negative predictor. CONCLUSIONS: LDL-C control improved similarly over time in publicly and privately insured adults but was stagnant among the uninsured. Healthcare insurance largely addresses socioeconomic barriers to effective LDL-C management, yet poverty retains an independent adverse effect.