Differential Impact of Index Stroke on Dementia Risk in African-Americans Compared to Whites.

OBJECTIVE: To compare whites and African-Americans in terms of dementia risk following index stroke. METHODS: The data consisted of billing and International Classification of Diseases, Ninth Revision diagnosis codes from the South Carolina Revenue and Fiscal Affairs office on all hospital discharges within the state between 2000 and 2012. The sample consisted of 68,758 individuals with a diagnosis of ischemic stroke prior to 2010 (49,262 white [71.65%] and 19,496 African-Americans [28.35%]). We identified individuals in the dataset who were subsequently diagnosed with any of 5 categories of dementia and evaluated time to dementia diagnosis in Cox Proportional Hazards models. We plotted cumulative hazard curves to illustrate the effect of race on dementia risk after controlling for age, sex, and occurrence of intervening stroke. RESULTS: Age at index stroke was significantly different between the 2 groups, with African-Americans being younger on average (70.0 [SD 12.5] in whites versus 64.5 [SD 14.1] in African-Americans, P < .0001). Adjusted hazard ratios revealed that African-American race increased risk for all 5 categories of dementia following incident stroke, ranging from 1.37 for AD to 1.95 for vascular dementia. Age, female sex, and intervening stroke likewise increased risk for dementia. CONCLUSIONS: African-Americans are at higher risk for dementia than whites within 5 years of ischemic stroke, regardless of dementia subtype. Incident strokes may have a greater likelihood of precipitating dementia in African-Americans due to higher prevalence of nonstroke cerebrovascular disease or other metabolic or vascular factors that contribute to cognitive impairment.

Health care improvement and cost reduction opportunities in hypertensive Medicaid beneficiaries.

Hypertension and its complications are more frequent and occur about a decade earlier in life among high-risk groups, especially in the Southeast. Moreover, socioeconomic status is inversely related to hypertension and cardiovascular complications. Low-income, young and middle-aged adults living in the Southeast may be at especially high risk. Data on inpatient admissions among hypertensive Medicaid beneficiaries living in this region may provide insights on the burden of hypertension-related disease and on opportunities for successful intervention. A study of hospitalization rates and costs among 44,440 hypertensive Medicaid beneficiaries in South Carolina from 1993-1996 showed that 16,883 (38%) were continuously enrolled in Medicaid. Of this group, 63% were African American and 74% were women. Among the continuously enrolled patients, 7637, or about 45%, were hospitalized during the 4-year period. These 7637 individuals accounted for 20,698 hospital admissions, i.e., 2.7 admissions per person, over the 4-year interval. Nearly two thirds of the hospitalizations included a cardiovascular or renal diagnosis. Hospital claims paid reached nearly $90 million for the 7637 hypertensive Medicaid recipients during the 4-year period. Among patients discharged from the hospital with congestive heart failure, 33% filled a prescription for an angiotensin-converting enzyme inhibitor within 90 days; 13% of patients discharged with an acute myocardial infarction filled a prescription for a beta blocker within 90 days. The data confirm that hypertensive Medicaid beneficiaries in the Southeast are hospitalized at high rates. Cardiovascular and renal morbidity account for the majority of the inpatient admissions. The findings suggest that the application of evidence-based guidelines would improve health, avoid cost, and reduce racial disparities in health outcomes.

A current assessment of rurally linked exposures as potential risk factors for sarcoidosis.

PURPOSE: To identify and quantify the risk of developing sarcoidosis associated with specific rural exposures previously recognized as potential risk factors for this disease. METHODS: A matched case-control design was carried out with a 2-to-1 ratio of controls to cases. Case exposure histories were determine from a detailed questionnaire collecting self-reported information covering the period from birth through disease development and comparing that to exposure histories for the corresponding period in age-, race-, and gender-matched controls identified using Random Digit Dial survey methodology. Conditional logistic regression was used to analyze the matched data while controlling for several baseline variables. RESULTS: A number of exposures were found to be univariately associated with the development of sarcoidosis including: the use of wood stoves, the use of fireplaces, the use of nonpublic water supplies, and living or working on a farm. A dose-response gradient was detected from exposure to wood stoves and fireplaces continued to be significantly associated with sarcoidosis in multivariable models. CONCLUSIONS: The results of this study provide further support for the hypothesis that behaviors associated with rural living play some role in the development of sarcoidosis. This study further suggests that exposures involving the handling or burning of wood such as using wood stoves or fireplaces for home heating may, in part, explain this rural association.

Prevention education and evaluation in U.S. medical schools: a status report.

The Prevention Curriculum Assistance Program (PCAP) was initiated to help U.S. medical schools examine the extent to which they are evaluating the learning of medical students about disease prevention/health promotion. A survey was sent to all 144 allopathic and osteopathic medical schools, with an overall response rate of 68%. The results revealed more emphasis on teaching and evaluating the learning of medical students in the areas of clinical preventive services and quantitative methods, and less emphasis on the community dimensions of medical practice and health services organization and delivery. Written tests and unstructured observation are the most common methods of evaluation. Fewer than half of all respondents were satisfied with the quality of their assessment of student achievement in any of the four domains of prevention education. More than 30% expressed a desire to receive assistance with designing curricula and/ or evaluation methods in each of the four content areas examined. Several indicated their willingness to assist colleagues who want to improve their prevention curricula and/or measurement strategies. This study identified a need for more attention and support for prevention education and evaluation programs. Curriculum leaders can help by designating prevention a priority area and appointing faculty to be responsible for monitoring the content and quality of prevention teaching throughout the curriculum. Resources such as the Internet can be utilized to establish a network whereby medical schools can collaborate to improve their educational programs and evaluation methods in prevention.

Geographic variation in sarcoidosis in South Carolina: its relation to socioeconomic status and health care indicators.

Geographic patterns of sarcoidosis have been detected and studied on a global scale. However, the associations between these disease patterns and population characteristics have not been determined. The authors studied the geographic pattern of sarcoidosis in South Carolina and its relation to socioeconomic status (SES) and health status indicators. Hospitalization rates for the period 1985-1995 were used as geographic indicators of sarcoidosis. Rates were assessed for the 46 counties in South Carolina, adjusting for differences in SES, availability/accessibility of health care, diagnostic practices, and hospital utilization. Patterns in geographic variation were assessed based on physiographic characteristics and proximity to the Atlantic coastline. Significant variation was identified with an increase in sarcoidosis rates proximal to the Atlantic coastline. Population characteristics were identified that appeared to explain regional variation in sarcoidosis in Caucasians; however, regression analysis was unable to explain the regional differences in disease distribution by variation in SES, diagnostic practices, accessibility/availability, or hospital utilization in African Americans. These results suggest that the development of sarcoidosis is associated with a geographically linked risk factor in African Americans. This work supports the need for additional studies that will identify this risk factor(s).

Hypertension-related morbidity and mortality in the southeastern United States.

Stroke mortality is higher in the Southeast compared with other regions of the United States. The prevalence of hypertension is also higher (black men = 35%, black women = 37.7%, white men = 26.5%, white women = 21.5%), and the proportion of patients whose hypertension is being controlled is poor, especially in white and black men. The prevalence of hypertension-related complications other than stroke is also higher in the Southeast. The five states with the highest death rates for congestive heart failure are all in the southern region. Of the 15 states with the highest rates of end-stage renal disease, 10 are in the Southeast. Obesity is very prevalent (24% to 28%) in the Southeast. Although Michigan tops the ranking for all states, 6 of the top 15 states are in the Southeast, as are 7 of the 10 states with the highest reported prevalence regarding no leisure-time physical activity. Similar to other areas of the United States, dietary sodium and saturated fat intake are high in the Southeast; dietary potassium intake appears to be relatively low. Other factors that may be associated with the high prevalence, poor control, and excess morbidity and mortality of hypertension-related complications in the Southeast include misperceptions of the seriousness of the problem, the severity of the hypertension, lack of adequate follow-up, reduced access to health care, the cost of treatment, and possibly, low birth weights. The Consortium of Southeastern Hypertension Control (COSEHC) is a nonprofit organization created in 1992 in response to a compelling need to improve the disproportionate hypertension-related morbidity and mortality throughout this region. The purpose of this position paper is to summarize the data that document the problem, the consequences, and possible causative factors.

Is race related to glycemic control? An assessment of glycosylated hemoglobin in two South Carolina communities.

To consider the relationship between race and long-term glycemic control, as measured by glycosylated hemoglobin (GHb), we analyzed data from a community-based sample of 3175 adults in the South Carolina Cardiovascular Disease Prevention Project. A clinically meaningful difference for mean GHb levels (10.5 vs 8.4%, P < 0.001) was present between black people and white people reporting diabetes. Similarly, a significant association between race and GHb was present among people reporting "borderline diabetes" or no diabetes. Logistic regression confirmed this finding in all three diabetic categories, however, controlling for insulin use in the diabetic group reduced (P < 0.001) the association between GHb and race. These findings confirm that further improvements in glycemic control are necessary, especially for black patients and that black people not reporting diabetes have higher GHb levels compared to white people, possibly due to undiagnosed diabetes.

Leisure time physical activity: are there black/white differences?

BACKGROUND: Behavioral risk factor surveillance survey data collected during 1984 and 1985 in South Carolina were analyzed. METHODS: This article is based on telephone interviews conducted with 2,005 individuals (431 black, 1574 white), mean age, 45.1 years, selected by random-digit dialing. Information on the type, frequency, and duration of leisure time physical activity was used to estimate leisure time energy expenditure (kcal/week) averaged over the previous month. The median level of leisure time energy expenditure differed significantly (all P less than 0.001) by gender (men = 741, women = 421), age (six categories; youngest, 18-29 years = 780; oldest, 70+ = 301), annual household income (four categories; lowest, less than or equal to $10,000 = 300; highest, greater than $35,000 = 870), body mass index (kg/m2, less than or equal to 24.1 = 601, greater than or equal to 30.1 = 180), and race (black = 301, white = 601). RESULTS: Leisure time energy expenditure generally decreased with increasing age and body mass index and increased with increasing levels of education and income among all race/gender groups. Logistic regression analyses revealed that after adjustment for gender (if applicable), age, income, and body mass index, the variable race made a statistically significant contribution to the model, in the total sample (P less than .03) and for women P less than .001), but not for men. CONCLUSIONS: Our results suggest that blacks living in the South, particularly black women, have lower levels of leisure time physical activity compared with their white counterparts after control for several important confounders.

Breast cancer screening in a biracial community: the Charleston tricounty experience.

Breast cancer remains a major cause of death among women in South Carolina. Mammography, breast self-examination, and clinical breast examination are effective methods for early detection and subsequent mortality reduction. The Tricounty Breast Cancer Screening Survey assessed knowledge of these methods and recommendations among 503 women in the Charleston area. While 57% of all respondents reported performing breast self-examination at least once per month, 13% of blacks and 6% of whites reported that they do not know how to perform the procedure. Clinical breast examinations within the past year were reported by 69%, yet 11% of blacks and 4% of whites reported that they had never had the examination. More than one third (40%) of all 503 women reported ever having had a mammogram, and 22% reported having had one within the past year. However, 18% of the blacks and 5% of whites reported never having heard of the procedure. The major barriers to mammography appear to be the belief that women do not need regular mammograms and the lack of recommendations by their physicians. Survey results support the need for educating women about what the procedures are, the importance of using them regularly, and the means to comply with them.