Community burden and prognostic impact of reduced kidney function among patients hospitalized with acute decompensated heart failure: The Atherosclerosis Risk in Communities (ARIC) Study Community Surveillance.

BACKGROUND: Kidney dysfunction is prevalent and impacts prognosis in patients with acute decompensated heart failure (ADHF). However, most previous reports were from a single hospital, limiting their generalizability. Also, contemporary data using new equation for estimated glomerular filtration rate (eGFR) are needed. METHODS AND RESULTS: We analyzed data from the ARIC Community Surveillance for ADHF conducted for residents aged ≥55 years in four US communities between 2005-2011. All ADHF cases (n = 5, 391) were adjudicated and weighted to represent those communities (24,932 weighted cases). The association of kidney function (creatinine-based eGFR by the CKD-EPI equation and blood urea nitrogen [BUN]) during hospitalization with 1-year mortality was assessed using logistic regression. Based on worst and last serum creatinine, there were 82.5% and 70.6% with reduced eGFR (<60 ml/min/1.73m2) and 37.4% and 26.6% with severely reduced eGFR (<30 ml/min/1.73m2), respectively. Lower eGFR (regardless of last or worst eGFR), particularly eGFR <30 ml/min/1.73m2, was significantly associated with higher 1-year mortality independently of potential confounders (odds ratio 1.60 [95% CI 1.26-2.04] for last eGFR 15-29 ml/min/1.73m2 and 2.30 [1.76-3.00] for <15 compared to eGFR ≥60). The association was largely consistent across demographic subgroups. Of interest, when both eGFR and BUN were modeled together, only BUN remained significant. CONCLUSIONS: Severely reduced eGFR (<30 ml/min/1.73m2) was observed in ~30% of ADHF cases and was an independent predictor of 1-year mortality in community. For prediction, BUN appeared to be superior to eGFR. These findings suggest the need of close attention to kidney dysfunction among ADHF patients.

Identification of Heart Failure Events in Medicare Claims: The Atherosclerosis Risk in Communities (ARIC) Study.

BACKGROUND: We examined the accuracy of Medicare heart failure (HF) diagnostic codes in the identification of acute decompensated (ADHF and chronic stable (CSHF) HF. METHODS AND RESULTS: Hospitalizations were identified from medical discharge records for Atherosclerosis Risk in Communities (ARIC) study participants with linked Medicare Provider Analysis and Review (MedPAR) files for the years 2005-2009. The ARIC study classification of ADHF and CSHF, based on adjudicated review of medical records, was considered to be the criterion standard. A total 8,239 ARIC medical records and MedPAR records meeting fee-for-service (FFS) criteria matched on unique participant ID and date of discharge (68.5% match). Agreement between HF diagnostic codes from the 2 data sources found in the matched records for codes in any position (κ > 0.9) was attenuated for primary diagnostic codes (κ < 0.8). Sensitivity of HF diagnostic codes found in Medicare claims in the identification of ADHF and CSHF was low, especially for the primary diagnostic codes. CONCLUSION: Matching of hospitalizations from Medicare claims with those obtained from abstracted medical records is incomplete, even for hospitalizations meeting FFS criteria. Within matched records, HF diagnostic codes from Medicare show excellent agreement with HF diagnostic codes obtained from medical record abstraction. The Medicare data may, however, overestimate the occurrence of hospitalized ADHF or CSHF.

Prediction of incident heart failure in general practice: the Atherosclerosis Risk in Communities (ARIC) Study.

BACKGROUND: A simple and effective heart failure (HF) risk score would facilitate the primary prevention and early diagnosis of HF in general practice. We examined the external validity of existing HF risk scores, optimized a 10-year HF risk function, and examined the incremental value of several biomarkers, including N-terminal pro-brain natriuretic peptide. METHODS AND RESULTS: During 15.5 years (210 102 person-years of follow-up), 1487 HF events were recorded among 13 555 members of the biethnic Atherosclerosis Risk in Communities (ARIC) Study cohort. The area under curve from the Framingham-published, Framingham-recalibrated, Health ABC HF recalibrated, and ARIC risk scores were 0.610, 0.762, 0.783, and 0.797, respectively. On addition of N-terminal pro-brain natriuretic peptide, the optimism-corrected area under curve of the ARIC HF risk score increased from 0.773 (95% CI, 0.753-0.787) to 0.805 (95% CI, 0.792-0.820). Inclusion of N-terminal pro-brain natriuretic peptide improved the overall classification of recalibrated Framingham, recalibrated Health ABC, and ARIC risk scores by 18%, 12%, and 13%, respectively. In contrast, cystatin C or high-sensitivity C-reactive protein did not add toward incremental risk prediction. CONCLUSIONS: The ARIC HF risk score is more parsimonious yet performs slightly better than the extant risk scores in predicting 10-year risk of incident HF. The inclusion of N-terminal pro-brain natriuretic peptide markedly improves HF risk prediction. A simplified risk score restricted to a patient's age, race, sex, and N-terminal pro-brain natriuretic peptide performs comparably to the full score (area under curve, 0.745) and is suitable for automated reporting from laboratory panels and electronic medical records.

Variation in rates of fatal coronary heart disease by neighborhood socioeconomic status: the atherosclerosis risk in communities surveillance (1992-2002).

PURPOSE: Racial and gender disparities in out-of-hospital deaths from coronary heart disease (CHD) have been well-documented, yet disparities by neighborhood socioeconomic status (nSES) have been less systematically studied in US population-based surveillance efforts. METHODS: We examined the association of nSES, classified into tertiles, with 3,743 out-of-hospital fatal CHD events, and a subset of 2,191 events classified as sudden, among persons aged 35 to 74 years in four US communities under surveillance by the Atherosclerosis Risk in Communities (ARIC). Poisson generalized linear mixed models generated age-, race- (white, black) and gender-specific standardized mortality rate ratios and 95% confidence intervals (RR, 95% CI). RESULTS: Regardless of nSES measure used, inverse associations of nSES with all out-of-hospital fatal CHD and sudden fatal CHD were seen in all race-gender groups. The magnitude of these associations was larger among women than men. Further, among blacks, associations of low nSES (vs. high nSES) were stronger for sudden cardiac deaths (SCD) than for all out-of-hospital fatal CHD. CONCLUSIONS: Low nSES was associated with an increased risk of out-of-hospital CHD death and SCD. Measures of the neighborhood context are useful tools in population-based surveillance efforts for documenting and monitoring socioeconomic disparities in mortality over time.

Racial/ethnic heterogeneity in the socioeconomic patterning of CVD risk factors: in the United States: the multi-ethnic study of atherosclerosis.

Many studies document racial variation, gender differences, and socioeconomic status (SES) patterning in cardiovascular disease (CVD) risk factors but few studies have investigated heterogeneity in SES differences by race/ethnicity or gender. Using data from the Multi-Ethnic Study of Atherosclerosis (N=6,814) and stratified regression models, we investigated race/ethnic differences in the SES patterning of diabetes, hypertension, smoking, and body mass index (BMI). Inverse socioeconomic gradients in hypertension, diabetes, smoking, and BMI were observed in White and Black women but associations were weaker or absent in Hispanic and Chinese women (except in the case of diabetes for Hispanic women). Even greater heterogeneity in social patterning of risk factors was observed in men. In White men all four risk factors were inversely associated with socioeconomic position, although often associations were only present or were stronger for education than for income. The inverse socioeconomic patterning was much less consistent in men of other races/ethnic groups, and higher SES was associated with higher BMI in non-White men. These findings have implications for understanding the causes of social patterning, for the analysis of SES adjusted race/ethnic differences, and for the targeting of interventions.

Life-course socioeconomic positions and subclinical atherosclerosis in the multi-ethnic study of atherosclerosis.

A major limitation of past work on the social patterning of atherosclerosis has been the reliance on measures of neighborhood or individual-level socioeconomic position (SEP) assessed at a single point in time in adulthood. Risk of chronic disease is thought to accumulate throughout the life-course, so the use of a measure for a single point in time may result in inaccurate estimates of the social patterning of subclinical disease. Using data from the US Multi-Ethnic Study of Atherosclerosis (MESA), we examined the relation between childhood SEP [CSEP] (father or caretaker's education), adulthood SEP [ASEP] (a summary score of income, education, and wealth), and 20-year average exposure to neighborhood poverty [NSEP] (residential addresses geocoded and linked to census data) and the prevalence of subclinical atherosclerosis, as assessed by common carotid intimal-medial thickness (IMT) in mid to late adulthood. Participants were 45-84 years of age at baseline and were sampled from six study sites in the United States. After adjustment for age, CSEP and ASEP were both inversely and independently associated with IMT in men. All three indicators CSEP, ASEP, and NSEP were inversely and independently associated with IMT in women. Associations were somewhat reduced after adjustment for cardiovascular risk factors, suggesting that these factors may play a mediating role. There was evidence of heterogeneity in effects of NSEP by gender, and in the effects of ASEP and NSEP by race/ethnicity. Our results contribute to the growing body of work that shows that SEP at multiple points in the life-course, and at the individual and neighborhood level, contributes to the development of atherosclerosis.

Socioeconomic position, race/ethnicity, and inflammation in the multi-ethnic study of atherosclerosis.

BACKGROUND: Low socioeconomic position is known to be associated with cardiovascular events and atherosclerosis. Reasons for these associations remain a topic of research. Inflammation could be an important mediating mechanism linking socioeconomic position to cardiovascular risk. METHODS AND RESULTS: This cross-sectional study used data from the baseline examination of the Multi-Ethnic Study of Atherosclerosis (MESA), a study of 6814 men and women 45 to 84 years of age. Race- and ethnicity-stratified regression analyses were used to estimate associations of household income and education with C-reactive protein and interleukin-6 before and after adjustment for infection and medication use, psychosocial factors, behaviors, adiposity, and diabetes mellitus. Low income was associated with higher concentrations of interleukin-6 in all race/ethnic groups. Percent differences associated with 1-SD-lower income were 9% (95% confidence interval [CI], 7 to 11), 6% (95% CI, 1 to 10), 8% (95% CI, 4 to 11), and 8% (95% CI, 3 to 13) for whites, Chinese, blacks, and Hispanics. Low levels of education were associated with higher levels of interleukin-6 only among whites and blacks (percent difference in interleukin-6 associated with 1-SD-lower education: 9% [95% CI, 6 to 12] among Whites, and 7% [95% CI, 3 to 10] among blacks). Similar patterns were observed for C-reactive protein. Adiposity was the single most important factor explaining socioeconomic position associations, especially among blacks and whites. A smaller effect was seen for psychosocial factors and behaviors in all race groups. CONCLUSIONS: Both household income and education are associated with inflammation, but associations vary across race/ethnic groups. Associations likely result from socioeconomic position patterning of adiposity and other factors.

Access to health care among Hispanic/Latino children: United States, 1998-2001.

OBJECTIVE: This report presents national estimates on access to health care for five subgroups of Hispanic/Latino children in the United States: Mexican, Puerto Rican, Cuban, Central or South American, and other Hispanic. For comparison, estimates are also presented for non-Hispanic white children. METHODS: Data for persons of all ages in the U.S. civilian noninstitutionalized population are collected each year in the National Health Interview Survey (NHIS), which is conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. Each year, data are collected for approximately 100,000 persons in 40,000 households. In the 1998-2001 surveys combined, 53,510 interviews (14,284 Hispanic/Latino children) were completed by knowledgeable adults for a subsample of children under age 18 years, with an overall response rate of 80.2%. RESULTS: Each year, an estimated 3.0 million (25.7%) Hispanic/Latino children lacked health insurance coverage at the time of interview, 1.6 million (14.1%) had no usual place to go for health care during the past year, and 1.4 million (17.6%) experienced unmet health care needs during the past year due to cost. Of the five Hispanic/Latino subgroups, Mexican children were most likely (30.4%) to lack health insurance coverage, followed by Central or South American children (23.8%) and other Hispanic children (18.6%). The percentage of children having a usual place to go for health care was highest for Cuban children (93.5%) and lowest for Mexican children (83.3%). The percentage of children who experienced unmet medical needs due to cost in the past year was 18.3% for Mexican children, 16.3% for Puerto Rican children, 12.8% for Central or South American children, and 8.3% for Cuban children. Lack of access to health care was most prevalent among Hispanic/Latino children who had poor or near poor poverty status, whose parents had less than a high school diploma, and who were foreign born. CONCLUSION: Access to health care varied among subgroups of Hispanic/Latino children. Understanding subgroup differences may help community-based programs improve access to care among Hispanic/Latino children.

Prevalence of self-reported heart failure among US adults: results from the 1999 National Health Interview Survey.

OBJECTIVE: The objective of the present study was to determine the prevalence of self-reported heart failure among US adults. METHODS: Data from the 1999 National Health Interview Survey were analyzed. A total of 30,801 sampled adults aged >or=18 years were given a list of major medical conditions, which included heart failure (HF), and asked if they had ever been told by a doctor or other health professional that they had any of the conditions. Analyses were conducted with the use of SUDAAN software to account for the complex sample design. RESULTS: An estimated 2.4 million adults had been told by a doctor or other health professional that they had HF. The prevalence of self-reported HF for age groups 18 to 39, 40 to 64, 65 to 74, and 75 to 105 years were 0.1%, 1.1%, 3.6%, and 5.5%, respectively. HF was most prevalent among ever-smokers, obese persons, and persons aged >or=65 years. No difference was found in the prevalence of self-reported HF between black and white persons. The most common comorbid conditions for those with HF were hypertension, coronary heart disease, and diabetes. Compared with those without HF, the elderly persons with HF were 8 times as likely to have severe mobility difficulties and 2 to 3 times as likely to have severe depression. Half of the elderly persons with HF had been hospitalized, visited an emergency room, or had >10 clinic visits in the past year. Black patients were more likely than white patients to have been unable to pay for prescription medicine and to have seen a medical specialist during the past year. CONCLUSIONS: This nationally representative survey indicates that an estimated 2.4 million adults had been told by a doctor or other health professional that they had heart failure. Black patients with HF were less likely than white patients to have received the needed care.

Utilization of dental care services by Asians and native Hawaiian or other Pacific Islanders: United States, 1997-2000.

OBJECTIVE: This report describes national estimates of dental care service utilization and unmet dental care needs due to cost for six Asian ethnic subgroups and the native Hawaiian or other Pacific Islander (NHOPI) population. METHODS: Combined data from the 1997-2000 National Health Interview Surveys (NHISs), conducted by the Centers for Disease Control's National Center for Health Statistics, were analyzed to produce estimates for Asians and NHOPIs aged 2 years and over. Information on dental care service utilization and unmet dental care needs due to cost was self-reported by persons aged 18 years and over. For children aged 2-17 years, the information was collected from an adult who was knowledgeable about the child's health. RESULTS: Approximately 64% of Asian and 56% NHOPI persons had visited a dentist at least once in the past year. Utilization of dental care services, however, varies significantly by ethnic subgroup. Asian Indians were most likely to have never had a dental visit and the NHOPIs were most likely to experience unmet dental care needs in the past year. Among adults, Japanese Americans (68.2%) were most likely and NHOPIs (49.3%) were least likely to have had a dental visit in the past year. Underutilization of dental care services was most prevalent among Asian adults with poor or near poor poverty status, without health insurance coverage, and who had resided in the United States for less than 5 years. Among children, NHOPIs (82.0%) were most likely and Asian Indians (60.1%) were least likely to have had a dental visit in the past year. Underutilization was most prevalent among Asian children who were not living with their parents or living with a single parent, who had no insurance coverage, who had poor or near poor poverty status, and whose parents had less than 12 years of education. CONCLUSIONS: Utilization of dental care services and unmet dental care needs due to cost vary among the Asian ethnic subgroups and the NHOPI population.

Utilization of complementary and alternative medicine by United States adults: results from the 1999 national health interview survey.

OBJECTIVE: To measure utilization of complementary and alternative medicine (CAM) by US adults. METHODS: We analyzed data from the 1999 National Health Interview Survey (NHIS), which covers the noninstitutionalized civilian US population. Information on 12 types of CAM use in the past 12 months was obtained from 30,801 respondents aged 18 years and older. Statistical analyses were performed using the SUDAAN software package to account for the complex sample design of the NHIS. RESULTS: An estimated 28.9% of US adults used at least one CAM therapy in the past year. The three most commonly used therapies were spiritual healing or prayer (13.7%), herbal medicine (9.6%), and chiropractic therapies (7.6%). The use of CAM was most prevalent among women, persons aged 35 to 54 years, and persons with an educational attainment of > or =16 years. The overall CAM use was higher for white non-Hispanic persons (30.8%) than for Hispanic (19.9%) and black non-Hispanic persons (24.1%). Although the use was higher for persons who had health insurance than for those who did not, the difference was not statistically significant after adjusting for age, gender and educational attainment. Compared with nonusers, CAM users were more likely to use conventional medical services. CONCLUSIONS: Estimates of CAM use in this nationally representative sample were considerably lower than have been reported in previous surveys. Most CAM therapies are used by US adults in conjunction with conventional medical services.