The association between social determinants of health and patient-centred outcomes in adults with heart failure with reduced ejection fraction.

AIMS: To explore the associations between social determinants of health and patient-centred outcomes among adults with chronic heart failure with reduced ejection fraction. DESIGN: Cross-sectional online self-report survey. METHODS: A survey assessing social determinants of health (demographics, socio-economic position, affordability of care and social support) and patient-centred outcomes, including the Kansas City Cardiomyopathy Questionnaire-12 and validated measures of medication adherence, treatment satisfaction, treatment burden and mental health, was completed by 512 adults with chronic heart failure with a reduced ejection fraction between 06 March and 29 June 2020. Multivariable analyses included linear and logistic regression. RESULTS: Female gender, having a care partner, and being offered financial assistance with medications were associated with worse health status, while perceiving medication as affordable and being married were associated with better health status. Females and having Medicaid, dual Medicaid/Medicare or no medical insurance were associated with a higher likelihood of depression, and non-white race/ethnicity was associated with less depression. Medication adherence was lower in patients having a care partner and offered financial assistance. Patients being offered financial and medication management assistance were more likely to be overwhelmed by the treatment burden, whereas those having some college education were less so. CONCLUSIONS: Social determinants of health are associated with patients' disease-specific health status, mental health and treatment satisfaction and burden. These findings underscore the importance of assessing social determinants of health in clinical practice and the need for developing and testing novel strategies to determine whether they improve patients' health. IMPACT: The relationship between social determinants of health- and patient-centred outcomes was assessed; affordability of care and social support factors were most strongly associated with outcomes for patients with chronic heart failure and reduced ejection fraction, underscoring the importance of assessing social determinants of health in routine clinical care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Social determinants of health data could potentially inform care delivery for patients with heart failure and reduced ejection fraction by helping to identify those who require additional support to manage their symptoms, access care and adhere to treatment. Social support and affordability of treatment were associated with most patient-centred outcomes, suggesting these factors may provide clinicians with an indicator of a patient's level of general well-being that could be assessed during routine follow-up care. REPORTING METHOD: This research followed the STROBE checklist for cross-sectional studies. PATIENT OR PUBLIC CONTRIBUTION: Adults who have heart failure with reduced ejection fraction that consented to participate in the study provided the data used for all analyses reported on in the manuscript. Service users, caregivers or members of the public had no involvement in the study.

The Utility of Nursing Notes Among Medicare Patients With Heart Failure to Predict 30-Day Rehospitalization: A Pilot Study.

BACKGROUND: For patients with heart failure (HF), there have been efforts to reduce the risk of 30-day rehospitalization, such as developing predictive models using electronic health records. Few previous studies used clinical notes to predict 30-day rehospitalization. OBJECTIVE: The aim of this study was to assess the utility of nursing notes versus discharge summaries to predict 30-day rehospitalization among patients with HF. METHODS: In this pilot study, we used free-text discharge summaries and nursing notes collected from a tertiary hospital. We randomly selected 500 Medicare patients with HF. We followed the natural language processing and machine learning pipeline for data analysis. RESULTS: Thirty-day rehospitalization risk prediction using discharge summaries (n = 500) produced an area under the receiver operating characteristic curve of 0.74 (Bag of Words + Neural Network). Thirty-day rehospitalization risk prediction using nursing notes (n = 2046) resulted in an area under the receiver operating characteristic curve of 0.85 (Bag of Words + Neural Network). CONCLUSION: Nursing notes provide a superior input to risk models for 30-day rehospitalization in Medicare patients with HF compared with discharge summaries.

Association Between Early Trauma and Ideal Cardiovascular Health Among Black Americans: Results From the Morehouse-Emory Cardiovascular (MECA) Center for Health Equity.

BACKGROUND: Early trauma (general, emotional, physical, and sexual abuse before age 18 years) has been associated with both cardiovascular disease risk and lifestyle-related risk factors for cardiovascular disease, including smoking, obesity, and physical inactivity. Despite higher prevalence, the association between early trauma and cardiovascular health (CVH) has been understudied in Black Americans, especially those from low-income backgrounds, who may be doubly vulnerable. Therefore, we investigated the association between early trauma and CVH, particularly among low-income Black Americans. METHODS: We recruited 457 Black adults (age 53±10, 38% male) without known cardiovascular disease from the Atlanta, GA, metropolitan area using personalized, community-based recruitment methods. The Early Trauma Inventory was administered to assess overall early traumatic life experiences which include physical, sexual, emotional abuse, and general trauma. Our primary outcome was the American Heart Association Life's Simple 7, which is a set of 7 CVH metrics, including 4 lifestyle-related factors (smoking, body mass index, physical activity, and diet) and three physiologically measured health factors (blood pressure, total blood cholesterol, and blood glucose). We used linear regression models adjusting for age, sex, socioeconomic status, and depression to test the association between early trauma and CVH and tested the early trauma by household income (<$50 000) interaction. RESULTS: Higher levels of early trauma were associated with lower Life's Simple 7 scores (ß, -0.05 [95% CI, -0.09 to -0.01], P=0.02, per 1 unit increase in the Early Trauma Inventory score) among lower, but not higher, income Black participants (P value for interaction=0.04). Subtypes of early trauma linked to Life's Simple 7 were general trauma, emotional abuse, and sexual abuse. Exploratory analyses demonstrated that early trauma was only associated with the body mass index and smoking components of Life's Simple 7. CONCLUSIONS: Early trauma, including general trauma, emotional abuse, and sexual abuse, may be associated with worse CVH among low-, but not higher-income Black adults.

Individual Psychosocial Resilience, Neighborhood Context, and Cardiovascular Health in Black Adults: A Multilevel Investigation From the Morehouse-Emory Cardiovascular Center for Health Equity Study.

BACKGROUND: Despite well-documented cardiovascular disparities between racial groups, within-race determinants of cardiovascular health among Black adults remain understudied. Factors promoting cardiovascular resilience among Black adults in particular warrant further investigation. Our objective was to examine whether individual psychosocial resilience and neighborhood-level cardiovascular resilience were associated with better cardiovascular health in Black adults, measured utilizing Life's Simple 7 (LS7) scores. METHODS: We assessed LS7 scores in 389 Black adults (mean age, 53±10 years; 39% men) living in Atlanta, Georgia. A composite score of individual psychosocial resilience was created by assessing environmental mastery, purpose in life, optimism, resilient coping, and depressive symptoms. Neighborhood-level cardiovascular resilience was separately determined by the census tract-level rates of cardiovascular mortality/morbidity events. Generalized linear mixed regression models were used to examine the association between individual psychosocial resilience, neighborhood cardiovascular resilience, and LS7 scores. RESULTS: Higher individual psychosocial resilience was significantly associated with higher LS7 (ß=0.38 [0.16-0.59] per 1 SD) after adjustment for sociodemographic factors. Similarly, higher neighborhood-level cardiovascular resilience was significantly associated with higher LS7 (ß=0.23 [0.02-0.45] per 1 SD). When jointly examined, high individual psychosocial resilience (>median) was independently associated with higher LS7 (ß=0.73 [0.31-1.17]), whereas living in high-resilience neighborhoods (>median) was not. The largest difference in LS7 score was between those with high and low psychosocial resilience living in low-resilience neighborhoods (8.38 [7.90-8.86] versus 7.42 [7.04-7.79]). CONCLUSIONS: Individual psychosocial resilience in Black adults is associated with better cardiovascular health.

Cardiovascular Risk and Resilience Among Black Adults: Rationale and Design of the MECA Study.

Background Cardiovascular disease incidence, prevalence, morbidity, and mortality have declined in the past several decades; however, disparities persist among subsets of the population. Notably, blacks have not experienced the same improvements on the whole as whites. Furthermore, frequent reports of relatively poorer health statistics among the black population have led to a broad assumption that black race reliably predicts relatively poorer health outcomes. However, substantial intraethnic and intraracial heterogeneity exists; moreover, individuals with similar risk factors and environmental exposures are often known to experience vastly different cardiovascular health outcomes. Thus, some individuals have good outcomes even in the presence of cardiovascular risk factors, a concept known as resilience. Methods and Results The MECA (Morehouse-Emory Center for Health Equity) Study was designed to investigate the multilevel exposures that contribute to "resilience" in the face of risk for poor cardiovascular health among blacks in the greater Atlanta, GA, metropolitan area. We used census tract data to determine "at-risk" and "resilient" neighborhoods with high or low prevalence of cardiovascular morbidity and mortality, based on cardiovascular death, hospitalization, and emergency department visits for blacks. More than 1400 individuals from these census tracts assented to demographic, health, and psychosocial questionnaires administered through telephone surveys. Afterwards, ≈500 individuals were recruited to enroll in a clinical study, where risk biomarkers, such as oxidative stress, and inflammatory markers, endothelial progenitor cells, metabolomic and microRNA profiles, and subclinical vascular dysfunction were measured. In addition, comprehensive behavioral questionnaires were collected and ideal cardiovascular health metrics were assessed using the American Heart Association's Life Simple 7 measure. Last, 150 individuals with low Life Simple 7 were recruited and randomized to a behavioral mobile health (eHealth) plus health coach or eHealth only intervention and followed up for improvement. Conclusions The MECA Study is investigating socioenvironmental and individual behavioral measures that promote resilience to cardiovascular disease in blacks by assessing biological, functional, and molecular mechanisms. REGISTRATION URL: https://www.clini​caltr​ials.gov. Unique identifier: NCT03308812.

Projected Costs of Informal Caregiving for Cardiovascular Disease: 2015 to 2035: A Policy Statement From the American Heart Association.

INTRODUCTION: In a recent report, the American Heart Association estimated that medical costs and productivity losses of cardiovascular disease (CVD) are expected to grow from $555 billion in 2015 to $1.1 trillion in 2035. Although the burden is significant, the estimate does not include the costs of family, informal, or unpaid caregiving provided to patients with CVD. In this analysis, we estimated projections of costs of informal caregiving attributable to CVD for 2015 to 2035. METHODS: We used data from the 2014 Health and Retirement Survey to estimate hours of informal caregiving for individuals with CVD by age/sex/race using a zero-inflated binomial model and controlling for sociodemographic factors and health conditions. Costs of informal caregiving were estimated separately for hypertension, coronary heart disease, heart failure, stroke, and other heart disease. We analyzed data from a nationally representative sample of 16 731 noninstitutionalized adults ≥54 years of age. The value of caregiving hours was monetized by the use of home health aide workers' wages. The per-person costs were multiplied by census population counts to estimate nation-level costs and to be consistent with other American Heart Association analyses of burden of CVD, and the costs were projected from 2015 through 2035, assuming that within each age/sex/racial group, CVD prevalence and caregiving hours remain constant. RESULTS: The costs of informal caregiving for patients with CVD were estimated to be $61 billion in 2015 and are projected to increase to $128 billion in 2035. Costs of informal caregiving of patients with stroke constitute more than half of the total costs of CVD informal caregiving ($31 billion in 2015 and $66 billion in 2035). By age, costs are the highest among those 65 to 79 years of age in 2015 but are expected to be surpassed by costs among those ≥80 years of age by 2035. Costs of informal caregiving for patients with CVD represent an additional 11% of medical and productivity costs attributable to CVD. CONCLUSIONS: The burden of informal caregiving for patients with CVD is significant; accounting for these costs increases total CVD costs to $616 billion in 2015 and $1.2 trillion in 2035. These estimates have important research and policy implications, and they may be used to guide policy development to reduce the burden of CVD on patients and their caregivers.

High neighborhood incarceration rate is associated with cardiometabolic disease in nonincarcerated black individuals.

PURPOSE: To examine the association between residence in neighborhoods with high rates of incarceration and cardiometabolic disease among nonincarcerated individuals. METHODS: We used data from two community cohort studies (n = 1368) in Atlanta, Georgia-META-Health and Predictive Health (2005-2012)-to assess the association between neighborhood incarceration rate and cardiometabolic disease, adjusting for individual-level and neighborhood-level factors. We also examined the interaction between race and neighborhood incarceration rate. RESULTS: Individuals living in neighborhoods with high incarceration rates were more likely to have dyslipidemia (odds ratio [OR] = 1.47; 95% confidence interval [CI] = 1.03-2.09) and metabolic syndrome (OR = 1.67; 95% CI = 1.07-2.59) in fully adjusted models. Interactions between race and neighborhood incarceration rate were significant; black individuals living in neighborhoods with high incarceration rates were more likely to have hypertension (OR = 1.59; 95% CI = 1.01-2.49), dyslipidemia (OR = 1.77; 95% CI = 1.12-2.80), and metabolic syndrome (OR = 1.80; 95% CI = 1.09-2.99). CONCLUSIONS: Black individuals living in neighborhoods with high rates of incarceration have worse cardiometabolic health profiles. Criminal justice reform may help reduce race-specific health disparities in the United States.

Socioeconomic status discrimination and C-reactive protein in African-American and White adults.

OBJECTIVES: We examined the association between socioeconomic status (SES) discrimination and C-reactive protein (CRP) in a biracial cohort of middle-aged adults using an intersectionality framework. METHODS: Participants were 401 African-American and White adults from a population-based cohort in the Southeastern United States. SES discrimination was self-reported with a modified Experiences of Discrimination Scale, and CRP levels were assayed from blood samples. Linear regression analyses were used to examine the associations among SES discrimination, race, education, and CRP after controlling for age, gender, racial and gender discrimination, financial and general stress, body mass index, smoking, sleep quality, and depressive symptoms. Intersectional effects were tested using race×SES discrimination, education×SES discrimination and race×education×SES discrimination interactions. RESULTS: Adjusting for sociodemographics, racial discrimination, gender discrimination, and all relevant two-way interaction terms, we observed a significant race×education×SES discrimination interaction (p=0.019). In adjusted models stratified by race and education, SES discrimination was associated with elevated CRP among higher educated African-Americans (ß=0.29, p=0.018), but not lower educated African-Americans (ß=-0.13, p=0.32); or lower educated (ß=-0.02, p=0.92) or higher educated (ß=-0.01, p=0.90) Whites. CONCLUSIONS: Findings support the relevance of SES discrimination as an important discriminatory stressor for CRP specifically among higher educated African-Americans.

Recruitment Strategies and Costs Associated With Enrolling People With Insomnia and High Blood Pressure Into an Online Behavioral Sleep Intervention: A Single-Site Pilot Study.

BACKGROUND: Recruitment in clinical research is a common challenge and source of study failure. The reporting of recruitment methods and costs in hypertension trials is limited especially for smaller, single-site trials, online intervention trials, and trials using newer online recruitment strategies. OBJECTIVE: The aims of this study are to describe and examine the feasibility of newer online-e-mail recruitment strategies and traditional recruitment strategies used to enroll participants with insomnia and high blood pressure into an online behavioral sleep intervention study (Sleeping for Heart Health). METHODS: The 16 online-e-mail-based and traditional recruitment strategies used are described. Recruitment strategy feasibility was examined by study interest and enrollee yields, conversion rates, and costs (direct, remuneration, labor, and cost per enrollee). RESULTS: From August 2014 to October 2015, 183 people were screened and 58 (31.7%) enrolled in the study (51.1 ± 12.9 years, 63.8% female, 72.4% African American, 136 ± 12/88 ± 7 mm Hg, 87.9% self-reported hypertension, 67.2% self-reported antihypertensive medication use). The recruitment strategies yielding the highest enrollees were the university hospital phone waiting message system (25.4%), Craigslist (22.4%), and flyers (20.3%) at a per enrollee cost of $42.84, $98.90, and $128.27, respectively. The university hospital phone waiting message system (55.6%) and flyers (54.5%) had the highest interested participant to enrolled participant conversion rate of all recruitment strategies. CONCLUSION: Approximately 70% of all enrolled participants were recruited from the university hospital phone waiting message system, Craigslist, or flyers. Given the recruitment challenges that most researchers face, we encourage the documenting, assessing, and reporting of detailed recruitment strategies and associated recruitment costs so that other researchers may benefit.

Antecedents of self-care in adults with congenital heart defects.

BACKGROUND: Adults with congenital heart defects (ACHD) face long-term complications related to prior surgery, abnormal anatomy, and acquired cardiovascular conditions. Although self-care is an important part of chronic illness management, few studies have explored self-care in the ACHD population. The purpose of this study is to describe self-care and its antecedents in the ACHD population. METHODS: Persons with moderate or severe ACHD (N=132) were recruited from a single ACHD center. Self-care (health maintenance behaviors, monitoring and management of symptoms), and potential antecedents including sociodemographic and clinical characteristics, ACHD knowledge, behavioral characteristics (depressive symptoms and self-efficacy), and family-related factors (parental overprotection and perceived family support) were collected via self-report and chart review. Multiple regression was used to identify antecedents of self-care maintenance, monitoring, and management. RESULTS: Only 44.7%, 27.3%, and 23.3% of participants performed adequate levels of self-care maintenance, monitoring and management, respectively. In multiple regression analysis, self-efficacy, education, gender, perceived family support, and comorbidities explained 25% of the variance in self-care maintenance (R(2)=.248, F(5, 123)=9.44, p<.001). Age, depressive symptoms, self-efficacy, and NYHA Class explained 23% of the variance in self-care monitoring (R(2)=.232, F(2, 124)=10.66, p<.001). Self-efficacy and NYHA Class explained 9% of the variance in self-care management (R(2)=.094, F(2, 80)=5.27, p=.007). CONCLUSIONS: Low levels of self-care are common among persons with ACHD. Multiple factors, including modifiable factors of self-efficacy, depressive symptoms, and perceived family support, are associated with self-care and should be considered in designing future interventions to improve outcomes in the ACHD population.

An economic evaluation of a self-care intervention in persons with heart failure and diabetes.

BACKGROUND: Persons with concomitant heart failure (HF) and diabetes mellitus constitute a growing population whose quality of life is encumbered with worse clinical outcomes as well as high health resource use (HRU) and costs. METHODS AND RESULTS: Extensive data on HRU and costs were collected as part of a prospective cost-effectiveness analysis of a self-care intervention to improve outcomes in persons with both HF and diabetes. HRU costs were assigned from a Medicare reimbursement perspective. Patients (n = 134) randomized to the self-care intervention and those receiving usual care/attention control were followed for 6 months, revealing significant differences in the number of hospitalization days and associated costs between groups. The mean number of inpatient days was 3 with bootstrapped bias-corrected (BCa) confidence intervals (CIs) of 1.8-4.4 d for the intervention group and 7.3 d (BCa CI 4.1-10.9 d) in the control group: P = .044. Total direct HRU costs per participant were an estimated $9,065 (BCa CI $6,496-$11,936) in the intervention and $16,712 (BCa CI 8,200-$26,621) in the control group, for a mean difference of -$7,647 (BCa CI -$17,588 to $809; P = .21) in favor of the intervention, including intervention costs estimated to be $130.67 per patient. CONCLUSIONS: The self-care intervention demonstrated dominance in lowering costs without sacrificing quality-adjusted life-years.

Psychosocial factors associated with diet quality in a working adult population.

The associations between specific intra- and inter-personal psychosocial factors and dietary patterns were explored in a healthy, working adult sample of university and health center employees (N = 640) who were enrolled in a prospective predictive health study. Participants had a mean age of 48 (SD = 11) years and were 67% women and 30% minority. Baseline psychosocial measures of perceived stress, depressive symptoms, social support, and family functioning were examined for their relationships with three diet quality indices-AHEI, DASH, and the Mediterranean. Dietary intake was of moderate quality in this high-income, well-educated, psychosocially healthy population. Social support was positively associated with better diet quality for all three indices (p < .01). Further research should focus on socio-environmental factors associated with diet quality.

Educational needs for improving self-care in heart failure patients with diabetes.

PURPOSE: To explore the need for self-monitoring and self-care education in heart failure patients with diabetes (HF- DM patients) by describing cognitive and affective factors to provide guidance in developing effective self-management education. METHODS: A cross-sectional correlation design was employed using baseline patient data from a study testing a 12-week patient and family dyad intervention to improve dietary and medication-taking self-management behaviors in HF patients. Data from 116 participants recruited from metropolitan Atlanta area were used. Demographic and comorbidities, physical function, psychological distress, relationship with health care provider, self-efficacy (medication taking and low sodium diet), and behavioral outcomes (medications, dietary habits) were assessed. Descriptive statistics and a series of chi-square tests, t tests, or Mann-Whitney tests were performed to compare HF patients with and without DM. RESULTS: HF-DM patients were older and heavier, had more comorbidities, and took more daily medications than HF patients. High self-efficacy on medication and low-sodium diet was reported in both groups with no significant difference. Although HF-DM patients took more daily medications than HF, both groups exhibited high HF medication-taking behaviors. The HF-DM patients consumed significantly lower total sugar than HF patients but clinically higher levels of sodium. CONCLUSIONS: Diabetes educators need to be aware of potential conflicts of treatment regimens to manage 2 chronic diseases. Special and integrated diabetes self-management education programs that incorporate principles of HF self-management should be developed to improve self-management behavior in HF-DM patients.

Challenges and strategies of dyad research: cardiovascular examples.

This article highlights challenges in recruitment, retention, attrition, data collection, and analysis when studying dyads in cardiovascular research. Including family members in studies is particularly important because family members often have a major role in treatment of patients with cardiovascular illness. The partnership of a patient-family member is referred to as a dyad and may include the cardiovascular patient and another relative, such as an adult child, sibling, spouse, son-in-law or daughter-in-law, or unmarried partner. Insights gained from previous research may facilitate and improve rigor when reviewing and conducting studies involving dyads with cardiovascular and other chronic diseases. Including patients and partners in descriptive and intervention studies will allow researchers to more fully explore family factors that may be salient in health outcomes.

Heart failure symptom assessment and management: can caregivers serve as proxy?

BACKGROUND: : Caregivers (CGs) of heart failure (HF) patients are increasingly assuming greater responsibilities in symptom assessment, evaluation, and decision making and may be asked to serve as proxies. The purpose of this study was to examine the degree of congruence between HF patients and their primary CG on symptom assessment and self-care management behaviors. METHODS: : The sample consisted of 70 HF patients receiving home healthcare and their designated CG. Patients were primarily between 40 and 85 years of age and female (60%). Caregivers were predominately female (76%) and spouses (43%). Congruence in symptom assessment and management between HF patients and their designated CGs was measured in this descriptive cross-sectional study using the Heart Failure Symptom Survey and Self-care of Heart Failure Index. RESULTS: : The Spearman correlation coefficient and concordance correlation coefficient were used to assess the degree of congruence on symptom evaluation scores from the Heart Failure Symptom Survey. Dyads had the strongest correlations on ratings of the HF patients' symptoms of extremity edema, difficulty concentrating, and dizziness. Lower congruence (Spearman correlation <0.40) was found on feeling depressed, shortness of breath at night, and shortness of breath when lying down. Scores on the Self-care of Heart Failure Index self-care management and self-care confidence scales were not significantly different within the HF dyads. CONCLUSIONS: : Based on moderate levels of correlations on most HF symptoms in this study, the CG as proxy appears to be a reasonable substitute for patient responses in a community setting. However, greater family preparation for symptom assessment is warranted to improve congruence for future symptom assessment.

Supraventricular dysrhythmias: nursing research to improve health outcomes.

Cardiovascular nursing practice includes accountability for the clinical and organizational processes to ensure positive outcomes for patients having cardiac dysrhythmias. For patients with supraventricular dysrhythmias, nurses have studied patient outcomes related to mortality, morbidity, quality of life, psychological and physical functioning, and symptoms. Nurses have also explored these same outcomes associated with the management of supraventricular dysrhythmias. In addition, nurses have contributed to understanding organizational outcomes such as healthcare utilization and costs associated with these patients. For patients with atrial fibrillation after cardiac surgery, nurses have studied patient and organizational outcomes related to mortality, morbidity, symptoms, psychological and physical functioning, and economic outcomes. This research has included numerous interdisciplinary studies, and most of it has been descriptive or observational in design. Areas for future nursing outcomes research, including more interventional studies, are discussed.

Gender differences in implantable cardioverter-defibrillator patients at the time of insertion.

Gender differences in physical and psychological health and responses in persons receiving implantable cardioverter-defibrillators (ICDs) have been reported but are not well delineated. This study examined symptoms of pain and sleep difficulties, functional status, and psychological responses in 180 (75%) men and 60 (25%) women before and immediately following their first ICD implantation. Women were significantly younger, less likely to be married, and had less history of coronary artery disease than men. Forty-eight percent of women were New York Heart Association class III-IV vs. 27% of men (p<0.05). Women had lower functional status and were more likely to report symptoms of increased pain severity and sleep difficulties. Differences in functional status and pain were reduced after adjusting for New York Heart Association class and age, respectively. There were no differences in depressive symptoms or anxiety. Clinical implications of gender-related responses include the need to address symptoms of heart failure as well as increased pain and sleep difficulties in women at the time surrounding ICD implantation. Longitudinal studies and gender-focused nursing interventions should be developed to promote better understanding of responses and to improve recovery outcomes for ICD patients.

Economics methods in the Clinical Outcomes Utilizing percutaneous coronary Revascularization and Aggressive Guideline-driven drug Evaluation (COURAGE) trial.

Percutaneous coronary intervention (PCI) remains a major therapeutic option for the treatment of chronic coronary artery disease. In the COURAGE trial, 2287 patients with chronic coronary disease were randomized between PCI with medical management and medical management alone. Embedded within the COURAGE trial is a detailed economic analysis being conducted in three health care systems: the US Veterans Administration (VA), Canada, and the US non-VA. Resource use and costs are being collected for each system and overall. Survival is assessed internally in the trial with mean follow-up of 4.5 years. Long-term mean survival will be estimated by projecting survival beyond the trial period by extrapolating the in-trial hazard rates. Utility is being assessed at baseline and at 1, 3, and 6 months and annually thereafter, using a computer-administered standard gamble. Quality-adjusted life years are calculated by multiplying survival by utility. The incremental cost-effectiveness ratio of PCI will be defined as the additional cost of PCI divided by the gain in life years and quality-adjusted life years. The 95% confidence regions of efficacy and costs will be determined by bootstrap over a range of acceptability thresholds, which will then be displayed in the cost-effectiveness plane and as a cost-effectiveness acceptability curve. A multilevel regression model will assess cost-effectiveness from a net benefit perspective. These approaches should provide the most detailed assessment available of the cost-effectiveness of PCI for coronary artery disease.

Building bridges: a partnership between professional nursing and the Centers for Disease Control and Prevention to reduce the burden of heart disease and stroke.

The escalating burden of heart disease and stroke in the United States, coupled with the complexity of public health goals to prevent and control chronic diseases, warrant new strategies and partners. The 2.7 million nurses in the United States represent the nation's largest healthcare profession and, through their professional organizations, constitute a strategic partner for the Centers for Disease Control and Prevention (CDC) Heart Disease and Stroke Programs. In addition, because heart disease and stroke rank first and third among leading causes of death in women in the United States, and 95% of nurses are women, nurses represent an important population to target with preventive cardiovascular health approaches. The authors describe a proposed CDC strategic partnership with professional nursing organizations, including goals aimed at improving the capacity of nurses as change agents in the area of heart disease and stroke, as well as promoting change among the change agents to reduce nurses' risk for cardiovascular disease. The primary goals of the partnership between key professional nursing organizations and the CDC Cardiovascular Health (CVH) Programs follow: (1) share information and develop effective communication; (2) link with key professional and community organizations; (3) assess capabilities and expertise that nursing organizations can add to CDC's internal and external partnerships, including the Public Health Action Plan; (4) explore possible linkages with the CDC-funded state-level heart disease and stroke prevention programs and emerging CDC stroke networks; (5) develop, disseminate, and apply evidence-based guidelines to improve outcomes of care; and (6) develop policy and environment strategies in work-site settings to prevent heart disease and stroke in women and among the membership of professional nursing organizations. The development and implementation of a CDC CVH Program Professional Nurse Partnership have strong potential for enhancing collaborative public health efforts to prevent heart disease and stroke, and to improve cardiovascular outcomes for hypertension, high cholesterol, myocardial infarction, stroke, and heart failure.