Data for Equity: Creating an Antiracist, Intersectional Approach to Data in a Local Health Department.

OBJECTIVE: To develop recommendations to embed equity into data work at a local health department and a framework for antiracist data praxis. DESIGN: A working group comprised staff from across the agency whose positions involved data collection, analysis, interpretation, or communication met during April-July 2018 to identify and discuss successes and challenges experienced by staff and to generate recommendations for achieving equitable data practices. SETTING: Local health department in New York City. RESULTS: The recommendations encompassed 6 themes: strengthening analytic skills, communication and interpretation, data collection and aggregation, community engagement, infrastructure and capacity building, and leadership and innovation. Specific projects are underway or have been completed. CONCLUSIONS: Improving equity in data requires changes to data processes and commitment to racial and intersectional justice and process change at all levels of the organization and across job functions. We developed a collaborative model for how a local health department can reform data work to embed an equity lens. This framework serves as a model for jurisdictions to build upon in their own efforts to promote equitable health outcomes and become antiracist organizations.

Changes in the Geographic Patterns of Heart Disease Mortality in the United States: 1973 to 2010.

BACKGROUND: Although many studies have documented the dramatic declines in heart disease mortality in the United States at the national level, little attention has been given to the temporal changes in the geographic patterns of heart disease mortality. METHODS AND RESULTS: Age-adjusted and spatially smoothed county-level heart disease death rates were calculated for 2-year intervals from 1973 to 1974 to 2009 to 2010 for those aged ≥35 years. Heart disease deaths were defined according to the International Classification of Diseases codes for diseases of the heart in the eighth, ninth, and tenth revisions of the International Classification of Diseases. A fully Bayesian spatiotemporal model was used to produce precise rate estimates, even in counties with small populations. A substantial shift in the concentration of high-rate counties from the Northeast to the Deep South was observed, along with a concentration of slow-decline counties in the South and a nearly 2-fold increase in the geographic inequality among counties. CONCLUSIONS: The dramatic change in the geographic patterns of heart disease mortality during 40 years highlights the importance of small-area surveillance to reveal patterns that are hidden at the national level, gives communities the historical context for understanding their current burden of heart disease, and provides important clues for understanding the determinants of the geographic disparities in heart disease mortality.

Metropolitan racial residential segregation and cardiovascular mortality: exploring pathways.

Racial residential segregation has been associated with an increased risk for heart disease and stroke deaths. However, there has been little research into the role that candidate mediating pathways may play in the relationship between segregation and heart disease or stroke deaths. In this study, we examined the relationship between metropolitan statistical area (MSA)-level segregation and heart disease and stroke mortality rates, by age and race, and also estimated the effects of various educational, economic, social, and health-care indicators (which we refer to as pathways) on this relationship. We used Poisson mixed models to assess the relationship between the isolation index in 265 U.S. MSAs and county-level (heart disease, stroke) mortality rates. All models were stratified by race (non-Hispanic black, non-Hispanic white), age group (35-64 years, ≥ 65 years), and cause of death (heart disease, stroke). We included each potential pathway in the model separately to evaluate its effect on the segregation-mortality association. Among blacks, segregation was positively associated with heart disease mortality rates in both age groups but only with stroke mortality rates in the older age group. Among whites, segregation was marginally associated with heart disease mortality rates in the younger age group and was positively associated with heart disease mortality rates in the older age group. Three of the potential pathways we explored attenuated relationships between segregation and mortality rates among both blacks and whites: percentage of female-headed households, percentage of residents living in poverty, and median household income. Because the percentage of female-headed households can be seen as a proxy for the extent of social disorganization, our finding that it has the greatest attenuating effect on the relationship between racial segregation and heart disease and stroke mortality rates suggests that social disorganization may play a strong role in the elevated rates of heart disease and stroke found in racially segregated metropolitan areas.

Association of the neighborhood retail food environment with sodium and potassium intake among US adults.

INTRODUCTION: High sodium intake and low potassium intake, which can contribute to hypertension and risk of cardiovascular disease, may be related to the availability of healthful food in neighborhood stores. Despite evidence linking food environment with diet quality, this relationship has not been evaluated in the United States. The modified retail food environment index (mRFEI) provides a composite measure of the retail food environment and represents the percentage of healthful-food vendors within a 0.5 mile buffer of a census tract. METHODS: We analyzed data from 8,779 participants in the National Health and Nutrition Examination Survey, 2005-2008. By using linear regression, we assessed the relationship between mRFEI and sodium intake, potassium intake, and the sodium-potassium ratio. Models were stratified by region (South and non-South) and included participant and neighborhood characteristics. RESULTS: In the non-South region, higher mRFEI scores (indicating a more healthful food environment) were not associated with sodium intake, were positively associated with potassium intake (P [trend] = .005), and were negatively associated with the sodium-potassium ratio (P [trend] = .02); these associations diminished when neighborhood characteristics were included, but remained close to statistical significance for potassium intake (P [trend] = .05) and sodium-potassium ratio (P [trend] = .07). In the South, mRFEI scores were not associated with sodium intake, were negatively associated with potassium intake (P [trend] = < .001), and were positively associated with sodium-potassium ratio (P [trend] = .01). These associations also diminished after controlling for neighborhood characteristics for both potassium intake (P [trend] = .03) and sodium-potassium ratio (P [trend] = .40). CONCLUSION: We found no association between mRFEI and sodium intake. The association between mRFEI and potassium intake and the sodium-potassium ratio varied by region. National strategies to reduce sodium in the food supply may be most effective to reduce sodium intake. Strategies aimed at the local level should consider regional context and neighborhood characteristics.

Nocturnal sleep enhances working memory training in Parkinson's disease but not Lewy body dementia.

Working memory is essential to higher order cognition (e.g. fluid intelligence) and to performance of daily activities. Though working memory capacity was traditionally thought to be inflexible, recent studies report that working memory capacity can be trained and that offline processes occurring during sleep may facilitate improvements in working memory performance. We utilized a 48-h in-laboratory protocol consisting of repeated digit span forward (short-term attention measure) and digit span backward (working memory measure) tests and overnight polysomnography to investigate the specific sleep-dependent processes that may facilitate working memory performance improvements in the synucleinopathies. We found that digit span backward performance improved following a nocturnal sleep interval in patients with Parkinson's disease on dopaminergic medication, but not in those not taking dopaminergic medication and not in patients with dementia with Lewy bodies. Furthermore, the improvements in patients with Parkinson's disease on dopaminergic medication were positively correlated with the amount of slow-wave sleep that patients obtained between training sessions and negatively correlated with severity of nocturnal oxygen desaturation. The translational implication is that working memory capacity is potentially modifiable in patients with Parkinson's disease but that sleep disturbances may first need to be corrected.

EMS medical direction and prehospital practices for acute cardiovascular events.

OBJECTIVE: The purpose of this analysis was to determine whether there is an association between type of emergency medical services (EMS) medical direction and local EMS agency practices and characteristics specifically related to emergency response for acute cardiovascular events. METHODS: We surveyed 1,292 EMS agencies in nine states. For each cardiovascular prehospital procedure or practice, we compared the proportion of agencies that employed paid (full- or part-time) medical directors with the proportion of agencies that employed volunteer medical directors. We also compared the proportion of EMS agencies who reported direct interaction between emergency medical technicians (EMTs) and their medical director within the previous four weeks with the proportion of agencies who reported no direct interaction. Chi-square tests were used to assess statistical differences in proportion of agencies with a specific procedure by medical director employment status and medical director interaction. We repeated these comparisons using t-tests to evaluate mean differences in call volume. RESULTS: The EMS agencies with prehospital cardiovascular response policies were more likely to report employment of a paid medical director and less likely to report employment of a volunteer medical director. Similarly, agencies with prehospital cardiovascular response practices were more likely to report recent medical director interaction and less likely to report absence of recent medical director interaction. Mean call volumes for chest pain, cardiac arrest, and stroke were higher among agencies having paid medical directors (compared with agencies having volunteer medical directors) and agencies having recent medical director interaction (compared with agencies not having recent medical director interaction). CONCLUSIONS: Our study demonstrated that EMS agencies with a paid medical director and agencies with medical director interaction with EMTs in the previous four weeks were more likely to have prehospital cardiovascular procedures in place. Given the strong relationship that both employment status and direct interaction have with the presence of these practices, agencies with limited resources to provide a paid medical director or a medical director that can be actively involved with EMTs should be supported through partnerships and other interventions to ensure that they receive the necessary levels of medical director oversight.

ECHO (Extension for Community Healthcare Outcomes) Autism STAT: A Diagnostic Accuracy Study of Community-Based Primary Care Diagnosis of Autism Spectrum Disorder.

OBJECTIVE: Children can be reliably diagnosed with autism spectrum disorder (ASD) by a highly trained clinician as early as 12 to 24 months of age, but recent estimates indicate that the average age of diagnosis is 4.4 years. We hypothesized that trained primary care physicians and practitioners can reliably and accurately diagnose children 14 to 48 months with unambiguous symptoms of ASD. METHODS: Through this diagnostic accuracy study, 20 patients diagnosed with ASD by clinicians trained through the ECHO (Extension for Community Healthcare Outcomes) Autism STAT program participated in an independent gold-standard evaluation at a regional autism center. Caregiver perceptions of the diagnostic process were also assessed. RESULTS: Of the 20 patients who received a diagnosis of ASD by a trained clinician and completed the study, 19 diagnoses were confirmed by a gold-standard evaluation. Caregivers indicated that undergoing diagnosis in their local community rather than an autism specialty center was helpful (4.8/5 on a 5-point Likert scale, n = 19). Results of this study demonstrate that primary care clinicians can be trained to reliably diagnose ASD in children 14 to 48 months with unambiguous symptoms. CONCLUSION: Diagnosis in the primary care setting may lead to earlier diagnosis and quicker connection to evidence-based therapies and interventions. Given the potential impact of increasing access to high-quality diagnostic services, the role of primary care clinicians in the diagnosis of ASD should be further evaluated.

Daytime alertness in Parkinson's disease: potentially dose-dependent, divergent effects by drug class.

Many patients with idiopathic Parkinson's disease experience difficulties maintaining daytime alertness. Controversy exists regarding whether this reflects effects of antiparkinsonian medications, the disease itself, or other factors such as nocturnal sleep disturbances. In this study we examined the phenomenon by evaluating medicated and unmedicated Parkinson's patients with objective polysomnographic measurements of nocturnal sleep and daytime alertness. Patients (n = 63) underwent a 48-hour laboratory-based study incorporating 2 consecutive nights of overnight polysomnography and 2 days of Maintenance of Wakefulness Testing. We examined correlates of individual differences in alertness, including demographics, clinical features, nocturnal sleep variables, and class and dosage of anti-Parkinson's medications. Results indicated that, first, relative to unmediated patients, all classes of dopaminergic medications were associated with reduced daytime alertness, and this effect was not mediated by disease duration or disease severity. Second, the results showed that increasing dosages of dopamine agonists were associated with less daytime alertness, whereas higher levels of levodopa were associated with higher levels of alertness. Variables unrelated to the Maintenance of Wakefulness Test defined daytime alertness including age, sex, years with diagnosis, motor impairment score, and most nocturnal sleep variables. Deficits in objectively assessed daytime alertness in Parkinson's disease appear to be a function of both the disease and the medications and their doses used. The apparent divergent dose-dependent effects of drug class in Parkinson's disease are anticipated by basic science studies of the sleep/wake cycle under different pharmacological agents.

Factors associated with emergency medical services scope of practice for acute cardiovascular events.

OBJECTIVES: To examine prehospital emergency medical services (EMS) scope of practice for acute cardiovascular events and characteristics that may affect scope of practice; and to describe variations in EMS scope of practice for these events and the characteristics associated with that variability. METHODS: In 2008, we conducted a telephone survey of 1,939 eligible EMS providers in nine states to measure EMS agency characteristics, medical director involvement, and 18 interventions authorized for prehospital care of acute cardiovascular events by three levels of emergency medical technician (EMT) personnel. RESULTS: A total of 1,292 providers responded to the survey, for a response rate of 67%. EMS scope of practice interventions varied by EMT personnel level, with the proportion of authorized interventions increasing as expected from EMT-Basic to EMT-Paramedic. Seven of eight statistically significant associations indicated that EMS agencies in urban settings were less likely to authorize interventions (odds ratios <0.7) for any level of EMS personnel. Based on the subset of six statistically significant associations, fire department-based EMS agencies were two to three times more likely to authorize interventions for EMT-Intermediate personnel. Volunteer EMS agencies were more than twice as likely as nonvolunteer agencies to authorize interventions for EMT-Basic and EMT-Intermediate personnel but were less likely to authorize any one of the 11 interventions for EMT-Paramedics. Greater medical director involvement was associated with greater likelihood of authorization of seven of the 18 interventions for EMT-Basic and EMT-Paramedic personnel but had no association with EMT-Intermediate personnel. CONCLUSIONS: We noted statistically significant variations in scope of practice by rural vs. urban setting, medical director involvement, and type of EMS service (fire department-based/non-fire department-based; volunteer/paid). These variations highlight local differences in the composition and capacity of EMS providers and offer important information for the transition towards the implementation of a national scope of practice model.

Restless Legs Symptoms and Periodic Leg Movements in Sleep Among Patients with Parkinson's Disease.

BACKGROUND: The association between restless legs syndrome (RLS) and Parkinson's disease (PD) remains controversial, with epidemiologic and descriptive evidence suggesting some potential overlap while mechanistic/genetic studies suggesting relative independence of the conditions. OBJECTIVE: To examine a known, objectively measured endophenotype for RLS, periodic leg movements (PLMS) in sleep, in patients with PD and relate that objective finding to restless legs symptoms. METHODS: We performed polysomnography for one (n = 8) or two (n = 67) consecutive nights in 75 PD patients and examined the association of PLMS with restless legs symptoms. RESULTS: We found no association between restless legs symptoms and PLMS in PD. Prevalence of both was similar to data reported previously in other PD samples. CONCLUSION: We interpret these results as suggesting that restless legs symptoms in PD patients may represent a different phenomenon and pathophysiology than RLS in the non-PD population.

Phasic muscle activity in sleep and clinical features of Parkinson disease.

OBJECTIVE: The absence of atonia during rapid eye movement (REM) sleep and dream-enactment behavior (REM sleep behavior disorder [RBD]) are common features of sleep in the alpha-synucleinopathies. This study examined this phenomenon quantitatively, using the phasic electromyographic metric (PEM), in relation to clinical features of idiopathic Parkinson disease (PD). Based on previous studies suggesting that RBD may be prognostic for the development of later parkinsonism, we hypothesized that clinical indicators of disease severity and more rapid progression would be related to PEM. METHODS: A cross-sectional convenience sample of 55 idiopathic PD patients from a movement disorders clinic in a tertiary care medical center underwent overnight polysomnography. PEM, the percentage of 2.5-second intervals containing phasic muscle activity, was quantified separately for REM and non-REM (NREM) sleep from 5 different electrode sites. RESULTS: Higher PEM rates were seen in patients with symmetric disease, as well as in akinetic-rigid versus tremor-predominant patients. Men had higher PEM relative to women. Results occurred in all muscle groups in both REM and NREM sleep. INTERPRETATION: Although our data were cross-sectional, phasic muscle activity during sleep suggests disinhibition of descending motor projections in PD broadly reflective of more advanced and/or progressive disease. Elevated PEM during sleep may represent a functional window into brainstem modulation of spinal cord activity and is broadly consistent with the early pathologic involvement of non-nigral brainstem regions in PD, as described by Braak.

Sleep disturbance in dementia with Lewy bodies and Alzheimer's disease: a multicenter analysis.

BACKGROUND/AIMS: Evidence suggests that patients with dementia with Lewy bodies (DLB) may have more nocturnal sleep disturbance than patients with Alzheimer's disease (AD). We sought to confirm such observations using a large, prospectively collected, standardized, multicenter-derived database, i.e. the National Alzheimer's Coordinating Center Uniform Data Set. METHODS: Nocturnal sleep disturbance (NSD) data, as characterized by the Neuropsychiatric Inventory Questionnaire (NPI-Q), were derived from 4,531 patients collected between September 2005 and November 2008 from 32 National Institute on Aging participating AD centers. Patient and informant characteristics were compared between those with and without NSD by dementia diagnosis (DLB and probable AD). Finally, a logistic regression model was created to quantify the association between NSD status and diagnosis while adjusting for these patient/informant characteristics, as well as center. RESULTS: NSD was more frequent in clinically diagnosed DLB relative to clinically diagnosed AD (odds ratio = 2.93, 95% confidence interval = 2.22-3.86). These results were independent from the gender of the patient or informant, whether the informant lived with the patient, and other patient characteristics, such as dementia severity, depressive symptoms, and NPI-Q-derived measures of hallucinations, delusions, agitation and apathy. In AD, but not DLB, patients, NSD was associated with more advanced disease. Comorbidity of NSD with hallucinations, agitation and apathy was higher in DLB than in AD. There was also evidence that the percentage of DLB cases with NSD showed wide variation across centers. CONCLUSION: As defined by the NPI-Q, endorsement of the nocturnal behavior item by informants is more likely in patients with DLB when compared to AD, even after the adjustment of key patient/informant characteristics.

Racial residential segregation and stroke mortality in Atlanta.

OBJECTIVE: To assess the association between neighborhood-level racial residential segregation and stroke mortality using a spatially derived segregation index. DESIGN: Cross-sectional study SETTING: Atlanta Metropolitan Statistical Area METHODS: The study population consisted of non-Hispanic Black and White residents of the Atlanta Metropolitan Statistical Area during the time period Jan 1, 2000 to December 31, 2006. Census tract-level stroke death rates for Blacks and Whites were modeled as a function of the segregation index while controlling for two neighborhood-level chronic stressors (poverty, low education). RESULTS: Racial segregation was positively associated with stroke mortality for both Blacks and Whites aged 35-64 years. Among Blacks and Whites aged 65 or older, segregation was negatively associated with stroke mortality after controlling for the two stressors, suggesting that they were pathways between segregation and stroke death rates. CONCLUSION: Future studies are needed to identify additional pathways between residential segregation and other health outcomes, and to collect data that support a life course approach to understanding the impact of residential segregation on health.

Geographic and sociodemographic disparities in drive times to Joint Commission-certified primary stroke centers in North Carolina, South Carolina, and Georgia.

INTRODUCTION: Timely access to facilities that provide acute stroke care is necessary to reduce disabilities and death from stroke. We examined geographic and sociodemographic disparities in drive times to Joint Commission-certified primary stroke centers (JCPSCs) and other hospitals with stroke care quality improvement initiatives in North Carolina, South Carolina, and Georgia. METHODS: We defined boundaries for 30- and 60-minute drive-time areas to JCPSCs and other hospitals  by  using geographic information systems (GIS) mapping technology and calculated the proportions of the population living in these drive-time areas by sociodemographic characteristics. Age-adjusted county-level stroke death rates were overlaid onto the drive-time areas. RESULTS: Approximately 55% of the population lived within a 30-minute drive time to a JCPSC; 77% lived within a 60-minute drive time. Disparities in percentage of the population within 30-minute drive times were found by race/ethnicity, education, income, and urban/rural status; the disparity was largest between urban areas (70% lived within 30-minute drive time) and rural areas (26%). The rural coastal plains had the largest concentration of counties with high stroke death rates and the fewest JCPSCs. CONCLUSION: Many areas in this tri-state region lack timely access to JCPSCs. Alternative strategies are needed to expand provision of quality acute stroke care in this region. GIS modeling is valuable for examining and strategically planning the distribution of hospitals providing acute stroke care.

Heart Disease Death Rates Among Blacks and Whites Aged ≥35 Years - United States, 1968-2015.

PROBLEM/CONDITION: Heart disease is the leading cause of death in the United States. In 2015, heart disease accounted for approximately 630,000 deaths, representing one in four deaths in the United States. Although heart disease death rates decreased 68% for the total population from 1968 to 2015, marked disparities in decreases exist by race and state. PERIOD COVERED: 1968-2015. DESCRIPTION OF SYSTEM: The National Vital Statistics System (NVSS) data on deaths in the United States were abstracted for heart disease using diagnosis codes from the eighth, ninth, and tenth revisions of the International Classification of Diseases (ICD-8, ICD-9, and ICD-10) for 1968-2015. Population estimates were obtained from NVSS files. National and state-specific heart disease death rates for the total population and by race for adults aged ≥35 years were calculated for 1968-2015. National and state-specific black-white heart disease mortality ratios also were calculated. Death rates were age standardized to the 2000 U.S. standard population. Joinpoint regression was used to perform time trend analyses. RESULTS: From 1968 to 2015, heart disease death rates decreased for the total U.S. population among adults aged ≥35 years, from 1,034.5 to 327.2 per 100,000 population, respectively, with variations in the magnitude of decreases by race and state. Rates decreased for the total population an average of 2.4% per year, with greater average decreases among whites (2.4% per year) than blacks (2.2% per year). At the national level, heart disease death rates for blacks and whites were similar at the start of the study period (1968) but began to diverge in the late 1970s, when rates for blacks plateaued while rates for whites continued to decrease. Heart disease death rates among blacks remained higher than among whites for the remainder of the study period. Nationwide, the black-white ratio of heart disease death rates increased from 1.04 in 1968 to 1.21 in 2015, with large increases occurring during the 1970s and 1980s followed by small but steady increases until approximately 2005. Since 2005, modest decreases have occurred in the black-white ratio of heart disease death rates at the national level. The majority of states had increases in black-white mortality ratios from 1968 to 2015. The number of states with black-white mortality ratios >1 increased from 16 (40%) to 27 (67.5%). INTERPRETATION: Although heart disease death rates decreased both for blacks and whites from 1968 to 2015, substantial differences in decreases were found by race and state. At the national level and in most states, blacks experienced smaller decreases in heart disease death rates than whites for the majority of the period. Overall, the black-white disparity in heart disease death rates increased from 1968 to 2005, with a modest decrease from 2005 to 2015. PUBLIC HEALTH ACTION: Since 1968, substantial increases have occurred in black-white disparities of heart disease death rates in the United States at the national level and in many states. These increases appear to be due to faster decreases in heart disease death rates for whites than blacks, particularly from the late 1970s until the mid-2000s. Despite modest decreases in black-white disparities at the national level since 2005, in 2015, heart disease death rates were 21% higher among blacks than among whites. This study demonstrates the use of NVSS data to conduct surveillance of heart disease death rates by race and of black-white disparities in heart disease death rates. Continued surveillance of temporal trends in heart disease death rates by race can provide valuable information to policy makers and public health practitioners working to reduce heart disease death rates both for blacks and whites and disparities between blacks and whites.

Habitual and Recent Sleep Durations: Graded and Interactive Risk for Impaired Glycemic Control in a Biracial Population.

BACKGROUND: We examined how habitual sleep duration interacts with recent sleep (2 nights) to predict morning oral glucose tolerance test results. We hypothesized that short habitual and recent sleep durations would be additive for poor glucose control. METHODS: A biracial population of adults (n = 1559) without known diabetes and recruited from the workforce of 2 urban universities was assessed for glycated hemoglobin and underwent oral glucose tolerance testing. We used plasma 2-hour postloading (75 g) measurements. Participants answered sleep questions using 30-minute forced-choice formats. We employed multivariable logistic regression to derive odds ratios. RESULTS: Shorter habitual sleep duration was associated with greater odds ratios of glycated hemoglobin ≥6.0% increasing by 30-minute intervals beginning at <7.0 hours and were more pronounced as durations shortened. Among participants with glycated hemoglobin <6.0% and <7.0 hours of habitual sleep (n = 636), abnormal glucose tolerance (2-hour oral glucose tolerance test ≥140 mg/dL) was significantly associated with a total sleep duration of ≤11 hours the 2 nights preceding oral glucose tolerance testing, but was not associated with longer sleep durations. Results were independent of age, sex, race, body mass index, smoking, history of cardiovascular disease, or use of antihypertensive or cholesterol-lowering medication. Additional analyses implied that longer-than-usual recent sleep durations were protective for abnormal oral glucose tolerance testing. DISCUSSION: Short habitual and recent sleep durations interact in predicting abnormal glucose on oral glucose tolerance testing. Self-reported data are sufficiently sensitive to reflect 30-minute differences in sleep between individuals. Future studies examining other aspects of sleep, such as perceived sleep quality and objectively measured sleep duration and architecture, would be necessary to confirm these findings. CONCLUSIONS: Short sleep duration for 2 nights prior to morning oral glucose tolerance testing may elevate glucose levels, this effect being detected among individuals habitually obtaining <7 hours sleep and obtaining ≤11 hours of sleep for 2 nights preceding testing.

County Health Factors Associated with Avoidable Deaths from Cardiovascular Disease in the United States, 2006-2010.

OBJECTIVE: Many cardiovascular deaths can be avoided through primary prevention to address cardiovascular disease (CVD) risk factors or better access to quality medical care. In this cross-sectional study, we examined the relationship between four county-level health factors and rates of avoidable death from CVD during 2006-2010. METHODS: We defined avoidable deaths from CVD as deaths among U.S. residents younger than 75 years of age caused by the following underlying conditions, using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes: ischemic heart disease (I20-I25), chronic rheumatic heart disease (I05-I09), hypertensive disease (I10-I15), or cerebrovascular disease (I60-I69). We stratified county-level death rates by race (non-Hispanic white or non-Hispanic black) and age-standardized them to the 2000 U.S. standard population. We used County Health Rankings data to rank county-level z scores corresponding to four health factors: health behavior, clinical care, social and economic factors, and physical environment. We used Poisson rate ratios (RRs) and 95% confidence intervals (CIs) to compare rates of avoidable death from CVD by health-factor quartile. RESULTS: In a comparison of worst-ranked and best-ranked counties, social and economic factors had the strongest association with rates of avoidable death per 100,000 population from CVD for the total population (RR=1.49; 95% CI 1.39, 1.60) and for each racial/ethnic group (non-Hispanic white: RR=1.37; 95% CI 1.29, 1.45; non-Hispanic black: RR=1.54; 95% CI 1.42, 1.67). Among the non-Hispanic white population, health behaviors had the next strongest association, followed by clinical care. Among the non-Hispanic black population, we observed a significant association with clinical care and physical environment in a comparison of worst-ranked and best-ranked counties. CONCLUSION: Social and economic factors have the strongest association with rates of avoidable death from CVD by county, which reinforces the importance of social and economic interventions to address geographic disparities in avoidable deaths from CVD.

Comparing methods of measuring geographic patterns in temporal trends: an application to county-level heart disease mortality in the United States, 1973 to 2010.

PURPOSE: To demonstrate the implications of choosing analytical methods for quantifying spatiotemporal trends, we compare the assumptions, implementation, and outcomes of popular methods using county-level heart disease mortality in the United States between 1973 and 2010. METHODS: We applied four regression-based approaches (joinpoint regression, both aspatial and spatial generalized linear mixed models, and Bayesian space-time model) and compared resulting inferences for geographic patterns of local estimates of annual percent change and associated uncertainty. RESULTS: The average local percent change in heart disease mortality from each method was -4.5%, with the Bayesian model having the smallest range of values. The associated uncertainty in percent change differed markedly across the methods, with the Bayesian space-time model producing the narrowest range of variance (0.0-0.8). The geographic pattern of percent change was consistent across methods with smaller declines in the South Central United States and larger declines in the Northeast and Midwest. However, the geographic patterns of uncertainty differed markedly between methods. CONCLUSIONS: The similarity of results, including geographic patterns, for magnitude of percent change across these methods validates the underlying spatial pattern of declines in heart disease mortality. However, marked differences in degree of uncertainty indicate that Bayesian modeling offers substantially more precise estimates.