Association Between Sleep Duration and Ideal Cardiovascular Health Among US Adults, National Health and Nutrition Examination Survey, 2013-2016.

INTRODUCTION: Short or long sleep duration is a risk factor for cardiovascular disease, but the association between sleep duration and cardiovascular health is unclear. Our objective was to quantify the association between sleep duration and ideal cardiovascular health (CVH) in US adults. We hypothesized that very short (<6 h) and very long (≥9 h) sleep duration were associated with poorer CVH compared with sleep lasting 7 to <8 hours. METHODS: We conducted a cross-sectional evaluation of the nationally representative National Health and Nutrition Examination Survey in 2 cycles (2013-2014 and 2015-2016). Participants were 7,784 cardiovascular disease-free US adults aged 20 to 75. Self-reported sleep duration was categorized as <6 hours, 6 to <7 hours, 7 to <8 hours, 8 to <9 hours, and ≥9 hours. The American Heart Association's ideal CVH metrics were used to determine the number of ideal CVH components, dichotomized as ideal (5-7 components) or not ideal (0-4 components). Survey-weighted logistic and linear regression models were used to determine the association between sleep duration and ideal CVH. RESULTS: The weighted prevalences of those who slept 7 to <8 hours were 30.4%, very short sleep duration (<6 h), 9.0%, and very long duration (≥9 h), 13.5%. Only 21.3% of the population had ideal CVH. Compared with 7 to <8 hours, very short duration (OR = 0.65; 95% confidence interval [CI], 0.47-0.90) and very long duration (OR = 0.72; 95% CI, 0.55-0.94) were associated with decreased odds of ideal CVH. We confirmed findings by using linear regression. CONCLUSIONS: Very short and very long sleep duration were associated with decreased odds of ideal CVH and lower mean CVH scores. Future research should focus on clarifying causal associations between sleep duration and ideal CVH.

Racial/Ethnic Differences in Diabetes Screening and Hyperglycemia Among US Women After Gestational Diabetes.

INTRODUCTION: Gestational diabetes mellitus (GDM) is the most common complication of pregnancy and is associated with an increased risk for type 2 diabetes. Racial/ethnic minority populations are at a higher risk than non-Hispanic white populations of developing type 2 diabetes after GDM. The aim of this study was to describe racial/ethnic differences in hyperglycemia and receipt of screening services in a nationally representative sample of women with a history of GDM. METHODS: Our sample included 765 women from the US National Health and Nutrition Examination Survey (2007-2016) with a history of GDM. We used logistic, multinomial, linear, and proportional hazards regression to evaluate racial/ethnic differences in development of diabetes after GDM, hyperglycemia (measured by HbA1c), and receipt of diabetes screening services. RESULTS: Non-Hispanic black women had 63% higher risk and Hispanic women and "other" racial/ethnic women had more than double the risk for diabetes compared with non-Hispanic white women. Among women with a GDM history who did not receive a diagnosis of diabetes by the time of the study examination, both non-Hispanic black women and Hispanic women were more likely than non-Hispanic white women to be in the prediabetes or diabetes range (measured HbA1c ≥5.7%). However, non-Hispanic black women had 2.07 (95% confidence interval, 1.29-3.81) times the odds of being screened for diabetes compared with non-Hispanic white women (P = .02). CONCLUSION: Delays in identification of hyperglycemia and diagnosis of diabetes in racial/ethnic minority women may reflect differential delivery of guideline-based care or poor follow-up of abnormal screening test results.

Association of Burnout with Workforce-Reducing Factors among EMS Professionals.

OBJECTIVES: Emergency medical services (EMS) professionals often work long hours at multiple jobs and endure frequent exposure to traumatic events. The stressors inherent to the prehospital setting may increase the likelihood of experiencing burnout and lead providers to exit the profession, representing a serious workforce and public health concern. Our objectives were to estimate the prevalence of burnout, identify characteristics associated with experiencing burnout, and quantify its relationship with factors that negatively impact EMS workforce stability, namely sickness absence and turnover intentions. METHODS: A random sample of 10,620 emergency medical technicians (EMTs) and 10,540 paramedics was selected from the National EMS Certification database to receive an electronic questionnaire between October, 2015 and November, 2015. Using the validated Copenhagen Burnout Inventory (CBI), we assessed burnout across three dimensions: personal, work-related, and patient-related. We used multivariable logistic regression modeling to identify burnout predictors and quantify the association between burnout and our workforce-related outcomes: reporting ten or more days of work absence due to personal illness in the past 12 months, and intending to leave an EMS job or the profession within the next 12 months. RESULTS: Burnout was more prevalent among paramedics than EMTs (personal: 38.3% vs. 24.9%, work-related: 30.1% vs. 19.1%, and patient-related: 14.4% vs. 5.5%). Variables associated with increased burnout in all dimensions included certification at the paramedic level, having between five and 15 years of EMS experience, and increased weekly call volume. After adjustment, burnout was associated with over a two-fold increase in odds of reporting ten or more days of sickness absence in the past year. Burnout was associated with greater odds of intending to leave an EMS job (personal OR:2.45, 95% CI:1.95-3.06, work-related OR:3.37, 95% CI:2.67-4.26, patient-related OR: 2.38, 95% CI:1.74-3.26) or the EMS profession (personal OR:2.70, 95% CI:1.94-3.74, work-related OR:3.43, 95% CI:2.47-4.75, patient-related OR:3.69, 95% CI:2.42-5.63). CONCLUSIONS: The high estimated prevalence of burnout among EMS professionals represents a significant concern for the physical and mental well-being of this critical healthcare workforce. Further, the strong association between burnout and variables that negatively impact the number of available EMS professionals signals an important workforce concern that warrants further prospective investigation.

High cardiovascular disease mortality after endometrial cancer diagnosis: Results from the Surveillance, Epidemiology, and End Results (SEER) Database.

Obesity is a strong risk factor for developing endometrial cancer and cardiovascular disease (CVD); consequently, understanding CVD mortality among endometrial cancer survivors is important. We analyzed Surveillance, Epidemiology and End Results Program data for 157,496 endometrial cancer cases diagnosed between 1988 and 2012. We calculated standardized mortality ratios (SMRs) for CVD and all-cause mortality comparing endometrial cancer cases and general population women. We categorized women into one of three prognostic groups (excellent, intermediate and poor) based on tumor characteristics. Cumulative incidence function curves were plotted to visualize absolute mortality risk in the presence of competing risks. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression for cause-specific mortality. Deaths were as follows: endometrial cancer 40.6%, CVD 20.5%, other cancers 18.7% and other causes 20.3%. Women with endometrial cancer were more likely to die from CVD (age-adjusted SMR = 8.8, 95% CI = 8.7-9.0) and all causes (age-adjusted SMR = 15.9, 95% CI = 15.8-16.0) compared to general population women. In case-only analyses, higher CVD mortality was associated with older age, Black ethnicity and lack of surgical treatment. Poor prognosis cancers (non-endometrioid histology and late stage) were related to higher mortality from each cause, with the highest HRs observed for endometrial cancer-specific mortality. Among women diagnosed with excellent prognosis tumors (endometrioid, well-differentiated and early stage), absolute risk of CVD mortality surpassed endometrial cancer-specific mortality 5 years after diagnosis. Women diagnosed with common forms of endometrial cancer have a high CVD burden. After diagnosis, cardiovascular health should be emphasized for these women to reduce mortality.

Cardiovascular disease mortality among women with endometrial cancer in the Iowa Women's Health Study.

PURPOSE: Obesity is associated with endometrial cancer (EC) development and cardiovascular disease (CVD) mortality. As the number of obese EC survivors continues to increase, an examination of CVD mortality in this vulnerable population is warranted. METHODS: In the Iowa Women's Health Study (1986-2011), we examined CVD mortality among 552 women with EC compared with 2,352 age- and body mass index-matched women without EC (controls). Hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD mortality were estimated using multivariable-adjusted Cox proportional hazards regression models stratified by an indicator for match set. RESULTS: Compared to controls, women with EC more often reported a history of diabetes, hypertension, and never smoking. Compared with controls, women with EC had lower CVD mortality (HR 0.75, 95% CI 0.56-0.99), and higher all-cause mortality (HR 1.50, 95% CI 1.30-1.74). CONCLUSIONS: Although some CVD risk factors were more common in women with versus without EC, CVD mortality was lower among the former group. Additional well-adjusted analyses with larger study populations are needed to understand interactions between CVD risk factors with CVD mortality among EC survivors. The CVD risk factor profile of EC survivors warrants emphasis on cardiovascular health.

Is Surgical Menopause Associated With Future Levels of Cardiovascular Risk Factor Independent of Antecedent Levels? The CARDIA Study.

In the present study, we compared changes in risk factors for cardiovascular disease (CVD) before and after natural menopause (NM), hysterectomy with at least 1 ovary conserved (HOC), or hysterectomy with bilateral oophorectomy (HBSO). Data were obtained from women 18-30 years of age who were enrolled in the Coronary Artery Risk Development in Young Adults Study (1985-2011). Piecewise linear mixed models were used to examine changes in CVD risk factors from baseline to the index visit (the first visit after the date of NM or hysterectomy) and after index visit until the end of follow-up. During 25 years of follow-up, 1,045 women reached menopause (for NM, n = 588; for HOC, n = 304; and for HBSO, n = 153). At baseline, women with either type of hysterectomy had less favorable values for CVD risk factors. When comparing the annual rates of change of all CVD risk factors from baseline until the index visit to those from the index visit to the end of follow-up, we saw a small increase in rate of change for high-density lipoprotein cholesterol (ß = 0.28 mg/dL; P = 0.002) and a decrease for triglycerides (ß =-0.006 mg/dL; P = 0.027) for all groups. Hysterectomy was not associated with risk factors for CVD after accounting for baseline values. However, antecedent young-adult levels of CVD risk factors were strong predictors of levels of postmenopausal risk factors.

Prepregnancy and Gestational Diabetes and Cessation of Breastfeeding <1 Week Postpartum, United States, 2016-2018.

OBJECTIVES: Diabetes may delay milk letdown, and perceiving milk production as insufficient can lead to breastfeeding cessation. We evaluated whether prepregnancy or gestational diabetes is associated with cessation of breastfeeding by 1 week postpartum. METHODS: We analyzed 2016-2018 data from 42 sites in the Pregnancy Risk Assessment Monitoring System, a population-based survey of women with a recent live birth. Participants were surveyed 2-6 months after childbirth. We used logistic regression models to evaluate the relationship between prepregnancy or gestational diabetes only and breastfeeding <1 week postpartum among women who had initiated breastfeeding. RESULTS: Among 82 050 women who initiated breastfeeding, 4.5% reported breastfeeding <1 week postpartum. Overall, 11.7% of women reported any history of diabetes in the 3 months before becoming pregnant; 3.3% reported prepregnancy diabetes, and 8.4% reported gestational diabetes only. In both unadjusted and adjusted models, the prevalence of breastfeeding <1 week postpartum did not differ significantly among women with prepregnancy diabetes or gestational diabetes only compared with women without any history of diabetes. The prevalence of breastfeeding <1 week postpartum was 4.4% among women without any history of diabetes, 5.6% among women with prepregnancy diabetes (adjusted prevalence ratio [aPR] = 1.15; 95% CI, 0.91-1.46), and 4.5% among women with gestational diabetes only (aPR = 1.01; 95% CI, 0.84-1.20). CONCLUSIONS: We found no association between a history of diabetes prepregnancy or gestational diabetes only and breastfeeding <1 week postpartum in a large, population-based survey of postpartum women who initiated breastfeeding. Regardless of their diabetes status, women who want to breastfeed might benefit from interventions that support their ability to continue breastfeeding.

Real-world safety and effectiveness of elexacaftor/tezacaftor/ivacaftor in people with cystic fibrosis: Interim results of a long-term registry-based study.

BACKGROUND: Phase 3 clinical trials showed elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was safe and efficacious in people with cystic fibrosis (CF) with ≥1 F508del-CFTR allele. To assess long-term effects of ELX/TEZ/IVA under real-world conditions of use, a 5-year observational registry-based study is being conducted. We report interim results from the first 2 years of follow-up. METHODS: The study included people with CF in the US Cystic Fibrosis Foundation Patient Registry (CFFPR) who initiated ELX/TEZ/IVA between October 2019 and December 2020. Pulmonary exacerbations (PEx), percent predicted forced expiratory volume in 1 second (ppFEV1), hospitalizations, bacterial pathogens, body mass index (BMI), CF complications and comorbidities, and liver function tests (LFTs) after treatment initiation were compared with the 5-year pre-treatment period. Death and lung transplantation were assessed relative to 2019 CFFPR data. RESULTS: 16,116 people with CF were included (mean treatment duration 20.4 months). Among those with 5 years of pre-treatment data, mean PEx/patient/year declined to 0.18 (95% CI: 0.17, 0.19) in Years 1 and 2 post-treatment from 0.86 (95% CI: 0.83, 0.88) in the baseline year (79% reduction), after a continued increase observed pre-treatment. Similarly, a decline in mean hospitalizations/patient/year was observed in Year 1 that was sustained in Year 2 (74% reduction from baseline year). The mean absolute change in ppFEV1 from baseline was +8.2 percentage points (95% CI: 8.0, 8.4) in Year 1 and +8.9 percentage points (95% CI: 8.7, 9.1) in Year 2, after a continued decline observed pre-treatment. Positive bacterial cultures decreased for all evaluated pathogens, and mean BMI increased by 1.6 kg/m2 (95% CI: 1.5, 1.6) by Year 2. No new safety concerns were identified based on evaluation of CF complications, comorbidities, and LFTs. The annualized rates of death (0.47% [95% CI: 0.39, 0.55]) and lung transplantation (0.16% [95% CI: 0.12, 0.22]) were considerably lower than reported in 2019 (1.65% and 1.08%, respectively). CONCLUSIONS: ELX/TEZ/IVA treatment was associated with sustained improvements in lung function, reduced frequency of PEx and all-cause hospitalization, increased BMI, and lower prevalence of positive bacterial cultures. Additionally, there was a 72% lower rate of death and 85% lower rate of lung transplantation relative to the year before ELX/TEZ/IVA availability. These results, from the largest cohort of ELX/TEZ/IVA-treated people to date, extend our understanding of the broad clinical benefits of ELX/TEZ/IVA.

Mothers' Perspectives on a Mother/Infant Dyad Postpartum Primary Care Program Following Gestational Diabetes Mellitus: A Qualitative Pilot Study.

PURPOSE: The purpose of this study is to characterize mothers' experiences within a mother/infant dyad postpartum primary care program (Dyad) following gestational diabetes mellitus (GDM) to inform improvements in the delivery of care. METHODS: A qualitative pilot study of women (n = 10) enrolled in a mother/infant Dyad program was conducted in a primary care practice at a large, urban academic medical center. Respondents were asked a series of open-ended questions about their experience with GDM, the Dyad program, and health behaviors. Interviews were audio-recorded, transcribed verbatim, and analyzed using ground theory with NVivo 12 Plus software. RESULTS: Three key themes emerged: (1) Dyad program experience, (2) implementation of health behavior changes, and (3) acknowledgment of future GDM and type 2 diabetes mellitus (T2DM) health risks. Respondents felt that the program conveniently served mother and infant health care needs in a single appointment. Respondents also valued support from primary care providers when implementing health behavior changes. The Dyad program provided an opportunity for respondents to understand their current and future risk for developing GDM and T2DM. CONCLUSIONS: Postpartum women enrolled in the Dyad program received highly personalized primary care services. The results of our study will help integrate patient-centered strategies into models for GDM care to maintain patient engagement in postpartum clinical services.

Ten-year cardiovascular risk among cancer survivors: The National Health and Nutrition Examination Survey.

BACKGROUND: Cancer survivors have a higher risk of developing and dying from cardiovascular disease (CVD) compared to the general population. We sought to determine whether 10-year risk of atherosclerotic CVD (ASCVD) is elevated among those with vs. without a cancer history in a nationally representative U.S. sample. METHODS: Participants aged 40-79 years with no CVD history were included from the 2007-2016 National Health and Nutrition Examination Survey. Cancer history was self-reported and 10-year risk of ASCVD was estimated using Pooled Cohort Equations. We used logistic regression to estimate associations between cancer history and odds of elevated (≥7.5%) vs. low (<7.5%) 10-year ASCVD risk. An interaction between age and cancer history was examined. RESULTS: A total of 15,095 participants were included (mean age = 55.2 years) with 12.3% (n = 1,604) reporting a cancer history. Individuals with vs. without a cancer history had increased odds of elevated 10-year ASCVD risk (OR = 3.42, 95% CI: 2.51-4.66). Specifically, those with bladder/kidney, prostate, colorectal, lung, melanoma, or testicular cancer had a 2.72-10.47 higher odds of elevated 10-year ASCVD risk. Additionally, age was an effect modifier: a cancer history was associated with 1.24 (95% CI: 1.19-4.21) times higher odds of elevated 10-year ASCVD risk among those aged 60-69, but not with other age groups. CONCLUSIONS: Adults with a history of self-reported cancer had higher 10-year ASCVD risk. ASCVD risk assessment and clinical surveillance of cardiovascular health following a cancer diagnosis could potentially reduce disease burden and prolong survival, especially for patients with specific cancers and high ASCVD risk.

Associations of anthropometric measures of obesity with physical limitations in older adults.

Introduction: Physical limitations are associated loss of independence, lower quality of life, greater healthcare costs, and mortality. Changes in body composition during the aging process contribute to the decline in physical functioning. Body mass index is commonly used to quantify adiposity; however, measurements that better capture abdominal obesity may confer better advantage for risk of physical limitations.Methods: We used data from the 2013-2014 National Health and Nutrition Examination Survey to compare the associations of (1) body mass index, (2) sagittal abdominal diameter, and (3) waist circumference with physical limitations in adults 60-80 years (n = 1258). We used weighted logistic regression models to allow for estimates that are representative of the US population.Results: All three anthropometric measures were significantly associated with physical limitations. Abdominal fat measurements (sagittal abdominal diameter and waist circumference) were more strongly associated with physical limitations in men. However, they were not independently associated with physical limitations after controlling for body mass index. All three measurements did not differ in their ability to distinguish presence of physical limitations.Conclusions: Our data suggest that abdominal fat measurements are not independently associated with physical limitations after accounting for body mass index. Body mass index, waist circumference, and sagittal abdominal diameter are all of equal practical value for identifying older adults at risk for physical limitations.IMPLICATIONS FOR REHABILITATIONOur data suggest that both sagittal abdominal diameter and waist circumference are not independently associated with physical limitations after accounting for body mass index.Strategies to manage overall body weight may be the most effective goal of primary prevention of disability and to support the rehabilitation process.Body mass index, waist circumference, and sagittal abdominal diameter are all of equal practical value for health professionals to identify older adults at higher risk for physical limitations.Practitioners should consider the measures that are most feasible and easiest to obtain in the clinical setting.

Physical activity and risk of cardiovascular disease by weight status among U.S adults.

PURPOSE: We sought to determine whether the association between physical activity and 10-year cardiovascular disease (CVD) risk varies among normal weight, overweight, and obese adults in a nationally-representative sample of the United States. METHODS: Data were from the National Health and Nutrition Examination Survey 2007-2016. A subset of 22,476 participants aged 30-64 years was included with no CVD history. Physical activity level was self-reported and stratified into sedentary (0 min/week), inactive (1-149 mins/week), or active (≥150 mins/week) of moderate or vigorous activities. Framingham risk scores were classified as low/intermediate (<20%) or high 10-year CVD risk (≥20%). RESULTS: The average age of the population was 45.9 years, 52.3% were female, 33.6% were overweight (BMI 25.0-29.9kg/m2), and 35.7% were obese (BMI≥30kg/m2). Individuals who were overweight and obese had a higher 10-year CVD risk compared to those with normal weight (9.5 vs. 10.1 vs. 6.3%, P<0.001). The association of physical activity and high 10-year CVD risk differed by weight status. Among overweight and obese adults, individuals engaged in any physical activity had lower odds ofhigh 10-year CVD risk compared to sedentary individuals (overweight: OR active = 0.48, 95% CI: 0.36-0.64; OR inactive = 0.53, 95% CI: 0.45-0.86; obese: OR active = 0.50, 95% CI: 0.37-0.68; OR inactive = 0.66, 95% CI: 0.49-0.89). Among normal weight adults, individuals who were physically active had lower odds of high 10-year CVD risk (OR = 0.59, 95% CI: 0.28-0.87). When compared the joint effects of physical activity level and weight status, physical activity was associated with a larger magnitude of reduced odds of 10-year CVD risk than weight status. CONCLUSION: Participation in any level of physical activity is associated with a lower 10-year CVD risk for overweight and obese adults. Future studies are needed to identify effective modes and doses of exercise that offer optimal CVD benefits for populations with different weight statuses.

Cellphone laws and teens' calling while driving: analysis of repeated cross-sectional surveys in 2013, 2015, 2017, and 2019.

BACKGROUND: Distracted driving among teens is a public health and safety concern. Most states in the U.S. have sought to restrict cellphone use while driving by enacting laws. This study examines the difference in prevalence of self-reported calling while driving (CWD) between states with different cellphone bans. METHODS: Demographics and CWD data were extracted from state Youth Risk Behavior Surveys (YRBS) from 14 states in 2013, 2015, 2017, and 2019. The state YRBS is conducted every 2 years with a representative sample of 9th through 12th grade students attending public school. States were grouped by type of cellphone law(s): no ban (the absence of both handheld calling ban and young driver ban), young driver ban (a ban on all forms of cellphone use while driving, for young drivers only), or concurrent ban (a young driver ban plus a ban on handheld calling for all drivers irrespective of age). Poisson regression models with robust variance were used to estimate prevalence ratios comparing CWD prevalence across ban types. RESULTS: In total, 157,423 high school students participated in the surveys, and 65,044 (45%) participants reached the minimum age to obtain an intermediate license and drove during the 30 days prior the survey. Approximately 53% of participants reported CWD at least once during the previous 30 days, and the percentages varied widely by states (range: 51-55%). Compared to students from states with no ban, those from states with concurrent bans were 19%(95% CI: 14-24%) less likely to engage in CWD. Students in states with concurrent bans were 23% less likely to engage in CWD compared to students in states with young driver bans (95% CI:17-27%). CONCLUSIONS: Engaging in CWD is common among teen drivers. The concurrent implementation of a handheld calling ban and a young driver ban was associated with a lower prevalence of CWD.

Perceived Barriers to Type 2 Diabetes Prevention for Low-Income Women With a History of Gestational Diabetes: A Qualitative Secondary Data Analysis.

PURPOSE: The purpose of this qualitative study was to examine perceived barriers to adoption of lifestyle changes for type 2 diabetes prevention among a diverse group of low-income women with a history of gestational diabetes mellitus (GDM). METHODS: A secondary data analysis of 10 semistructured focus group discussions was conducted. Participants were low-income African American, Hispanic, and Appalachian women ages 18 to 45 years who were diagnosed with GDM in the past 10 years. A qualitative content analysis was conducted to identify key themes that emerged within and between groups. RESULTS: Four key themes emerged on the role of knowledge, affordability, accessibility, and social support in type 2 diabetes prevention. Women discussed a lack of awareness of the benefits of breastfeeding and type 2 diabetes prevention, inaccessibility of resources in their local communities to help them engage in lifestyle change, and the desire for more culturally relevant education on healthful food options and proper portion sizes. DISCUSSION: Study findings suggests that to improve effectiveness of type 2 diabetes prevention efforts among low-income women with GDM history, health care providers and public health practitioners should avoid using "one-size-fits-all" approaches to lifestyle change and instead use tailored interventions that address the cultural and environmental factors that impact women's ability to engage in recommended behavior change.

Black-White differences in hysterectomy prevalence: the CARDIA study.

OBJECTIVES: We evaluated the cross-sectional association between race and hysterectomy prevalence in a population-based cohort of US women and investigated participant characteristics associated with racial differences. METHODS: The cohort consisted of 1863 Black and White women in the Coronary Artery Risk Development in Young Adults (CARDIA) study from 2000 to 2002 (years 15 and 16 after baseline). We used logistic regression to examine unadjusted and multivariable adjusted odds ratios. RESULTS: Black women demonstrated greater odds of hysterectomy compared with White women (odds ratio [OR] = 3.52; 95% confidence interval [CI] = 2.52, 4.90). Adjustment for age, educational attainment, perceived barriers to accessing medical care, body mass index, polycystic ovarian syndrome, tubal ligation, depressive symptoms, age at menarche, and geographic location minimally altered the association (OR = 3.70; 95% CI = 2.44, 5.61). In a subset of the study population, those with directly imaged fibroids, the association was minimally attenuated (OR = 3.47; 95% CI = 2.23, 5.40). CONCLUSIONS: In both unadjusted and multivariable adjusted models, Black women, compared with White women, had increased odds of hysterectomy that persisted despite adjustment for participant characteristics. The increased odds are possibly related to decisions to undergo hysterectomy.

Cardiovascular Health Trends in Electronic Health Record Data (2012-2015): A Cross-Sectional Analysis of The Guideline Advantage™.

BACKGROUND: Electronic health record (EHR) data can measure cardiovascular health (CVH) of patient populations, but have limited generalizability when derived from one health care system. OBJECTIVE: We used The Guideline Advantage™ (TGA) data repository, comprising EHR data of patients from 8 diverse health care systems, to describe CVH of adult patients and progress towards the American Heart Association's (AHA's) 2020 Impact Goals. METHODS: Our analysis included 203,488 patients with 677,733 encounters recorded in TGA from 2012 to 2015. Five measures from EHRs [cigarette smoking status, body mass index (BMI), blood pressure (BP), cholesterol, and diabetes mellitus (DM)] were categorized as poor/intermediate/ideal according to AHA's Life's Simple 7 algorithm. We presented distributions and trends of CVH for each metric over time, first using all available data, and then in a subsample (n = 1,890) of patients with complete data on all metrics. RESULTS: Among all patients, the greatest stride towards ideal CVH attainment from 2012 to 2015 was for cigarette smoking (50.6 percent to 65 percent), followed by DM (17.3 percent to 20.7 percent) and BP (21.1 percent to 23.2 percent). Overall, prevalence of ideal CVH did not increase for any metric in the subsample. Males slightly improved in ideal CVH for BMI and cholesterol; meanwhile, females saw no improvement in ideal CVH for any metric. As ideal CVH for BP and cholesterol increased slightly among white patients, ideal CVH for BP, cholesterol, BMI, and DM worsened for non-whites. CONCLUSION: Despite improvements in some CVH metrics in the outpatient setting, more tangible progress is needed to meet AHA's 2020 Impact Goals.

The Impact of Advance Care Planning on End-of-Life Care: Do the Type and Timing Make a Difference for Patients With Advanced Cancer Referred to Hospice?

PURPOSE: This study aimed to determine the impact of advanced care planning (ACP) on potentially avoidable hospital admissions at the end of life (EOL) among a sample of hospice-referred patients with cancer, in order to present actionable considerations for the practicing clinician. METHODS: This study was designed as a retrospective cohort using electronic health record data that assessed likelihood of hospital admissions in the last 30 days of life for 1185 patients with a primary diagnosis of cancer, referred to hospice between January 1, 2014, and December 31, 2015, at a large academic medical center. Inverse probability treatment weighting based on calculated propensity scores balanced measured covariates between those with and without ACP at baseline. Odds ratios (ORs) were calculated from estimated potential outcome means for the impact of ACP on admissions in the last 30 days of life. RESULTS: A verified do-not-resuscitate (DNR) order prior to the last 30 days of life was associated with reduced odds of admission compared to those without a DNR (OR = 0.30; P < .001). An ACP note in the problem list prior to the last 30 days of life was associated with reduced odds of admission compared to those without an ACP note (OR = 0.71, P = .042), and further reduced odds if done 6 months prior to death (OR = 0.35, P < .001). CONCLUSIONS: This study shows that dedicated ACP documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice. Improving ACP processes prior to hospice referral holds promise for reducing EOL admissions.

Differences in Cardiovascular Health Metrics in Emergency Medical Technicians Compared to Paramedics: A Cross-Sectional Study of Emergency Medical Services Professionals.

BACKGROUND: Emergency Medical Services (EMS) professionals face high physical demands in high-stress settings; however, the prevalence of cardiovascular health (CVH) risk factors in this health care workforce has not been explored. The primary objective of this study was to compare the distribution of CVH and its individual components between a sample of emergency medical technicians (EMTs) and paramedics. The secondary objective was to identify associations between demographic and employment characteristics with ideal CVH in EMS professionals. METHODS: A cross-sectional survey based on the American Heart Association's (AHA; Dallas, Texas USA) Life's Simple 7 (LS7) was administered to nationally-certified EMTs and paramedics. The LS7 components were scored according to previously described cut points (ideal = 2; intermediate = 1; poor = 0). A composite CVH score (0-10) was calculated from the component scores, excluding cholesterol and blood glucose due to missing data. Multivariable logistic regression was used to estimate odds ratios (OR; 95% CI) for demographic and employment characteristics associated with optimal CVH (≥7 points). RESULTS: There were 24,708 respondents that were currently practicing and included. More EMTs achieved optimal CVH (n = 4,889; 48.8%) compared to paramedics (n = 4,338; 40.6%). Factors associated with higher odds of optimal CVH included: higher education level (eg, college graduate or more: OR = 2.26; 95% CI, 1.97-2.59); higher personal income (OR = 1.26; 95% CI, 1.17-1.37); and working in an urban versus rural area (OR = 1.31; 95% CI, 1.23-1.40). Paramedic certification level (OR = 0.84; 95% CI, 0.78-0.91), older age (eg, 50 years or older: OR = 0.65; 95% CI, 0.58-0.73), male sex (OR = 0.54; 95% CI, 0.50-0.56), working for a non-fire-based agency (eg, private service: OR = 0.68; 95% CI, 0.62-0.74), and providing medical transport service (OR = 0.81; 95% CI, 0.69-0.94) were associated with lower odds of optimal CVH. CONCLUSIONS: Several EMS-related characteristics were associated with lower odds of optimal CVH. Future studies should focus on better understanding the CVH and metabolic risk profiles for EMS professionals and their association with incident cardiovascular disease (CVD), major cardiac events, and occupational mortality.Cash RE, Crowe RP, Bower JK, Foraker RE, Panchal AR. Differences in cardiovascular health metrics in emergency medical technicians compared to paramedics: a crosssectional study of Emergency Medical Services professionals. Prehosp Disaster Med. 2019;34(3):288-296.

The childcare environment and children's physical activity.

BACKGROUND: With increased numbers of children attending child care, this setting presents an ideal opportunity to promote physical activity and the early development of healthy behaviors. The purpose of this study was to examine the relationships between the childcare environment and physical activity behavior of preschool children. METHODS: Aspects of the environment hypothesized to influence children's physical activity were assessed in 20 childcare centers using the Environment and Policy Assessment and Observation (EPAO) instrument. Physical activity behavior was assessed over 2 days using direct observation. RESULTS: Children in centers with supportive environments achieved more moderate-to-vigorous physical activity (15% of observations vs 9%; effect size [ES]=1.17), spent less time in sedentary activities (50% vs 61%; ES=-1.52), and had higher mean physical activity levels (2.68 vs 2.43; ES=1.41) compared to centers with less supportive environments. Facets of the physical and social environment related to physical activity behavior included active opportunities, portable play equipment, fixed play equipment, sedentary environment, and physical activity training and education. CONCLUSIONS: Previous research indicates that the childcare center that children attend significantly affects physical activity behavior. The current findings extend this evidence by identifying aspects of the childcare environment that relate to the physical activity behavior of children. These factors should be considered when identifying determinants of physical activity and designing interventions.