Health utilities associated with hemoglobin levels and blood loss in postmenopausal women: the Women's Health Initiative.

OBJECTIVES: The purpose of our study was to use health-related quality of life data from the Women's Health Initiative to calculate health-related utility weights and examine differences in these health utility weights across different hemoglobin (Hgb) levels. These utility weights could then be used in future cost-effectiveness studies. METHODS: Health utility weights were measured by the Short Form-6D (SF-6D), a health utility index derived from the Short Form Medical Outcomes questionnaire. Adjusted least square means were calculated for each level of Hgb at baseline and in longitudinal regression analysis the relationship between change in Hgb and change in the SF-6D was examined. Both baseline and longitudinal analyses were performed for all postmenopausal women and separately for those with self-reported heart failure, cancer, and osteoarthritis. RESULTS: Women with Hgb in the anemic range had lower health utility weights than those with higher Hgb levels. Longitudinally, a loss of of 2 g/dl Hgb or more was associated with a statistically significant and clinically meaningfully decline in SF-6D in all participants and also in the group of participants with cancer and osteoarthritis, but not in those with heart failure. CONCLUSIONS: Lower levels of Hgb and a loss of Hgb are associated with a statistically significant and clinically meaningful decrement in health utility in all postmenopausal women we studied and also in those with chronic conditions.

Coronary heart disease surveillance: field application of an epidemiologic algorithm.

This report describes the performance of a surveillance system and computerized algorithm for the assignment of definite or probable hospitalized cardiac events for large epidemiologic studies. The algorithm, developed by the Coordinating Committee for Community Demonstration Studies (CCCDS), evolved from the Gillum criteria, and included selected ICD-9-CM codes including codes 410 through 414 for discharge record screening, plus creatine kinase. For the small percentage of cases in which enzyme analysis was inconclusive (8%), presence of pain and/or Minnesota-coded electrocardiograms were included to define the outcome. All data items were easily obtained from medical records by trained lay record abstractors and required no interpretation. From January 1980 through December 1991, 21,183 medical records were screened for ICD-9-CM codes 410 through 414. Of all 410 to 411 ICD-9-CM codes (n = 9026), 36.9% (n = 3220) were classified as definite cardiac events and 10.6% (n = 1057) as probable events. Of all 412 through 414 codes (n = 9070), only 1.8% (n = 227) were classified as definite cardiac events and 5.4% (n = 716) as probable events. The epidemiologic diagnostic algorithm presented in this article used computerized data to assign diagnoses in a standard, objective manner, and was a lower cost alternative to classification of cardiac events on the basis of clinical review and/or more complex record abstraction approaches.

Daytime hypertension in obstructive sleep apnea. Prevalence and contributing risk factors.

We examined the prevalence of daytime hypertension in a modern sample of patients with obstructive sleep apnea (OSA) and assessed the relative risk factors contributing to the development of hypertension in this disorder. Daytime hypertension was present in 92 (45 percent) of 206 male and female patients with OSA. Stepwise logistic regression revealed that only age and body mass index (BMI) were predictors of hypertension in this population. A subsample of 152 male patients with OSA was then compared to 904 men identified from a geographically and ethnically similar general population. When one controlled for age and BMI, the prevalence of hypertension in the two groups was the same except for those aged 25 to 44 years who were markedly obese (BMI greater than 31 kg/m2). In this group, 47 percent of the patients with OSA were hypertensive vs 26 percent of control subjects (p less than 0.05). Our data suggest that the high prevalence of hypertension in OSA is primarily related to age and the excess obesity seen in these patients. In morbidly obese young patients with OSA, factors directly related to OSA may also be contributing to the development of hypertension. With increasing age, other competitive risks may obscure any independent effect that OSA may exert.

A new approach to surveillance for acute myocardial infarction: reproducibility and cost efficiency.

A new approach to surveillance of myocardial infarction, the major cardiovascular endpoint is described using an algorithm which depends primarily on enzyme data, using evidence of chest pain and positive electrocardiogram findings as supplemental information only. This approach is evaluated with respect to reproducibility by minimally trained abstractors, cost, and robustness with respect to different hospital systems as well as changes in diagnostic techniques and/or labelling over time. Two pilot studies demonstrate that, in comparison to more traditional approaches, the new surveillance system provides at least a 50% reduction in cost, is highly reproducible over different hospital systems, and potentially, is resilient to changes in diagnostic procedures or coding. The more general applicability of such an innovative surveillance approach to other disease endpoints, in which one reliable procedure contains most of the diagnostic information, is discussed with particular reference to cancer.

Education and risk factors for coronary heart disease: results from a New England community.

This article investigates the association of education with the estimated coronary heart disease (CHD) risk and the prevalence of CHD risk factors for men and women in a New England community over a period of 10 years. Educational differentials in knowledge of cardiovascular disease prevention, body mass index (BMI), total and high-density lipoprotein (HDL) cholesterol, cigarette smoking, and hypertension were examined for 3,765 respondents 25-64 years of age from five surveys of the Pawtucket Heart Health Program. We found a clear negative association between education and composite CHD risk. A stable separation in risk level was maintained across time between the least educated (< 12 years of education) and the other two educational groups (12, > or = 13 years of education) in both men and women. Educational differentials were observed in BMI and total and HDL cholesterol of the women 25-44 years of age. For men and women 25-44 years of age, smoking was negatively associated with education. Hypertension differed by education level among the women 45-64 years of age. These findings are highly comparable with the national data from aggregate vital statistics and the results of the National Health and Nutrition Examination Survey (NHANES) cohort follow-up.

Predicting physical activity change in men and women in two New England communities.

We describe the predictors of change in physical activity in a population-derived sample of residents of two New England communities. In 1986-1987 and again in 1990-1991, we assessed the self-reported physical activity of 1,081 survey respondents using a single question concerning the frequency of exercise-induced sweating. We measured and analyzed sociodemographic variables, cardiovascular disease risk factors, health knowledge and beliefs, social support variables, and exercise performance variables at baseline as potential predictors of physical activity change. We defined physical activity change in subjects as follows: maintainers (12.2%) persisted with > or = 3 times per week of activity, adopters (16.0%) increased activity to > or = 3 times per week, quitters (11.9%) decreased activity to < 3 times per week, and sedentary (59.9%) individuals persisted with < 3 times per week of activity. Using polychotomous multiple logistic regression analysis, we found that short-term success with exercise and weight loss, school children's recommendation of exercise, and work outside the home predicted adoption or maintenance of increased physical activity in women. For men, short-term success with exercise and weight loss and health beliefs regarding the role of exercise in preventing heart attacks and stroke were the major determinants of maintaining or adopting increased physical activity. This identification of the predictors of physical activity change provides the rationale for future sex-specific strategies aimed at increasing regular physical activity and long-term adherence to an active lifestyle.

Rapid measurement of blood cholesterol: evaluation of a new instrument.

Rapid and reliable techniques for the measurement of blood cholesterol are a necessary first step in implementing effective mass screening efforts to reduce the risks of cardiovascular disease. This paper reports preliminary data gathered on the Kodak Ektachem DT60, one of the first of a new generation of dry chemistry analyzers to appear on the market. The results of the first study demonstrated high reproducibility of the methodology (r = .98, p less than .0001) but showed an average 25 mg/dL underestimate of total blood cholesterol as compared with a standardized lipid laboratory. Changes in the manufacturer's calibration protocol in the second study with two other DT60s reduced this bias on serum samples to -18 mg/dL. A third study using fresh blood samples found a difference of 3-11 mg/dL between the two DT60s and the laboratory. A significant difference between the two analyzers was also found. Alternatives are available to enable those who use this instrument to correct for the observed bias. Despite some problems, several other advantages of the technology lend support for its expanded use in public health interventions.

Effectiveness of methods used to teach breast self-examination.

The efficacy of breast self-examination (BSE) is limited by the extent to which women can be taught to perform a frequent and proficient examination. We randomized 783 women from a health maintenance organization into group instruction, individual instruction, individual instruction with a reminder system, or minimal intervention designed to simulate an office encounter where BSE was encouraged but not taught. The percentage of lumps 1 cm and smaller detected in silicone breast models, the number of false-positive detections, the search technique, and the self-reported BSE frequency were measured before and four months after intervention. Multiple tests for comparisons of interventions showed that the interventions containing BSE instruction were comparable in increasing true- and false-positive detection of lumps and in improving search technique, but the minimal intervention resulted in lower scores for all three outcomes (P less than .0001). Women in all four intervention groups increased their BSE frequency over the four-month follow-up period, but the greatest improvement in frequency was reported among women receiving reminders.

Cross-sectional relationship between diet and physical activity in two southeastern New England communities.

The hypothesis that health promotive diets associated with higher levels of habitual physical activity confound the relationship between regular physical activity and health has not been well explored in epidemiologic studies. We evaluated self-reported physical activity, Willett Food Frequency dietary data, sociodemographic and physiologic factors cross-sectionally for 2,004 household survey participants in two southeastern New England communities. We compared the dietary habits of sedentary participants (n = 964) to those of moderately active (n = 600) and very active (n = 440) participants after adjusting for age, gender, education, smoking status, year of survey, and total calories. Our results showed that moderately active and very active participants consumed more fiber, less total fat, and less saturated fat than sedentary participants (P < .01). They also consumed more vitamins (A, C, D, E), beta carotene, and calcium, (P < .01), and ate more fruits and vegetables (P < .001) than sedentary participants. We found these relationships in both New England communities studied. This association between regular physical activity and diet suggests that the relationship of habitual physical activity and chronic disease may be confounded by diet.

The drug data base of the Pawtucket Heart Health Program: development and description.

Pharmacoepidemiology has become an important tool for identifying patterns of drug use and adverse drug reactions in the general population. Drug data bases derived from population-based samples have been particularly useful in addressing questions such as adherence to national guidelines for the treatment of chronic diseases. As part of the Pawtucket Heart Health Program, a continuing community-based research and demonstration project, detailed information regarding the use of drugs among the general population of two southeastern New England cities was collected using cross-sectional and longitudinal methodologies.

Changing trends in antihypertensive therapy in two New England communities during the 1980s.

The prevalence rates and correlates of antihypertensive drug use among individuals with hypertension were determined using data derived from five biennial population-based surveys conducted between 1981 and 1990 in two New England communities. Point prevalence estimates were determined for nine categories of antihypertensive agents at five time points, and were analyzed by age and sex using multiple logistic regression. In the first cross-sectional survey, the prevalence of use per 1000 individuals with hypertension was 235.4 for diuretics, 57.1 for beta-blockers, 65.5 for combination products, 29.2 for central alpha-agonists, 2.8 for peripheral alpha-antagonists, and 8.4 each for adrenergic blockers and direct vasodilators. The prevalence rates for calcium channel blockers and angiotensin-converting enzyme inhibitors increased sharply between the third and fourth survey cycles. Significant age- and sex-related differences in antihypertensive use were detected.

Sedentary lifestyle and risk of coronary heart disease in women.

Relatively few studies have assessed the prospective relationship of sedentary lifestyle and coronary heart disease (CHD) in women. We performed a nested case-control study, identifying 50 cases of acute CHD in women and 150 age-matched controls. Risk factors including sedentary lifestyle, cigarette smoking, hypertension, diabetes mellitus, total, and HDL cholesterol levels had been previously determined in this cohort using household survey techniques. The odds ratio (OR) of CHD in sedentary women was 2.1 (95% CI 1.0-4.3, P = 0.046). The odds ratio was similar (OR = 2.3, 95% CI 1.0-5.7, P = 0.051) after adjusting for potential confounders of hypertension, cigarette smoking, low HDL cholesterol, diabetes mellitus, and being U.S. born. This study suggests that sedentary lifestyle may be an independent risk factor for CHD in women, but its results are open to several contradictory interpretations. Further studies to investigate the prospective relationship of sedentary lifestyle and the risk of CHD in women are needed.

Physical activity, physical fitness, and coronary heart disease risk factors.

The relationships between physical activity, physical fitness, and coronary heart disease risk factors measured in a large community sample were evaluated. Self-reported physical activity using a single question, maximal oxygen consumption estimates derived from the Pawtucket Heart Health Step Test, blood pressure, nonfasting lipids, and body mass index were cross-sectionally evaluated in 381 men and 556 women. The correlation of estimated maximal oxygen consumption and self-reported physical activity was modest but statistically significant (r = 0.13 in men and r = 0.19 in women). Blood pressure, body mass index, and HDL cholesterol were correlated with physical fitness (r = 0.24-0.65) and correlated to self-reported physical activity (r = 0.09-0.14). Evaluation of coronary heart disease risk factors using both physical activity and physical fitness revealed a complex relationship that generally showed a stronger relationship with measures of physical fitness than with physical activity. This study suggests that simultaneous measurement of physical activity and physical fitness may be useful in epidemiologic studies of habitual physical activity and chronic disease.

Health practice correlates in three adult age groups: results from two community surveys.

Independently done surveys of a target population can make an important contribution to knowledge about the determinants of personal health behavior by highlighting variables that consistently emerge as significant predictors. This investigation examined the correlates of four health practice and knowledge indices related to cardiovascular disease (CVD) in two baseline community surveys of the Pawtucket Heart Health Program (N = 2,413; N = 2,808). An additional dimension was the use of three adult age groups (18-29, 30-49, 50-64) in conducting the analyses. Results of both surveys showed that sex was the strongest correlate of the four indices--knowledge of CVD, encouraging health practice changes in others, dietary intake, and exercise. The four indices related to CVD were also associated with years of education, primary language, and whether or not a recent cholesterol measurement had been obtained, although these relationships were not as consistent as the results for sex. Overall, about half of each survey's significant associations were also found in the other survey (survey 1, 30 of 62; survey 2, 30 of 56). Consistency of significant results between surveys was best for the group ages 30-49. In either survey, it was rare for an association between a predictor and behavioral index to appear in each of the three age groups. This study supports the importance of the subjects' sex in research on personal health practices, suggests the potential for independence even among health-related indices pertinent to a single type of illness, and emphasizes the usefulness of utilizing independent samples to identify important correlates of health behavior.

The FPbase microcomputer system for managing community health screening and intervention data bases.

Health promotion and intervention projects at State and community levels need computerized data bases to assist in making policy decisions and in operating the projects. Computer data base systems are used in entering, storing, retrieving, and analyzing information about health project activities and their participants in a timely and cost-effective manner. Computer support is essential for such labor-intensive tasks as post-screening followup of participants, identifying subpopulations, and evaluating recruitment efforts and behavior change programs. The Pawtucket Heart Health Program developed a microcomputer software package, FPbase, for community health project data base management. FPbase is described and is available for use by other organizations. FPbase incorporates formative and process interactive data base activities and is suitable for use in operating intervention and screening programs at State and local levels. The system accommodates management of data for social marketing, evaluation, followup, and promotional activities.

Measuring cardiovascular disease risk factor levels: international comparisons between Bremen-north/west (Germany) and two southeastern New England (USA) cities.

Cardiovascular disease risk factor comparisons were made on study populations from communities in two different countries with similar ongoing intervention programs. Baseline survey data from the intervention and comparison communities of the Pawtucket Heart Health Program in Pawtucket, Rhode Island, and from the intervention Region of Bremen-North/West of the German Cardiovascular Prevention Study were compared with respect to these cardiovascular disease risk factors: smoking, overweight, physical inactivity, hypertension, and hypercholesterolemia. The relationship between these variables and social class was also examined in an attempt to partially explain some of the cross cultural differences in risk factors and predicted CHD and CVD mortality. Results indicated statistically significant differences in amount of cigarettes smoked, exercise frequency, diet, body mass index, total cholesterol, HDL, and blood pressure. These risk factors were generally higher in the German population than in the American population as were the predicted CHD and CVD mortality. For the study populations of both countries, however, the lower the social class, the more prevalent the smoking, excess weight, and lack of physical activity.

Prevalence of hypertension, dyslipidemia, and dyslipidemic hypertension.

BACKGROUND: It has been proposed that dyslipidemic hypertension is part of a distinct metabolic syndrome related to insulin resistance. This paper describes the prevalence and cross-sectional relations of dyslipidemic hypertension in a population-based sample of men and women. METHODS: In two southeastern New England communities, 11,199 randomly selected participants were evaluated as part of a cross-sectional surveillance program of coronary heart disease risk factors between 1981 and 1990. RESULTS: The frequency of dyslipidemia was 38% and of hypertension was 26.5%; the conjoint frequency (dyslipidemic hypertension) was 15.0%, which is 1.49 times the expected value if the two diseases were independent P < .05). Using a discrete multivariate model, dyslipidemia and hypertension were associated with sex, obesity, and diabetes mellitus. The excess association of dyslipidemic hypertension, compared with individual effects of dyslipidemia and hypertension, was not related to these factors. CONCLUSIONS: This study suggests that dyslipidemic hypertension is common but may not be a unique entity associated with a distinct metabolic syndrome.

Persistence with non-selective NSAIDs and celecoxib among patients with gastroesophageal reflux disease and osteoarthritis or rheumatoid arthritis.

OBJECTIVE: Gastrointestinal (GI) symptoms are common in patients taking nonselective, nonsteroidal anti-inflammatory drugs (nsNSAIDs) and are often a reason for therapy discontinuation. In osteoarthritis (OA) and rheumatoid arthritis (RA) patients requiring pain control, selective COX-2 NSAID use is typically associated with less dyspepsia than is nsNSAID use. Little is known about NSAID tolerance in patients with gastroesophageal reflux disease (GERD). This study assessed nsNSAID and celecoxib prescription patterns, in particular persistence, in OA/RA patients with concomitant diagnosis of GERD. METHODS: An observational study of GERD patients with a diagnosis of OA/RA using two separate databases, the IMS Lifelink Health Plan Claims Database (PharMetrics) and Market Scan Claims Database (Medstat) was conducted. In each database, parallel and separate analyses were performed in adult patients who had their first GERD diagnosis in 2006 and who were subsequently diagnosed with OA or RA in the same year. From this subset of patients, celecoxib-naïve and nsNSAID-naïve cohorts were identified and patients were selected. Patients with pre-existing GI conditions were excluded from the study. Persistence, measured as time to discontinuation, was evaluated by Kaplan-Meier survival curves and Cox proportional hazards models. Reasons for discontinuations were not available in these databases. RESULTS: Fewer patients discontinued celecoxib as compared to nsNSAIDs during the 60 days of the first prescription and throughout the entire follow-up period. After adjusting for baseline characteristics, celecoxib patients still had significantly decreased risk of discontinuation as compared to nsNSAID patients (p < 0.0001). Replication of these observations in two separate, large patient databases increases the confidence in this study's conclusion. LIMITATIONS: Limitations include those inherent to claims data analyses and retrospective review, e.g. these data do not provide clinical information related to reasons for medication discontinuation. CONCLUSION: In patients with concomitant GERD and OA or RA who require anti-inflammatory treatment, significantly more patients treated with celecoxib were persistent with their treatment than were patients treated with nsNSAIDs.

Pawtucket Heart Health Program: the process of stimulating community change.

The Pawtucket Heart Health Program (PHHP) is a community-based research and demonstration project in cardiovascular disease (CVD) prevention located in the United States. Targeted risk factors include high blood pressure, elevated blood cholesterol, cigarette smoking, obesity and sedentary living. Evaluation methods included biennial household risk factor surveys in the education and comparison communities, morbidity and mortality surveillance in hospitals serving each community, and both formative evaluation and process tracking. Intervention methods are theoretically derived from social learning theory and seek to motivate, enable and maintain individual behavior change; modify social networks; and introduce environmental change in organizations and normative shifts in the community in ways that reduce the prevalence of CVD risk factors. The intervention strategy began as an organization-based model, and has evolved into a community-wide effort in which marketing research tools and techniques are employed. In the past 4 years, over 40,000 individual contacts have been made with PHHP programs, including 1,260 persons who have volunteered their time to deliver risk factor programs.

Comparison of three methods of teaching women how to perform breast self-examination.

This paper presents results from an experimental study designed to evaluate the relative effectiveness of three methods of teaching women how to do breast self-examination (BSE). Frequency of BSE, confidence in examination performance, proficiency of BSE technique, and lump detection performance were the main outcome variables assessed. The three training methods compared in this study were provision of a pamphlet describing how to do BSE, having women view a videotape depicting proper performance of BSE, and having women practice doing BSE on a life-like breast model. Results showed that passive methods of BSE instruction such as the use of pamphlets or films were of little value in helping women develop the tactile skills necessary for proficient BSE. Three months after training, it was found that lump detection performance, as measured on silicone breast models, was significantly higher among those women who had been given an opportunity to practice doing the breast examination on a breast model with corrective feedback given by a BSE instructor. The opportunity to practice doing the examination with corrective feedback on performance appears to be a critical variable in the acquisition of BSE skill.