Associations among claims-based care fragmentation, self-reported gaps in care coordination, and self-reported adverse events.

BACKGROUND: Fragmentation of care (that is, the use of multiple ambulatory providers without a dominant provider) may increase the risk of gaps in communication among providers. However, it is unclear whether people with fragmented care (as measured in claims) perceive more gaps in communication among their providers. It is also unclear whether people who perceive gaps in communication experience them as clinically significant (that is, whether they experience adverse events that they attribute to poor coordination). METHODS: We conducted a longitudinal study using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, including a survey on perceptions of healthcare (2017-2018) and linked fee-for-service Medicare claims (for the 12 months prior to the survey) (N = 4,296). We estimated correlation coefficients to determine associations between claims-based and self-reported numbers of ambulatory visits and ambulatory providers. We then used logistic regression to determine associations between claims-based fragmentation (measured with the reversed Bice-Boxerman Index [rBBI]) and self-reported gaps in care coordination and, separately, between claims-based fragmentation and self-reported adverse events that the respondent attributed to poor coordination. RESULTS: The correlation coefficient between claims-based and self-report was 0.37 for the number of visits and 0.38 for the number of providers (p < 0.0001 for each). Individuals with high fragmentation by claims (rBBI ≥ 0.85) had a 23% increased adjusted odds of reporting any gap in care coordination (95% CI 3%, 48%) and, separately, a 61% increased adjusted odds of reporting an adverse event that they attributed to poor coordination (95% CI 11%, 134%). CONCLUSIONS: Medicare beneficiaries with claims-based fragmentation also report gaps in communication among their providers. Moreover, these gaps appear to be clinically significant, with beneficiaries reporting adverse events that they attribute to poor coordination.

Development and initial validation of a disease-specific instrument to measure health-related quality of life in hypersensitivity pneumonitis.

Rationale and objective: Disease-specific health-related quality of life (HRQOL) instruments enable us to capture domains that are most relevant to specific patient populations and are useful when a more individualised approach to patient assessment is desired. In this study, we assessed the validity and reliability of the first instrument specifically developed to measure HRQOL in hypersensitivity pneumonitis (HP). Methods: A 39-item HP-HRQOL instrument and several anchors were collected from a cohort of patients with HP. Exploratory factor analysis and item reduction were utilised to construct a shortened version of the instrument. Several validity and reliability analyses were conducted on this version of the HP-HRQOL. Measurements and main results: 59 patients with HP completed the study. The revised HP-HRQOL instrument comprises 15 items composing two factors (domains): 1) impacts on daily life; and 2) mental wellbeing. Internal consistency reliability was strong for Factor 1 (Cronbach's α=0.94, 95% CI 0.92-0.96) and Factor 2 (Cronbach's α=0.89, 95% CI 0.85-0.94). Test-retest reliability was strong (ICC 0.94, 95% CI 0.89-0.97). The HP-HRQOL strongly correlated with other validated patient-reported outcome measures and moderately correlated with % predicted forced vital capacity. The HP-HRQOL distinguished between those with different severities of HP as determined by lung function and supplemental oxygen use. Conclusions: The HP-HRQOL, the first patient-reported outcome instrument specific to adults with HP, possesses strong validity and reliability characteristics for measuring disease-specific HRQOL and distinguishes among patients with different severities of disease.

Ambulatory Care Utilization Among Medicare Beneficiaries with Depression.

The association between depression and ambulatory care utilization is unclear. The authors sought to determine the association between untreated depression and ambulatory care utilization, including the extent to which care is fragmented, or spread across providers. The authors conducted a longitudinal study using data from the nationwide REasons for Geographic and Racial Differences in Stroke study linked to Medicare fee-for-service claims (N = 1412). They categorized participants into three study groups, based on self-reported depressive symptoms (Center for Epidemiological Studies Depression Scale score ≥ 4) and a medication inventory for antidepressants: Symptomatic Untreated (SU), Symptomatic Treated (ST), and Asymptomatic Treated (AT). The authors used descriptive statistics to characterize ambulatory care patterns by study group. They determined the association between the study group and fragmentation score (with high fragmentation defined as a reversed Bice-Boxerman Index ≥ 0.85) using multivariable logistic regression. All groups had similar numbers of primary care visits, but the SU group had the fewest specialist visits. The SU group had the lowest proportion of participants who received care from a psychiatrist (3.4% vs. 10.7% for ST and 11.9% for AT, pairwise P-values < 0.001). The SU group was the least likely to have highly fragmented care (adjusted odds ratio 0.68; 95% confidence interval 0.48, 0.95, compared with the ST group). These results suggest that older adults with untreated depression are not engaged in excess care-seeking behaviors. Rather, the results suggest undertreatment of depression in primary care and underutilization of psychiatric care.

Social Determinants of Health and Cardiovascular Risk among Adults with Diabetes: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

Background: Social determinants of health (SDOH) have been associated with diabetes risk; however, their association with cardiovascular disease (CVD) events in individuals with diabetes is poorly described. We hypothesized that a greater number of SDOH among individuals with diabetes would be associated with a higher risk of CVD events. Methods: The REasons for Geographic and Racial Differences in Stroke (REGARDS) study is a national, biracial cohort of 30,239 individuals ≥45 years old recruited in 2003-2007. We included 6,322 participants with diabetes at baseline, defined as healthcare professional diagnosis, diabetes medication use, or blood glucose values. Seven SDOH that were individually associated with CVD events were included (P<0.20). The outcome was CVD events, a composite of expert-adjudicated myocardial infarction, stroke, or cardiovascular death. We estimated Cox proportional hazard models to examine associations between number of SDOH (0, 1, 2, ≥3) and CVD events. Results: In an age and sex adjusted model, the presence of multiple SDOH significantly increased the risk of any CVD event (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.26 to 1.74 for two SDOH; HR, 1.68; 95% CI, 1.43 to 1.96 for ≥3 SDOH). This finding was attenuated but remained statistically significant in a fully adjusted model (HR, 1.19; 95% CI, 1.01 to 1.40 for two SDOH; HR, 1.27; 95% CI, 1.07 to 1.50 for ≥3 SDOH). Conclusion: Having multiple SDOH was independently associated with an increased risk of CVD events, a finding driven by cardiovascular death. Identifying individuals with diabetes who have multiple SDOH may be helpful for detecting those at higher risk of experiencing or dying from CVD events.

Association between Gaps in Care Coordination and Emergency Department Visits Among Children without Chronic Conditions or Special Needs.

OBJECTIVE: Prior studies and have shown that gaps in care coordination (CC) increase the risk of emergency department (ED) visits among children with special healthcare needs. This study aims to determine if gaps in CC are associated with an increased risk of ED visits among children without special needs (non-CSHCN). STUDY DESIGN: We conducted a cross-sectional study using the National Survey of Children's Health (2018-2019), representing children up to age 17. A "gap" in CC occurs if the adult proxy reported dissatisfaction with communication between providers or difficulty getting the help needed to coordinate care for the child. Using logistic regression models adjusting for age and sex, we measured the association between a gap in CC and 1 or more ED visits during the past 12 months overall and stratified by any special needs. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) were calculated. RESULTS: Between 2018 and 2019, 15% of respondents reported a gap in CC and 19.4% of children had at least one ED visit. Among non-CSHCN, these rates were 11% and 17%. In this population, a gap in CC was independently associated with an increased odds of ED use (AOR: 2.14; 95% CI 1.82, 2.52). CONCLUSIONS FOR PRACTICE: Self-reported gaps in ambulatory CC were associated with increased odds of ED visits even among non-CSHCN children with minor illnesses, suggesting that providers need to be aware of potential pitfalls in CC for all children, and ensure that pertinent information is available where needed.

Characterizing "collateral damage" in men and women with metastatic breast cancer (mBC) from diverse racial and ethnic backgrounds in New York City.

PURPOSE: Patients from diverse racial, ethnic, and socio-economic backgrounds may be particularly vulnerable to experiencing undue social and financial burdens ("collateral damage") from a metastatic breast cancer (mBC) diagnosis; however, these challenges have not been well explored in diverse populations. METHODS: From May 2022 to May 2023, English- or Spanish-speaking adults with mBC treated at four New York-Presbyterian (NYP) sites were invited to complete a survey that assessed collateral damage, social determinants of health, physical and psychosocial well-being, and patient-provider communication. Fisher's exact and the Kruskal-Wallis rank-sum tests assessed differences by race and ethnicity. RESULTS: Of 87 respondents, 14% identified as Hispanic, 28% non-Hispanic Black (NHB), 41% non-Hispanic White (NHW), 7% Asian American Pacific Islander (AAPI), and 10% other/multiracial. While 100% of Hispanic, NHW, and AAPI participants reported stable housing, 29% of NHB participants were worried about losing housing (p = 0.002). Forty-two percent of Hispanic and 46% of NHB participants (vs. 8%, NHW and 0%, AAPI, p = 0.005) were food insecure; 18% of Hispanic and 17% of NHB adults indicated lack of reliable transportation in the last year (vs. 0%, NHW/AAPI, p = 0.033). Participants were generally satisfied with the quality of communication that they had with their healthcare providers and overall physical and mental well-being were modestly poorer relative to healthy population norms. CONCLUSIONS: In our study, NHB and Hispanic mBC patients reported higher levels of financial concern and were more likely to experience food and transportation insecurity compared to NHW patients. Systematically connecting patients with resources to address unmet needs should be prioritized to identify feasible approaches to support economically vulnerable patients following an mBC diagnosis.

"Should I Prioritize My Cancer or My Diabetes?": Patient-Perceived Barriers to Co-Managing Cancer and Diabetes Mellitus.

Among patients with cancer, diabetes mellitus (DM) is a prevalent comorbid condition. With an aging population and an increase in the prevalence of cancer and DM, the number of cancer patients with DM will rise. To date, studies have largely focused on understanding the context of cancer and DM co-management from the perspectives of oncology and primary care providers. To better understand the potential barriers to optimal cancer and DM co-management, we conducted 17 semi-structured interviews with DM patients receiving cancer care at New York-Presbyterian Weill Cornell Medical Center outpatient oncology clinics in New York, NY. In total, 53% patients were female, 35% were non-White, and the mean age was 64.75 (SD 11.10) years. We qualitatively analyzed our data and identified the following nine themes: (1) patients develop DM during or after cancer treatment; (2) patients do not know about the possible interactions between DM and cancer treatment; (3) cancer care is prioritized over DM management; (4) severity of DM symptoms drive patients' DM self-management during cancer care; (5) impact of cancer treatment on quality of life; (6) demands from cancer care make DM management more difficult; (7) patients want individualized treatment plans that integrate DM and cancer co-management; (8) need for greater patient activation; (9) lack of patient-centered educational resources on DM management during cancer care. Owing to these results, our findings highlight the need to increase patient engagement by developing and disseminating patient-centered educational resources on cancer and DM to improve self-management practices and patient outcomes.

Racial and Ethnic Variation in Receipt and Intensity of Active Surveillance for Older Patients With Localized Prostate Cancer.

INTRODUCTION: The use of active surveillance (AS) for prostate cancer is increasing, and racial disparities have been identified in its implementation. We investigated differences by race and ethnicity in the utilization and intensity of AS by race and ethnicity among older men with low- and favorable intermediate-risk prostate cancer, with particular focus on the integration of multiparametric MRI (mpMRI) into AS protocols. METHODS: Using the Surveillance, Epidemiology, and End Results and Medicare fee-for-service linked database, we identified a cohort of men diagnosed between 2010 and 2017 with low- or favorable intermediate-risk prostate cancer. The odds of receiving AS were compared by patient race and ethnicity using multivariable logistic regression models, while the rates of usage of PSA tests, biopsy, and mpMRI within 2 years of diagnosis among men on AS were assessed using multivariable Poisson regression models. RESULTS: Our cohort included 33,542 men. The proportion of men with low-risk disease who underwent AS increased from 29.5% in 2010 to 51.7% in 2017, while the proportion among men with favorable intermediate disease grew from 11.4% to 17.2%. Hispanic (odds ratio [OR] = 0.68, 95% CI 0.58-0.79) and non-Hispanic Black men (OR = 0.78, 95% CI 0.68-0.89) were less likely to receive AS than non-Hispanic White men for low-risk disease, while non-Hispanic Black men were more likely to receive AS for favorable intermediate disease (OR = 1.21, 95% CI 1.04-1.39). Non-Hispanic Black men receiving AS underwent prostate MRI at a lower rate compared to non-Hispanic White men, regardless of whether they had low-risk (incidence rate ratio = 0.77, 95% CI 0.61-0.97) or favorable intermediate-risk (incidence rate ratio = 0.61, 95% CI 0.44-0.83) disease, respectively. CONCLUSIONS: The overall adoption of AS for low-risk prostate cancer increased among Medicare fee-for-service beneficiaries. However, a significant disparity exists for non-Hispanic Black men, as they exhibit lower rates of AS utilization. Moreover, non-Hispanic Black men are less likely to have access to novel technologies, such as mpMRI, as part of their AS protocols.

Ambulatory Care Fragmentation and Total Health Care Costs.

BACKGROUND: The magnitude of the relationship between ambulatory care fragmentation and subsequent total health care costs is unclear. OBJECTIVE: To determine the association between ambulatory care fragmentation and total health care costs. RESEARCH DESIGN: Longitudinal analysis of 15 years of data (2004-2018) from the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS: A total of 13,680 Medicare beneficiaries who are 65 years and older. MEASURES: We measured ambulatory care fragmentation in each calendar year, defining high fragmentation as a reversed Bice-Boxerman Index ≥0.85 and low as <0.85. We used generalized linear models to determine the association between ambulatory care fragmentation in 1 year and total Medicare expenditures (costs) in the following year, adjusting for baseline demographic and clinical characteristics, a time-varying comorbidity index, and accounting for geographic variation in reimbursement and inflation. RESULTS: The average participant was 70.9 years old; approximately half (53%) were women. One-fourth (26%) of participants had high fragmentation in the first year of observation. Those participants had a median of 9 visits to 6 providers, with the most frequently seen provider accounting for 29% of visits. By contrast, participants with low fragmentation had a median of 8 visits to 3 providers, with the most frequently seen provider accounting for 50% of visits. High fragmentation was associated with $1085 more in total adjusted costs per person per year (95% CI $713 to $1457) than low fragmentation. CONCLUSIONS: Highly fragmented ambulatory care in 1 year is independently associated with higher total costs the following year.

Racial and Ethnic Differences in Psychosocial Care Use Among Adults With Metastatic Breast Cancer: A Retrospective Analysis Across Six New York City Health Systems.

PURPOSE: A metastatic breast cancer (mBC) diagnosis can affect physical and emotional well-being. However, racial and ethnic differences in receipt of outpatient psychosocial care and supportive care medications in adults with mBC are not well described. METHODS: Adults with mBC were identified in the INSIGHT-Clinical Research Network, a database inclusive of >12 million patients receiving care across six New York City health systems. Outpatient psychosocial care was operationalized using Common Procedure Terminology codes for outpatient psychotherapy or counseling. Psychosocial/supportive care medications were defined using Rx Concept Unique Identifier codes. Associations between race/ethnicity and outpatient care and medication use were evaluated using logistic regression. RESULTS: Among 5,429 adults in the analytic cohort, mean age was 61 years and <1% were male; 53.6% were non-Hispanic White (NHW), 21.4% non-Hispanic Black (NHB), 15.9% Hispanic, 6.1% Asian/Native Hawaiian/Pacific Islander (A/NH/PI), and 3% other or unknown. Overall, 4.1% had ≥one outpatient psychosocial care visit and 63.4% were prescribed ≥one medication. Adjusted for age, compared with NHW, Hispanic patients were more likely (odds ratio [OR], 2.14 [95% CI, 1.55 to 2.92]) and A/NH/PI patients less likely (OR, 0.35 [95% CI, 0.12 to 0.78]) to have an outpatient visit. NHB (OR, 0.59 [95% CI, 0.51 to 0.68]) and Asian (OR, 0.36 [95% CI, 0.29 to 0.46]) patients were less likely to be prescribed medications. CONCLUSION: Despite the prevalence of depression, anxiety, and distress among patients with mBC, we observed low utilization of psychosocial outpatient care. Supportive medication use was more prevalent, although differences observed by race/ethnicity suggest that unmet needs exist.

Association of Healthy Lifestyle and Incident Polypharmacy.

BACKGROUND: Polypharmacy, commonly defined as taking ≥5 medications, is an undesirable state associated with lower quality of life. Strategies to prevent polypharmacy may be an important priority for patients. We sought to examine the association of healthy lifestyle, a modifiable risk factor, with incident polypharmacy. METHODS: We performed a secondary analysis of the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study, including 15,478 adults aged ≥45 years without polypharmacy at baseline. The primary exposure was healthy lifestyle at baseline as measured by the Healthy Behavior Score (HBS), a cumulative assessment of diet, exercise frequency, tobacco smoking, and sedentary time. HBS ranges from 0-8, whereby 0-2 indicates low HBS, 3-5 indicates moderate HBS, and 6-8 indicates high HBS. We used multinomial logistic regression to examine the association between HBS and incident polypharmacy, survival without polypharmacy, and death. RESULTS: Higher HBS (i.e., healthier lifestyle) was inversely associated with incident polypharmacy after adjusting for sociodemographic and baseline health variables. Compared with participants with low HBS, those with moderate HBS had lower odds of incident polypharmacy (odds ratio [OR] 0.85; 95% confidence interval [CI], 0.73-0.98) and lower odds of dying (OR 0.74; 95% CI, 0.65-0.83). Participants with high HBS had even lower odds of both incident polypharmacy (OR 0.75; 95% CI, 0.64-0.88) and death (OR 0.62; 95% CI, 0.54-0.70). There was an interaction for age, where the association between HBS and incident polypharmacy was most pronounced for participants aged ≤65 years. CONCLUSIONS: Healthier lifestyle was associated with lower risk for incident polypharmacy.

Risk Prediction for Atherosclerotic Cardiovascular Disease With and Without Race Stratification.

Importance: Use of race-specific risk prediction in clinical medicine is being questioned. Yet, the most commonly used prediction tool for atherosclerotic cardiovascular disease (ASCVD)-pooled cohort risk equations (PCEs)-uses race stratification. Objective: To quantify the incremental value of race-specific PCEs and determine whether adding social determinants of health (SDOH) instead of race improves model performance. Design, Setting, and Participants: Included in this analysis were participants from the biracial Reasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort study. Participants were aged 45 to 79 years, without ASCVD, and with low-density lipoprotein cholesterol level of 70 to 189 mg/dL or non-high-density lipoprotein cholesterol level of 100 to 219 mg/dL at baseline during the period of 2003 to 2007. Participants were followed up to 10 years for incident ASCVD, including myocardial infarction, coronary heart disease death, and fatal and nonfatal stroke. Study data were analyzed from July 2022 to February 2023. Main outcome/measures: Discrimination (C statistic, Net Reclassification Index [NRI]), and calibration (plots, Nam D'Agostino test statistic comparing observed to predicted events) were assessed for the original PCE, then for a set of best-fit, race-stratified equations including the same variables as in the PCE (model C), best-fit equations without race stratification (model D), and best-fit equations without race stratification but including SDOH as covariates (model E). Results: This study included 11 638 participants (mean [SD] age, 61.8 [8.3] years; 6764 female [58.1%]) from the REGARDS cohort. Across all strata (Black female, Black male, White female, and White male participants), C statistics did not change substantively compared with model C (Black female, 0.71; 95% CI, 0.68-0.75; Black male, 0.68; 95% CI, 0.64-0.73; White female, 0.77; 95% CI, 0.74-0.81; White male, 0.68; 95% CI, 0.64-0.71), in model D (Black female, 0.71; 95% CI, 0.67-0.75; Black male, 0.68; 95% CI, 0.63-0.72; White female, 0.76; 95% CI, 0.73-0.80; White male, 0.68; 95% CI, 0.65-0.71), or in model E (Black female, 0.72; 95% CI, 0.68-0.76; Black male, 0.68; 95% CI, 0.64-0.72; White female, 0.77; 95% CI, 0.74-0.80; White male, 0.68; 95% CI, 0.65-0.71). Comparing model D with E using the NRI showed a net percentage decline in the correct assignment to higher risk for male but not female individuals. The Nam D'Agostino test was not significant for all race-sex strata in each model series, indicating good calibration in all groups. Conclusions: Results of this cohort study suggest that PCE performed well overall but had poorer performance in both BM and WM participants compared with female participants regardless of race in the REGARDS cohort. Removal of race or the addition of SDOH did not improve model performance in any subgroup.

Association of educational attainment with cancer mortality in a national cohort study of black and white adults: A mediation analysis.

Background: Low educational attainment is associated with excess cancer mortality. However, the mechanisms driving this association remain unknown. Methods: Using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, we evaluated the associations of participant and parental/caregiver education with cancer mortality using Cox proportional hazards models, adjusting for socio-demographic characteristics and health conditions. We used principal components analysis to generate indices of measures representing the social determinants of health (SDOH) and health behaviors. We used structural equation modeling to determine if the association between educational attainment and cancer mortality was mediated by these domains. Results: Among 30,177 REGARDS participants included in this analysis, 3798 (12.6%) had less than a high school degree. In fully adjusted models, those without a high school education experienced about 50% greater risk of death than high school graduates and higher (White participants HR: 1.47; 95% CI: 1.23, 1.76 and Black HR: 1.54; 95% CI: 1.33, 1.79). There was evidence of a modest mediation effect for the association between education and cancer mortality by the SDOH domain score (White total effect HR: 1.25; 95% CI: 1.18, 1.33, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.21; 95% CI: 1.14, 1.28 and Black total effect HR: 1.24; 95% CI: 1.18, 1.29, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.19; 95% CI: 1.14, 1.24). There was no evidence of mediation by the health behaviors score. No significant associations were found for female caregiver/mother's or male caregiver/father's education (N = 13,209). Conclusions: In conclusion, participant education was strongly associated with cancer mortality, and this association was partially mediated by the SDOH domain score.

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure.

Importance: Involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Objective: To determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. Design, Setting, and Participants: This retrospective cohort study used data from the Reasons for Geographic and Racial Difference in Stroke (REGARDS) cohort. Participants included adults who experienced an adjudicated hospitalization for HF between 2009 and 2017 in all 48 contiguous states in the US. Data analysis was performed from November 2022 to January 2023. Exposures: A total of 9 candidate SDOH, aligned with the Healthy People 2030 conceptual model, were examined: Black race, social isolation, social network and/or caregiver availability, educational attainment less than high school, annual household income less than $35 000, living in rural area, living in a zip code with high poverty, living in a Health Professional Shortage Area, and living in a state with poor public health infrastructure. Main Outcomes and Measures: The primary outcome was cardiologist involvement, defined as involvement of a cardiologist as the primary responsible clinician or as a consultant. Bivariate associations between each SDOH and cardiologist involvement were examined using Poisson regression with robust SEs. Results: The study included 1000 participants (median [IQR] age, 77.8 [71.5-84.0] years; 479 women [47.9%]; 414 Black individuals [41.4%]; and 492 of 876 with low income [56.2%]) hospitalized at 549 unique US hospitals. Low annual household income (<$35 000) was the only SDOH with a statistically significant association with cardiologist involvement (relative risk, 0.88; 95% CI, 0.82-0.95). In a multivariable analysis adjusting for age, race, sex, HF characteristics, comorbidities, and hospital characteristics, low income remained inversely associated with cardiologist involvement (relative risk, 0.89; 95% CI, 0.82-0.97). Conclusions and Relevance: This cohort study found that adults with low household income were 11% less likely than adults with higher incomes to have a cardiologist involved in their care during a hospitalization for HF. These findings suggest that socioeconomic status may bias the care provided to patients hospitalized for HF.

Disparities in Guideline Concordant Statin Treatment in Individuals With Chronic Obstructive Pulmonary Disease.

Rationale: Cardiovascular disease (CVD) affects the prognosis of patients with chronic obstructive pulmonary disease (COPD). Black women with COPD have a disproportionate risk of CVD-related mortality, yet disparities in CVD prevention in COPD are unknown. Objectives: We aimed to identify race-sex differences in the receipt of statin treatment for CVD prevention, and whether these differences were explained by factors influencing health care utilization in the REasons for Geographic And Racial Differences in Stroke (REGARDS) COPD study sub-cohort. Methods: We conducted a cross-sectional analysis among REGARDS Medicare beneficiaries with COPD. Our primary outcome was the presence of statin on in-home pill bottle review among individuals with an indication. Prevalence ratios (PR) for statin treatment among race-sex groups compared to White men were estimated using Poisson regression with robust variance. We then adjusted for covariates previously shown to impact health care utilization. Results: Of the 2032 members within the COPD sub-cohort with sufficient data, 1435 participants (19% Black women, 14% Black men, 28% White women, and 39% White men) had a statin indication. All race-sex groups were less likely to receive statins than White men in unadjusted models. After adjusting for covariates that influence health care utilization, Black women (PR 0.76, 95% confidence interval [CI] 0.67 to 0.86) and White women (PR 0.84 95% CI 0.76 to 0.91) remained less likely to be treated compared to White men. Conclusions: All race-sex groups were less likely to receive statin treatment in the REGARDS COPD sub-cohort compared to White men. This difference persisted in women after controlling for individual health care utilization factors, suggesting structural interventions are needed.

Allostatic load and incident heart failure in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.

BACKGROUND: Allostatic load (AL) is the physiologic "wear and tear" on the body from stress. Yet, despite stress being implicated in the development heart failure (HF), it is unknown whether AL is associated with incident HF events. METHODS: We examined 16,765 participants without HF at baseline from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The main exposure was AL score quartile. AL was determined according to 11 physiologic parameters, whereby each parameter was assigned points (0-3) based on quartiles within the sample, and points were summed to create a total AL score ranging from 0-33. The outcome was incident HF event. We examined the association between AL quartile (Q1-Q4) and incident HF events using Cox proportional hazards models, adjusted for demographics, socioeconomic factors, and lifestyle. RESULTS: The mean age was 64 ± 9.6 years, 61.5% were women, and 38.7% were Black participants. Over a median follow up of 11.4 years, we observed 750 incident HF events (635 HF hospitalizations and 115 HF deaths). Compared to the lowest AL quartile (Q1), the fully adjusted hazards of an incident HF event increased in a graded fashion: Q2 HR 1.49 95% CI 1.12-1.98; Q3 HR 2.47 95% CI 1.89-3.23; Q4 HR 4.28 95% CI 3.28-5.59. The HRs for incident HF event in the fully adjusted model that also adjusted for CAD were attenuated, but remained significant and increased in a similar, graded fashion by AL quartile. There was a significant age interaction (p-for-interaction < 0.001), whereby the associations were observed across each age stratum, but the HRs were highest among those aged < 65 years. CONCLUSION: AL was associated with incident HF events, suggesting that AL could be an important risk factor and potential target for future interventions to prevent HF.

Association of racial residential segregation with all-cause and cancer-specific mortality in the reasons for geographic and racial differences in stroke (REGARDS) cohort study.

•Increased racial residential segregation increased the risk of all-cause mortality among White participants.•Higher interaction lowered the risk of all-cause mortality among White participants.•Higher isolation lowered the risk of cancer mortality among Black participants.

Psychosocial well-being during the COVID-19 pandemic among women with and without breast cancer.

OBJECTIVE: Treatment delays in combination with general social distancing practices to reduce transmission may have negative impacts on the mental health of women with breast cancer who may need more social and emotional support. We sought to elucidate the psychosocial effects of the COVID-19 pandemic among women with and without breast cancer in New York City. METHODS: We conducted a prospective cohort study among women aged 18+ across the spectrum of breast health care at New York Presbyterian (NYP)-Weill Cornell, NYP-Brooklyn Methodist Hospital and NYP-Queens. Women were contacted between June and October 2021 to assess their self-reported depression, stress, and anxiety during the COVID-19 pandemic. We compared women who were recently diagnosed, those with a history of breast cancer, and women without cancer whose other health visits were delayed during the pandemic. RESULTS: There were 85 women who completed the survey. Breast cancer survivors (42%) were the least likely to report a delay in care due to COVID compared to breast cancer patients who were recently diagnosed (67%) and women without cancer (67%). Compared to women without cancer and breast cancer survivors, women recently diagnosed with breast cancer reported higher levels of anxiety and depression with a statistically significant difference in perceived stress. CONCLUSIONS: Our findings highlight the need to identify and risk-stratify patients facing a new breast cancer diagnosis in and around the COVID-19 pandemic who may benefit from additional resources to mitigate the adverse impacts of the pandemic and a breast cancer diagnosis on psychosocial health.

Diabetes and Cancer Co-management Education: Leveraging the Patient Activated Learning System (PALS) for Patients with Breast Cancer.

More than 70% of cancer patients have one or more comorbid conditions, and diabetes is one of the most common and burdensome comorbidities. However, existing patient-centered education materials often fail to acknowledge how to co-manage cancer and diabetes, leaving patients feeling overwhelmed and searching for guidance. Our team sought to fill this knowledge gap by using the Patient Activated Learning System (PALS), a patient-centered, publicly available platform, to generate patient-centered education materials about co-managing diabetes and cancer. Using insights from 15 patient interview transcripts, we developed eight reusable knowledge objects (RKOs) for a variety of common questions that patients have about co-managing diabetes and cancer. The RKOs were written in collaboration with researchers and clinicians and then peer reviewed by experts. The eight evidence-based RKOs have the potential to equip patients with the knowledge to support cancer and diabetes co-management. There are no existing patient-centered educational resources to help patients manage their diabetes during cancer treatments. We filled this gap by using the Patient Activated Learning System (PALS) to generate evidence-based, patient-facing educational information that was written by researchers and clinicians and peer reviewed by experts. This educational content will support cancer and diabetes co-management for patients.