Advancing Peripheral Artery Disease Quality of Care and Outcomes Through Patient-Reported Health Status Assessment: A Scientific Statement From the American Heart Association.

Peripheral artery disease (PAD) is chronic in nature, and individualized chronic disease management is a central focus of care. To accommodate this reality, tools to measure the impact and quality of the PAD care delivered are necessary. Patient-reported outcomes (PROs) and instruments to measure them, that is, PRO measures, have been well studied in the research and clinical trial context, but a shift toward integrating them into clinical practice has yet to take place. A framework to use PRO measures as indicators of the quality of PAD care delivered, that is, PRO performance measures (PRO-PMs), is provided in this scientific statement. Measurement goals to consider by PAD clinical phenotypes are provided, as well as an overview of potential benefits of adopting PRO-PMs in the clinical practice of PAD care, including reducing unwanted variability and promoting health equity. A central discussion with considerations for risk adjustment of PRO-PMs, individualized PAD care, and the need for patient engagement strategies is offered. Furthermore, necessary conditions in terms of required competencies and training to handle PRO-PM data are discussed because the interpretation and handling of these data come with great responsibility and consequences for designing care that adopts a broader framework of risk that goes beyond the inclusion of biomedical variables. To conclude, health system perspectives and an agenda to reach the next steps in the implementation of PRO-PMs in PAD care are offered.

Moderate physical activity and healthy eating habits among older African American women with diabetes and hypertension: a qualitative study of barriers and facilitators.

OBJECTIVE: African American women have a high prevalence of atherosclerotic risk factors. Many of these atherosclerotic risk factors can be modified through increased physical activity and a healthy diet. DESIGN: We conducted a phenomenological qualitative study on perceptions of physical activity and healthy eating among 26 African American women, 55 years and older. Interviews were conducted and coded for emerging themes on barriers and facilitators of physical activity and dietary behaviors. RESULTS: Perceived barriers were pain and motivation to be active, limited definition of physical activity, time, preparation, cost of healthy meals, and daily decisions on food choice and preference. Facilitators were a routine of regular physical activity, awareness of healthy food choices, and influence of family. CONCLUSIONS: Overall, participants had a general perception about the importance of physical activity and healthy eating; however, their motivation to engage in these behaviors depends on their definition, personal motivation, and food preference.

Exploring African-American womens' experiences with substance use treatment: A review of the literature.

The aim of this systematic review is to synthesize evidence on treatment barriers among African-American women who seek treatment for substance use disorders. The authors reviewed articles from 1995 to 2018 on the topic of substance use disorders among African-American women. Based on the review of 13 articles, we found African-American women were more likely to encounter treatment readiness barriers compared to access barriers and system-related barriers. Personal and interpersonal barriers were more readily identified throughout the literature reviewed. However, African-American women did encounter other barriers such as access- and system-related barriers. In addition, the intersection of race, gender, and class was not addressed in the specific articles, but should be considered when working to remove treatment barriers for this population. While prevalence of alcohol and drug use is limited among African-American women, it is important to understand how treatment readiness barriers may limit successful completion of treatment and ongoing progress. Implications for treatment and future research in addressing barriers to treatment for African-American women are discussed.

Pioneer baby: suggestions for pre- and postnatal health promotion programs from rural English and Spanish-speaking pregnant and postpartum women.

In the United States, more than 9 million rural women (15-44 years old) experience limited access and delivery of reproductive healthcare services. Rurality coupled with lower socio-economic status are associated with increased maternal and neonatal morbidity and mortality. The purpose of this qualitative study was to gain in-depth information from underserved English- and Spanish-speaking pregnant and postpartum rural women on what they would value in a health promotion program. Three focus group sessions were conducted exploring four domains: (1) physical activity, (2) dietary habits, (3) fetal movement/kick counts, and (4) breastfeeding and other support resources. Five overarching themes were observed across domains, with the following health promotion needs: (1) information on safe exercises, (2) advice on healthy food and drink, (3) breastfeeding support, (4) guidance on counting fetal movement, and (5) self- and peer-education. Study findings will inform intervention programming that aims to improve pregnancy and birth outcomes.

Predictors of guideline treatment nonadherence and the impact on survival in patients with colorectal cancer.

BACKGROUND: This study investigated the effect of comorbidity, age, health insurance payer status, and race on the risk of patient nonadherence to NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colon and Rectal Cancers. In addition, the prognostic impact of NCCN treatment nonadherence on overall survival was assessed. PATIENTS AND METHODS: Patients with CRC who received primary treatment at Memorial University Medical Center from 2003 to 2010 were eligible for this study. Modified Poisson regression was used to obtain risk ratios for the outcome of nonadherence with NCCN Guidelines. Hazard ratios (HRs) for the relative risk of death from all causes were obtained through Cox regression. RESULTS: Guideline-adherent treatment was received by 82.7% of patients. Moderate/severe comorbidity, being uninsured, having rectal cancer, older age, and increasing tumor stage were associated with increased risks of receiving nonadherent treatment. Treatment nonadherence was associated with 3.6 times the risk of death (HR, 3.55; 95% CI, 2.16-5.85) in the first year after diagnosis and an 80% increased risk of death (HR, 1.80; 95% CI, 1.14-2.83) in years 2 to 5. The detrimental effect of nonadherence declined with increasing comorbidity and varied according to age. CONCLUSIONS: Although medically justifiable reasons exist for deviating from NCCN Guidelines when treating patients with colorectal cancer (CRC), those who received nonadherent treatment had much higher risks of death, especially in the first year after diagnosis. This study's results highlight the importance of cancer health services research to drive quality improvement efforts in cancer care for patients with CRC.

Smoking Behaviors Among Urban and Rural Pregnant Women Enrolled in the Kansas WIC Program.

Smoking during pregnancy is associated with poor birth outcomes. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a public nutritional assistance program for low-income pregnant women and their children up to age five. This study examined differences in smoking behavior among women enrolled in the Kansas WIC program. A secondary analysis was conducted using the Pregnancy Nutrition Surveillance System dataset of enrolled women between 2005 and 2011. Geographic residency status was obtained through application of the Census tract-based rural-urban commuting area codes. Chi square tests of association were used to assess differences. Multi-variable binary logistic regression was used to assess maternal characteristics and smoking 3 months prior to pregnancy. Total sample size averaged 21,650 women for years 2005 through 2011. Low-income, rural pregnant women smoked at significantly higher rates before, during, and after pregnancy. High smoking rates have remained unchanged since 2008. The following characteristics were associated with reduced odds of smoking 3 months prior to pregnancy: being 17 years old or younger, Hispanic, a high school graduate, urban location, normal body mass index, no live births prior to current pregnancy, and using multi-vitamins. Results from this study indicate that the WIC population in rural areas may have different needs regarding smoking cessation programming than the urban WIC population. Findings help inform WIC program administrators and assist in enhancing current smoking cessation services to the Kansas WIC population.

Characteristics associated with breastfeeding behaviors among urban versus rural women enrolled in the Kansas WIC program.

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a public nutritional assistance program for low-income women and their children up to age five. This study provides insight into maternal characteristics associated with breastfeeding among urban versus rural women. A secondary analysis was conducted using the Pregnancy Nutrition Surveillance System dataset of women enrolled in the Kansas WIC program in 2011. Geographic residency status was obtained through application of the Census tract-based rural-urban commuting area codes. Descriptive variables included maternal demographics, health, and lifestyle behaviors. A multivariable binary logistic regression was used to obtain adjusted odds ratios with 95 % confidence intervals. The outcome variable was initiation of breastfeeding. A P value of ≤0.05 was considered statistically significant. The total sample size was 17,067 women. Statistically significant differences regarding socio-demographics, program participation, and health behaviors for urban and rural WIC participants were observed. About 74 % of all WIC mothers initiated breastfeeding. Urban women who were Hispanic, aged 18-19, high school graduates, household income >$10,000/year, and started early prenatal care were more likely to breastfeed. Urban and rural women who were non-Hispanic black with some high school education were less likely to breastfeed. Increased breastfeeding initiation rates are the result of a collaborative effort between WIC and community organizations. Availability of prenatal services to rural women is critical in the success of breastfeeding promotion. Findings help inform WIC program administrators and assist in enhancing breastfeeding services to the Kansas WIC population.

Text messaging to motivate exercise among Latino adults at risk for vascular disease: a pilot study, 2013.

In 2013, we administered a 15-item survey to determine the extent of text message usage among Latino adults in Kansas; for a subset of the survey participants, we also conducted a 6-week pilot trial to determine the effect of text messaging on exercise behaviors. Among the 82 survey participants, 78% had unlimited text messaging. At baseline, all trial participants were at the stage of contemplation; at 6 weeks, one (9%) trial participant remained at the contemplation stage and the other 10 (91%) participants progressed to the action/maintenance/termination stage. Use of text messaging to motivate exercise is feasible and potentially efficacious among Latinos.

eDECIDE a web-based problem-solving interventions for diabetes self-management: Protocol for a pilot clinical trial.

Background: In the US, diabetes affects 13.2% of African Americans, compared to 7.6% of Caucasians. Behavioral factors, such as poor diet, low physical activity, and general lack of good self-management skills and self-care knowledge are associated with poor glucose control among African Americans. African Americans are 77% more likely to develop diabetes and its associated health complications compared to non-Hispanic whites. A higher disease burden and lower adherence to self-management among this populations calls for innovative approaches to self-management training. Problem solving is a reliable tool for the behavior change necessary to improve self-management. The American Association of Diabetes Educators identifies problem-solving as one of seven core diabetes self-management behaviors. Methods: We are using a randomized control trial design. Participants are randomized to either traditional DECIDE or eDECIDE intervention. Both interventions run bi-weekly over 18 weeks. Participant recruitment will take place through community health clinics, University health system registry, and through private clinics. The eDECIDE is an 18-week intervention designed to deliver problem-solving skills, goal setting, and education on the link between diabetes and cardiovascular disease. Conclusion: This study will provide feasibility and acceptability of the eDECIDE intervention in community populations. This pilot trial will help inform a powered full-scale study using the eDECIDE design.

Peripheral arterial disease is associated with higher rates of hip bone loss and increased fracture risk in older men.

BACKGROUND: Peripheral arterial disease (PAD) and osteoporosis are chronic illnesses that increase in prevalence with aging and certain metabolic disorders. The association between PAD, rates of bone loss, and fracture risk in older men is uncertain. METHODS AND RESULTS: We sought to test the hypothesis that PAD is associated with higher rates of bone loss and increased fracture risk. We analyzed data from a prospective cohort study involving 6 US centers and 5781 men at least 65 years of age. We assessed ankle-brachial index and hip bone mineral density, followed up prospectively for changes in hip bone mineral density and fractures. PAD was defined as a baseline ankle-brachial index <0.9. Hip bone mineral density was measured with dual x-ray absorptiometry at baseline and again an average of 4.6 years later. Incident nonspine fractures were ascertained by self-report and confirmed with radiography reports during an average of 5.4 years of follow-up. At baseline, the prevalence of PAD was 6.2%. After adjustment for age, race, site, and baseline bone mineral density, the mean annualized rate of bone loss at the total hip was -0.66% per year (95% confidence interval -0.78 to -0.54) in men with PAD compared with -0.34% per year (95% confidence interval -0.36 to -0.31) in men without PAD (P<0.001). After further adjustment for multiple potential confounders, the difference was attenuated (-0.49% in men with PAD versus -0.35% in men without PAD) but remained significant (P=0.02). Findings were similar at hip subregions. Twelve percent of men with PAD and 7.9% of those without PAD experienced an incident nonspine fracture (hazard ratio adjusted for age, race, and site=1.47, 95% confidence interval 1.07 to 2.04); this association was not altered substantially by further adjustment for multiple confounders. CONCLUSIONS: In community-dwelling older men, PAD was associated with higher rates of hip bone loss and increased risk of nonspine fractures. Further research should examine the biological mechanisms underlying the association between reduced limb blood flow and fractures.

Serum phosphorus levels and the spectrum of ankle-brachial index in older men: the Osteoporotic Fractures in Men (MrOS) study.

A higher serum phosphorus level is associated with cardiovascular disease (CVD) events among community-living populations. Mechanisms are unknown. The ankle-brachial index (ABI) provides information on both atherosclerosis and arterial stiffness. In this cross-sectional study (2000-2002), the authors evaluated the association of serum phosphorus levels with low (<0.90) and high (> or =1.40 or incompressible) ABI as compared with intermediate ABI in 5,330 older US men, among whom the mean serum phosphorus level was 3.2 mg/dL (standard deviation, 0.4), 6% had a low ABI, and 5% had a high ABI. Each 1-mg/dL increase in serum phosphorus level was associated with a 1.6-fold greater prevalence of low ABI (95% confidence interval (CI): 1.2, 2.1; P < 0.001) and a 1.4-fold greater prevalence of high ABI (95% CI: 1.0, 1.9; P = 0.03) in models adjusted for demographic factors, traditional CVD risk factors, and kidney function. However, the association of phosphorus with high ABI differed by chronic kidney disease (CKD) status (in persons with CKD, prevalence ratio = 2.96, 95% CI: 1.61, 5.45; in persons without CKD, prevalence ratio = 1.14, 95% CI: 0.81, 1.61; interaction P = 0.04). In conclusion, among community-living older men, higher phosphorus levels are associated with low ABI and are also associated with high ABI in persons with CKD. These associations may explain the link between serum phosphorus levels and CVD events.

Self-efficacy is associated with walking ability in persons with diabetes mellitus and peripheral arterial disease.

Self-efficacy is a known predictor for behavior change. Little is known about the association of self-efficacy with walking ability in individuals with diabetes mellitus and peripheral arterial disease (PAD). The objective of this study was to determine the association of self-efficacy with walking ability in individuals with diabetes mellitus and PAD. In this cross-sectional study, baseline data were analyzed from individuals with diabetes mellitus type 1 or 2 and PAD who were enrolled in a walking intervention clinical trial. As part of the baseline assessment, individuals completed questionnaires to ascertain self-efficacy and co-existing illnesses. In addition, participants completed a treadmill walking test and a 6-minute walking test. A total of 145 individuals were enrolled (mean age 66.5 +/- 10.1 years) with diabetes mellitus and PAD; 45 (31%) were women. The mean ankle-bracial index was 0.70 (range - 0.18-2.20) and the mean glycosylated hemoglobin value was 7.1 (SD 1.2). The mean distance walked, as per the treadmill walking test, was 418 meters (SD 258) and the mean distance walked, as per the 6-minute walking test, was 272 meters (SD 74). As measured by the treadmill walking test and the 6-minute walking test, self-efficacy was associated with treadmill walking distance, coefficient 33.0 (95% CI 11.0, 55.1; p = 0.0036), and the 6-minute walking test, coefficient 10.4 (95% CI 3.0, 17.7; p = 0.0061), after adjusting for comorbidities, social habits, and disease severity. In conclusion, self-efficacy, a psychosocial mediator for behavior change, was significantly associated with walking ability in individuals with diabetes mellitus and PAD. Future studies should determine the benefits of targeting self-efficacy to improve adherence to walking therapy in patients with PAD.

Predictors of smoking reduction among Blacks.

INTRODUCTION: Blacks who smoke have increased tobacco-related health risks. Cessation decreases the likelihood of many health problems. Smoking reduction may be important in the cessation process and potentially reduce health risks. METHODS: Because little is known about specific predictors of smoking reduction, we investigated factors predicting reduction among Black light smokers enrolled in a 26-week cessation trial. Specifically, we compared (a) reducers (reduced cigarettes per day [cpd] >or=50%) with nonreducers and (b) reducers with quitters. Baseline demographic, smoking-related, and psychosocial variables were collected, and Week 26 smoking status was assessed. RESULTS: Among 539 participants, 41.0% (n = 221) reduced their smoking, 17.6% (n = 95) quit, and 41.4% (n = 223) did not reduce their smoking by >or=50%. In comparison with reducers, nonreducers were more likely to have their first cigarette within 30 min of waking (odds ratio [OR] = 2.4, 95% CI = 1.47-3.93), lower baseline cpd (OR = 0.84, 95% CI = 0.77-0.93), higher baseline cotinine levels (OR = 1.002, 95% CI = 1.000-1.003), lower perceived stress (OR = 0.86, 95% CI = 0.78-0.95), and higher Smoking Consequences Questionnaire (SCQ) negative social impression scores (OR = 1.04, 95% CI = 1.01-1.06), after controlling for treatment arm, gender, and age. Significant predictors of smoking cessation versus reduction included lower baseline cpd (OR = 0.85, 95% CI = 0.75-0.95), higher nicotine dependence (OR = 1.47, 95% CI = 1.09-1.98), lower baseline cotinine levels (OR = 0.996, 95% CI = 0.994-0.998), higher body mass index (OR = 1.05, 95% CI = 1.01-1.08), lower perceived stress (OR = 0.82, 95% CI = 0.72-0.95), and higher SCQ negative social impression scores (OR = 1.05, 95% CI = 1.01-1.08). DISCUSSION: Distinct predictors are associated with different trajectories of smoking behavior change (i.e., reduction vs. cessation vs. no change).

Electronic Monitoring Of Mom's Schedule (eMOMS™): Protocol for a feasibility randomized controlled trial to improve postpartum weight, blood sugars, and breastfeeding among high BMI women.

BACKGROUND: Overweight and obesity are major risk factors for gestational diabetes among U.S. women. Evidence suggests that longer duration of breastfeeding among women with a history of gestational diabetes is associated with lower incidence of developing type 2 diabetes after pregnancy. Women may potentially benefit from a lifestyle change program that includes breastfeeding education and support. PURPOSE: To describe the design and justification of a combined breastfeeding, national Diabetes Prevention Program (DPP)-based feasibility randomized controlled trial, the electronic Monitoring Of Mom's Schedule (eMOMSTM) study. eMOMSTM compares the feasibility and efficacy of three interventions on six-month postpartum weight loss among women with a BMI ≥25. METHODS: The intervention is delivered via Facebook and includes three groups: DPP and breastfeeding (eMOMS1); DPP only (eMOMS2); and Usual Care (eMOMS3). Recruitment is ongoing at two clinical sites (rural and urban). A total of 72 women, 24 per group, will be randomly assigned to one of the three groups. It is anticipated that women in eMOMS1 will have greater weight loss and increased length of breastfeeding at three and six months postpartum compared to women in eMOMS2 and eMOMS3. Additional data will be collected on metabolic markers, anthropometrics, physical activity, nutrition, breastfeeding, and depression. Program cost will be compared to that of traditionally scheduled group meetings. Expected study completion date: October 2021. CONCLUSIONS: This study has the potential to define a high impact, cost effective intervention that can improve public health by reducing negative health outcomes associated with gestational diabetes among an at-risk population.

Efficacy of a multi-component intervention to promote physical activity among Latino adults: A randomized controlled trial.

Physical inactivity is highly prevalent in Latinos. Use of smartphone technology may improve physical activity (PA) among Latino adults. We sought to determine the efficacy of a multi-component intervention to promote PA among Latino adults. We conducted a 3-month, 2-arm randomized trial among Latino adults with one or more risk factors for cardiovascular disease (CVD). We adapted a scripted, counseling approach into text messages and combined this intervention with brief motivational interviewing delivered by telephone. We compared this intervention to a control group. Both groups received a handout on the benefits of PA. During the baseline visit, participants completed a validated medical history survey as well as an assessment of quality of life and exercise behaviors. The primary outcome was change at three months in mean steps per week. We enrolled 69 patients, 35 in the intervention arm and 34 in the control arm. The mean age of the cohort was 58.7 years (SD 6.82). At baseline, mean steps per week were 65,218.2 (SD 25420.8) for intervention participants compared to 71,581.26 (SD 26118.07) for control participants, P = 0.36. At 3 months, the change in mean steps per week was 31,184.6 (SD 26121.52) for participants randomized to the intervention compared to 15,370.9 (SD 22247.84) for those randomized to control, P = 0.045. Among Latino adults with one or more risk factors for CVD, there was an increase in mean steps per week among those randomized to an intervention, involving the use of smartphones, versus control. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/StudyNCT02622282.

The role of the community health delivery system in the health and well-being of justice-involved women: a narrative review.

BACKGROUND: Over seven million imprisoned and jailed women are released into the community each year and many are ill-equipped to meet the challenges of re-integration. Upon release into their community, women are faced with uncertain barriers and challenges using community services to improve their health and well-being and reuniting with families. Few studies have identified and described the barriers of the community health delivery system (CHDS)- a complex set of social, justice, and healthcare organizations that provide community services aimed to improve the health and well-being (i.e. safety, health, the success of integration, and life satisfaction) of justice-involved women. We conducted a narrative review of peer-reviewed and gray literature to identify and describe the CHDS and the CHDS service delivery. RESULTS: Peer-reviewed and gray literature (n = 82) describing the CHDS organizations' missions, incentives, goals, and services were coded in three domains, justice, social, and healthcare, to examine their service delivery to justice-involved women and their efforts to improve the health and well-being of justice-involved women. CONCLUSIONS: We found that the CHDS is fragmented, identified gaps in knowledge about the CHDS that serves justice-involved women, and offer recommendations to reduce fragmentation and integrate service delivery aimed to improve the health and well-being of justice-involved women.

Efficacy of Community-Based Exercise Therapy Among African American Patients With Peripheral Artery Disease: A Randomized Clinical Trial.

Importance: African American individuals are 2 times more likely than non-Hispanic white individuals to have peripheral artery disease (PAD). Structured community-based exercise therapy improves walking distance among patients with PAD, but these patients require motivation to adhere to therapy. Objective: To assess whether motivational interviewing (MI) is more efficacious than Patient-Centered Assessment and Counseling for Exercise (PACE) or control to improve walking distance in African American patients with PAD. Design, Setting, and Participants: In this 3-group randomized clinical trial, 174 African American patients with PAD were studied from May 1, 2012, to November 30, 2016, at health care centers, churches, and health fairs in Wichita, Kansas; Kansas City, Kansas, and Kansas City, Missouri. Interventions: Patients were randomized in a 1:1:1 fashion to 1 of 3 groups (57 to MI, 57 to PACE, and 60 to control). The 2 counseling interventions were delivered biweekly for 3 months and monthly for 3 months followed by a 6-month maintenance phase with limited contact. Control participants received a mailing at 3 and 9 months. Main Outcomes and Measures: The primary outcome was 6-month change in 6-minute walking performance. Secondary outcomes included 12-month change in walking performance and 6- and 12-month changes in quality of life. Results: A total of 174 African American patients (mean [SD] age, 64.2 [11.2] years; 128 [74.0%] female) were studied. At 6 months, mean (SE) change in walking distance by group was as follows: MI, -3.42 (4.55) m; PACE, 2.74 (6.00) m; and control, -0.18 (4.40) m. At 12 months, mean (SE) change in walking distance by group was as follows: MI, -7.75 (5.50) m; PACE, 13.75 (6.13) m; and control, -1.08 (5.73) m. Comparing each of the intervention arms (MI and PACE) with the control arm, no statistically significant increases in walking distance at 6 months (MI: change, -2.10 m; 95% CI, -16.54 to 12.35 m; PACE: change, 2.31 m; 95% CI, -11.36 to 15.97 m) or 12 months (MI: change, -5.56 m; 95% CI, -21.18 to 10.06 m; PACE: change, 14.24 m; 95% CI, -1.85 to 30.34 m) were found. Compared with MI, PACE resulted in a statistically significant increase in walking distance at 12 months of 19.80 m (95% CI, 3.33-36.28 m). Conclusions and Relevance: In a cohort of African American patients with PAD, MI was not efficacious in improving walking distance at 6 or 12 months. The results of this study do not support the use of MI to improve walking performance in African American patients with PAD. Trial Registration: ClinicalTrials.gov Identifier: NCT01321086.

Breastfeeding History and Risk of Stroke Among Parous Postmenopausal Women in the Women's Health Initiative.

Background Stroke is the third leading cause of death among US Hispanic and non-Hispanic black women aged 65 and older. One factor that may protect against stroke is breastfeeding. Few studies have assessed the association between breastfeeding and stroke and whether this association differs by race and ethnicity. Methods and Results Data were taken from the Women's Health Initiative Observational Study with follow-up through 2010; adjusted hazard ratios for stroke subsequent to childbirth were estimated with Cox regression models accounting for left and right censoring, overall and stratified by race/ethnicity. Of the 80 191 parous women in the Women's Health Initiative Observational Study, 2699 (3.4%) had experienced a stroke within a follow-up period of 12.6 years. The average age was 63.7 years at baseline. Fifty-eight percent (n=46 699) reported ever breastfeeding; 83% were non-Hispanic white, 8% were non-Hispanic black, 4% were Hispanic, and 5% were of other race/ethnicity. After adjustment for nonmodifiable potential confounders, compared with women who had never breastfed, women who reported ever breastfeeding had a 23% lower risk of stroke (adjusted hazard ratio=0.77; 95% confidence interval 0.70-0.83). This association was strongest for non-Hispanic black women (adjusted hazard ratio=0.52; 95% confidence interval 0.37-0.71). Further, breastfeeding for a relatively short duration (1-6 months) was associated with a 19% lower risk of stroke (adjusted hazard ratios=0.81; 95% confidence interval 0.74-0.89). This association appeared stronger with longer breastfeeding duration and among non-Hispanic white and non-Hispanic black women (test for trend P<0.01). Conclusions Study results show an association and dose-response relationship between breastfeeding and lower risk of stroke among postmenopausal women after adjustment for multiple stroke risk factors and lifestyle variables. Further investigation is warranted.

Hospital use and survival among Veterans Affairs beneficiaries.

BACKGROUND: Initiatives to reduce hospital care were part of the reorganization of the Department of Veterans Affairs (VA) medical care system undertaken in the mid-1990s. We examined changes in the use of VA health services and survival from 1994 through 1998 among VA beneficiaries with serious chronic diseases. We postulated that if access to hospital care was reduced too much, or if decreased hospital use was not offset by improvements in ambulatory care, urgent care visits would increase or survival rates would fall. METHODS: We tracked changes in risk-adjusted VA bed-day rates, rates of medical visits, rates of visits for testing and consultation, and rates of urgent care visits per patient-year among VA beneficiaries in nine disease cohorts (a total of 342,300 beneficiaries). Trends in non-VA hospital use by VA beneficiaries 65 years of age or older who were enrolled in fee-for-service Medicare were also studied. VA and Medicare vital-status data were used to calculate one-year survival rates. RESULTS: From 1994 through 1998, VA bed-day rates fell by 50 percent, rates of medical-clinic visits and visits for testing and consultation increased moderately, and rates of urgent care visits fell by 35 percent. The sharp decline in the use of VA hospitals was not compensated for by increases in the use of Medicare-reimbursed non-VA hospital care by veterans eligible for both VA care and Medicare, and the use of non-VA hospitals actually declined in four cohorts. The survival rates were essentially unchanged over the study period. CONCLUSIONS: The marked decline in VA hospital use from 1994 through 1998 did not curtail access to needed services and was not associated with serious consequences for chronically ill VA beneficiaries.