Community-Based Interventions to Address Disparities in Cardiometabolic Diseases Among Minoritized Racial and Ethnic Groups.

PURPOSE OF REVIEW: Cardiometabolic diseases (CMDs) are leading causes of death and disproportionally impact historically marginalized racial/ethnic groups in the United States. The American Heart Association developed the Life's Essential 8 (LE8) to promote optimal cardiovascular health (CVH) through eight health behaviors and health factors. The purpose of this review is to summarize contemporary community-engaged research (CER) studies incorporating the LE8 framework among racial/ethnic groups. REVIEW OF FINDINGS: Limited studies focused on the interface of CER and LE8. Based on synthesis of articles in this review, the application of CER to individual/collective LE8 metrics may improve CVH and reduce CMDs at the population level. Effective strategies include integration of technology, group activities, cultural/faith-based practices, social support, and structural/environmental changes. CER studies addressing LE8 factors in racial/ethnic groups play an essential role in improving CVH. Future studies should focus on broader scalability and health policy interventions to advance health equity.

Are primary care providers' nutrition care and food insecurity screening practices associated with their perceptions of team-based care?

BACKGROUND: Screening for food insecurity (FI) and providing nutrition care are important management strategies for chronic diseases, but rates are low. Aspects of team-based care and providers' nutrition competence may help inform interventions to improve these services. The objectives of this study were to describe US primary care providers' FI screening and nutrition care practices (counselling, referrals, and time spent counselling) and test for associations with scored measures of their perceptions of team-based care (care continuity, patient-centredness, coordination with external providers and resources) and nutrition competence (confidence counselling and attitudes towards nutrition). METHODS: Cross-sectional online survey data of primary care providers were described and analysed for associations using Wilcoxon rank sum tests. RESULTS: Of provider respondents (N = 92), 35% (n = 32) worked in clinics that screen for FI and had higher team perceptions (P = 0.006) versus those who do not. Those who reported counselling >30% patients about nutrition (57%, n = 52) and referring >10% patients to nutrition professionals (24%, n = 22) had significantly better attitudes towards nutrition (P = 0.013 and P = 0.04, respectively) compared with those with lower counselling and referral rates. Half (n = 46) of the providers reported spending >3-min counselling each patient about nutrition and had higher patient-centred care (P = 0.004) and nutrition competence (P < 0.001) compared with those who spent less time counselling. CONCLUSION: Providers in clinics that screen for FI had higher overall perceptions of team-based care, but their nutrition competence was not significantly different. Meanwhile, reported more time counselling was associated with a culture of patient-centredness. Promoting team-based care may be a mechanism for improving FI screening and nutrition care.

The Association Between Perceived Racial Discrimination and Hypertension in a Low-Income, Racially Integrated Urban Community.

We examined the association between perceived racial discrimination and hypertension among African Americans and whites who live in a low-income, racially integrated, urban community. Hypertension was defined as having a systolic blood pressure 140 mm Hg or more, a diastolic blood pressure 90 mm Hg or more, or taking antihypertensive medication(s). Perceived racial discrimination was based on self-reported responses of experiencing racial discrimination in various settings. Using modified Poisson multivariable regression models, we found no association between perceived racial discrimination and hypertension (prevalence ratio: 0.96, 95% confidence interval: 0.90-1.04). Findings suggest that social context may play a role in the relationship between perceived racial discrimination and hypertension.

Managed care and inpatient mortality in adults: effect of primary payer.

BACKGROUND: Because managed care is increasingly prevalent in health care finance and delivery, it is important to ascertain its effects on health care quality relative to that of fee-for-service plans. Some stakeholders are concerned that basing gatekeeping, provider selection, and utilization management on cost may lower quality of care. To date, research on this topic has been inconclusive, largely because of variation in research methods and covariates. Patient age has been the only consistently evaluated outcome predictor. This study provides a comprehensive assessment of the association between managed care and inpatient mortality for Medicare and privately insured patients. METHODS: A cross-sectional design was used to examine the association between managed care and inpatient mortality for four common inpatient conditions. Data from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases for 11 states were linked to data from the American Hospital Association Annual Survey Database. Hospital discharges were categorized as managed care or fee for service. A phased approach to multivariate logistic modeling examined the likelihood of inpatient mortality when adjusting for individual patient and hospital characteristics and for county fixed effects. RESULTS: Results showed different effects of managed care for Medicare and privately insured patients. Privately insured patients in managed care had an advantage over their fee-for-service counterparts in inpatient mortality for acute myocardial infarction, stroke, pneumonia, and congestive heart failure; no such advantage was found for the Medicare managed care population. To the extent that the study showed a protective effect of privately insured managed care, it was driven by individuals aged 65 years and older, who had consistently better outcomes than their non-managed care counterparts. CONCLUSIONS: Privately insured patients in managed care plans, especially older adults, had better outcomes than those in fee-for-service plans. Patients in Medicare managed care had outcomes similar to those in Medicare FFS. Additional research is needed to understand the role of patient selection, hospital quality, and differences among county populations in the decreased odds of inpatient mortality among patients in private managed care and to determine why this result does not hold for Medicare.

Examining hypertension risk among Black and White breast cancer survivors.

PURPOSE: Breast cancer survivors are at increased risk of cardiovascular dysfunction following their diagnosis; however, hypertension remains underexplored within this context. This retrospective cohort study examined the incidence of hypertension in breast cancer survivors and the association of race with hypertension risk among them. METHODS: Data for this study were abstracted from the electronic health records of women diagnosed with Stages I-III breast cancer. Incident hypertension diagnosis was identified through International Classification of Diseases codes. Bivariate associations were tested using Student's t-test and chi-squared test of independence. Bivariable Cox regression analysis was used to determine demographic and clinical factors that may have been associated with the development of hypertension. RESULTS: A total of 664 women were included. Most women were 50 years of age or younger (52.0%), White (33.0% Black), and received a mastectomy (80.6%). Overall, 45.5% of the cohort developed hypertension. The 1-year hypertension-free survival estimates were 47% (95% confidence interval [CI], 41-54) in Black women and 73% (95% CI, 69-77) in White women (p < 0.0001). Besides race, statistically significant predictors of hypertension included: age greater than 50 (vs. ≤50) (adjusted Hazard Ratio [HR]: 1.40; 95% CI, 1.09-1.80) and residing in a non-metropolitan area (vs. metropolitan) (adjusted HR: 1.60; 95% CI, 1.19-2.16). CONCLUSIONS: This study suggests that breast cancer survivors who are older, Black, or residing in non-metropolitan areas may benefit from added surveillance and hypertension prevention strategies during treatment. Future studies are needed to identify contributors to the observed racial and geographic disparities.

Association Between Maladaptive Eating Behaviors Among Black Women and Vicarious Racial Discrimination Following a High-Profile Event.

OBJECTIVE: Evidence suggests that racial discrimination causes stress among non-Hispanic Black women, and some Black women may cope with exposure to vicarious racial discrimination by engaging in maladaptive eating behaviors. METHODS: We examined eating behaviors among Black women (N = 254) before and after Freddie Gray's death while in police custody. Maladaptive eating behaviors were assessed using the three-factor eating questionnaire. Our independent variables included the following: (1) time period and (2) geographic proximity to the event. Three two-way analysis of covariance tests were conducted to assess potential effects of geographic proximity (close, distant), time period in relation to unrest (before, after unrest), and their interaction on emotional eating, uncontrolled eating, and cognitive restraint controlling for participant age. RESULTS: There was a statistically significant main effect of proximity to the unrest on emotional eating, F (1, 252) = 5.64, p = .018, and partial η2 = .022 such that women living in close geographic proximity to the unrest reported higher mean levels of emotional eating as compared to those living more distant to the unrest. There was also a borderline statistically significant interaction between geographic proximity and time period on cognitive restraint, F (1, 252) = 3.89, p = .050, and partial η2 = .015. CONCLUSION: Our study found a relationship between vicarious racial discrimination and maladaptive eating behaviors among Black women. Future work should examine stress related to vicarious racial discrimination and maladaptive eating behaviors longitudinally.

Hypertension Severity and Declines in Left Ventricular Ejection Fraction Among Women Receiving Adjuvant Chemotherapy for Breast Cancer (WF-97415 UPBEAT).

BACKGROUND: Hypertension is a risk factor for experiencing left ventricular ejection fraction (LVEF) declines during receipt of potentially cardiotoxic breast cancer (BC) treatment. We sought to determine whether the hypertension stage is associated with LVEF decline during BC treatment. METHODS: Across 24 centers, cardiac magnetic resonance measures of LVEF and brachial arterial blood pressure (BP) measurements were performed in women with stages I to III BC before and 3 months after initiating potentially cardiotoxic chemotherapy. Using multivariable analysis, we assessed in a blinded fashion the association between 3-month ΔLVEF and precancer treatment American Heart Association/American College of Cardiology stages of hypertension. RESULTS: Among 204 women, age averaged 56±1 years with 75% being White and 20% of Black race. Participants received anthracycline (45.6%), trastuzumab (22.5%), cyclophosphamide (52.9%), or paclitaxel (50%). After accounting for pretreatment LVEF, diabetes status, tobacco use, age, the number of antihypertensive medications, and body mass index, those with stage II hypertension experienced an LVEF decline of -2.89% ([95% CI, -0.69% to -5.19%]; P=0.01) relative to individuals with normal BP. Other stages saw nonsignificant declines relative to normal BP to elevated BP (-1.63% [95% CI, -0.62% to 3.88%]; P=0.16) and stage I hypertension (-0.94% [95% CI, -0.90% to 2.78%]; P=0.32). CONCLUSIONS: Compared with women receiving treatment for BC with normal BP, there is a stronger association of decline in LVEF in women with stage II hypertension relative to women with other hypertension stages. This raises the possibility that stage along with hypertension presence may be associated with an increased risk for the LVEF decline among women receiving potentially cardiotoxic chemotherapy for BC. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02791581 and NCT01719562.

Urban-Rural Disparities in Deaths of Despair: A County-Level Analysis 2004-2016 in the U.S.

Introduction: The purpose of this study is to examine nationwide disparities in drug, alcohol, and suicide mortality; evaluate the association between county-level characteristics and these mortality rates; and illustrate spatial patterns of mortality risk to identify areas with elevated risk. Methods: The authors applied a Bayesian spatial regression technique to investigate the association between U.S. county-level characteristics and drug, alcohol, and suicide mortality rates for 2004-2016, accounting for spatial correlation that occurs among counties. Results: Mortality risks from drug, alcohol, and suicide were positively associated with the degree of rurality, the proportion of vacant housing units, the population with a disability, the unemployed population, the population with low access to grocery stores, and the population with no health insurance. Conversely, risks were negatively associated with Hispanic population, non-Hispanic Black population, and population with a bachelor's degree or higher. Conclusions: Spatial disparities in drug, alcohol, and suicide mortality exist at the county level across the U.S. social determinants of health; educational attainment, degree of rurality, ethnicity, disability, unemployment, and health insurance status are important factors associated with these mortality rates. A comprehensive strategy that includes downstream interventions providing equitable access to healthcare services and upstream efforts in addressing socioeconomic conditions is warranted to effectively reduce these mortality burdens.

Neighborhood Factors, Individual Stressors, and Cardiovascular Health Among Black and White Adults in the US: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

Importance: Chronic stress has been posited to contribute to racial disparities in cardiovascular health. Investigation of whether neighborhood- and individual-level stressors mediate this disparity is needed. Objective: To examine whether racial differences in ideal cardiovascular health (ICH) are attenuated by experiences with neighborhood- and individual-level stressors within a racially and geographically diverse population sample. Design, Setting, and Participants: This cross-sectional study examined data from 7720 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study who completed the second in-home visit (2013-2016). The REGARDS study is a population-based, longitudinal study of 30 239 non-Hispanic Black and non-Hispanic White adults aged 45 years or older at baseline (2003-2007). Data for the present study were analyzed from June to July 2021 and in March 2022. Exposures: Neighborhood physical environment (eg, excessive noise, violence; scored from 7-28, with higher scores indicating more problems), neighborhood safety (scored as very safe, safe, or not safe), neighborhood social cohesion (eg, shared values; scored from 5-25, with higher scores indicating higher cohesion), perceived stress (eg, coping; scored from 0-16, with higher scores indicating greater perceived stress), and the experience of discrimination (yes or no). Main Outcomes and Measures: Ideal cardiovascular health (ICH), measured as a composite of 4 health behaviors (cigarette smoking, diet, physical activity, body mass index) and 3 health factors (blood pressure, cholesterol, and glucose levels). Results: The sample included 7720 participants (mean [SD] age, 71.9 [8.3] years; 4390 women [56.9%]; 2074 Black participants [26.9%]; and 5646 White participants [73.1%]). Black participants compared with White participants reported higher perceived stress (mean [SD] score, 3.2 [2.8] vs 2.8 [2.7]) and more often reported discrimination (77.0% vs 24.0%). Black participants also reported poorer neighborhood physical environment (mean [SD] score, 11.2 [3.8] vs 9.8 [2.9]) and social cohesion (mean [SD] score, 15.5 [2.0] vs 15.7 [1.9]) and more often reported their neighborhoods were unsafe (54.7% vs 24.3%). The odds of having a high total ICH score (ie, closer to ideal) were lower for Black adults compared with White adults, both overall (adjusted odds ratio [AOR], 0.53; 95% CI, 0.45-0.61) and by gender (men: AOR, 0.73 [95% CI, 0.57-0.93]; women: AOR, 0.45 [95% CI, 0.37-0.54]). In mediation analyses, the racial disparity in total ICH score was attenuated by neighborhood physical environment (5.14%), neighborhood safety (6.27%), neighborhood social cohesion (1.41%), and discrimination (11.01%). In stratified analyses, the factors that most attenuated the racial disparity in total ICH scores were neighborhood safety among men (12.32%) and discrimination among women (14.37%). Perceived stress did not attenuate the racial disparity in total ICH scores. Conclusions and Relevance: In this cross-sectional study of Black and White US adults aged 45 years and older, neighborhood-level factors, including safety and physical and social environments, and individual-level factors, including discrimination, attenuated racial disparities in cardiovascular health. Interventional approaches to improve ICH that separately target neighborhood context and discrimination by gender and race are warranted.

Rationale and Design of the Groceries for Black Residents of Boston to Stop Hypertension Among Adults Without Treated Hypertension (GoFresh) Trial.

BACKGROUND: Poor diet quality significantly contributes to hypertension disparities affecting Black adults. While the Dietary Approaches to Stop Hypertension (DASH) eating pattern lowers blood pressure (BP), access to DASH-patterned groceries is a major barrier for residents of urban food deserts. METHODS: The Groceries for Black Residents of Boston to Stop Hypertension among Adults without Treated Hypertension (GoFresh) study is one of five projects in the RESTORE Network, an AHA-funded initiative focused on hypertension prevention. GoFresh is testing whether online, dietitian-assisted, home-delivered, DASH-patterned groceries lowers BP among Black adults with elevated BP. This individual-level, parallel-arm trial will enroll up to 176 Black adults with SBP (systolic blood pressure) between 120 and <150 mm Hg residing in Boston-area communities with reduced grocery store access. Following randomization, half of the participants will be assigned to weekly sessions with a dietitian who will assist participants in ordering DASH-patterned groceries online for home delivery; the remainder will receive a $500 monthly stipend. Both interventions will last 3 months, followed by a 9-month maintenance phase. RESULTS: The primary outcome is the difference in SBP after 3 months. Secondary outcomes include a change in 24-hour ambulatory BP, body mass index, 24-hour urine sodium and potassium, hemoglobin A1C, lipids, fruit and vegetable intake, and saturated fat intake. Qualitative interviews with 45 participants 6 months after baseline assessments will determine barriers and facilitators to long-term maintenance of DASH-patterned grocery shopping. DISCUSSION: Findings from this study will inform ongoing work on scalable interventions to prevent hypertension among Black adults with implications for public and healthcare-based food supplementation programs. TRIAL REGISTRATION: NCT05121337. Registered on 16 November 2021, at ClinicalTrials.gov: https://clinicaltrials.gov/ct2/show/NCT05121337.

Stress Reduction to Decrease Hypertension for Black Women: A Scoping Review of Trials and Interventions.

INTRODUCTION: Chronic stress is a potential root cause of racial/ethnic disparities in cardiovascular disease. This review assesses literature surrounding effective stressreduction interventions to reduce hypertension (HTN)-a cardiovascular disease (CVD) risk factor-among an understudied population, non-Hispanic black (NHB) women. METHODS: We conducted an electronic search of PubMed and PsycINFO literature published between January 1, 2000 and February 1, 2020, employing the keywords: "blood pressure", "hypertension", and "women", "black", "African-American", "stress", "meditation", "stress-coping", "stress-management", and "faith-based". We manually searched the bibliographies for additional articles. Studies were excluded if they: were published before 2000; were not intervention-based; did not study Black women in the US; did not target stress reduction; or did not measure blood pressure as an outcome. Independent reviewers screened the articles, which were selected based on consensus. Effect sizes and statistical p values were reported as provided in the included articles. RESULTS: We identified 109 articles in total. Of those, six articles met inclusion criteria. Stronger evidence presented by a randomized control trial supported the efficacy of transcendental meditation with reductions in systolic and diastolic blood pressure up to 7 mmHg. Relaxation exercises, support groups, and therapeutic massage emerged as potentially beneficial in non-randomized pilot trials with reductions in systolic BP up to 9 mmHg and diastolic BP up to 5 mmHg varying by type and duration of the intervention. CONCLUSIONS: This scoping review found that faith-based strategies and meditation can be effective stress reduction techniques to reduce BP among NHB women. However, much remains to be known about how these strategies may be leveraged to reduce blood pressure within this highly vulnerable population.

The Weight of Racial Discrimination: Examining the Association Between Racial Discrimination and Change in Adiposity Among Emerging Adult Women Enrolled in a Behavioral Weight Loss Program.

BACKGROUND: Non-Hispanic Black (NHB) emerging adult (EA) women are at disproportionate risk for obesity but experience limited benefit from behavioral weight loss (BWL) programs. Race-related stress could play a role; the goal of this study was to examine the association between racial discrimination (RD) and early (3 months) changes in adiposity, and to explore potential protective factors, among EA in an adapted BWL program. METHODS: This is an ancillary study of non-Hispanic White (NHW) and NHB EA women enrolled in an adapted BWL trial (N = 49; 55.1% NHB; Age 21.2 (2.1); BMI = 33.0 + 4.3 kg/m2). At baseline, group- and personal-level RD (RD-group and RD-personal), racial identity (NHB women only), vigilant coping, and social support were assessed via validated questionnaires. Weight and waist circumference were measured objectively at 0 and 3 months. RESULTS: NHW women manifested greater reductions in waist circumference relative to NHB women (p = .004). RD-personal did not predict change in waist circumference at 3 months (p = .402); however, the association between RD-group and change in waist circumference was statistically significant (p = .015), such that reporting greater group-level discrimination predicted a smaller decrease in waist circumference; the model explained 22% of the variance. Social support and vigilant coping were not statistically significant in the model. Among NHB women only, higher racial identity-centrality predicted greater reduction in waist circumference (p = .019). CONCLUSION: Findings suggest racial discrimination could contribute to greater cardiometabolic risk during this developmental period. Future research should examine how experiences of racial discrimination unfold in the daily lives of NHB women to inform mechanistic interventions to enhance health and well-being. TRIAL REGISTRATION: NCT02736981. Low Intensity Weight Loss for Young Adults.

Contributions of Structural Racism to the Food Environment: A Photovoice Study of Black Residents With Hypertension in Baltimore, MD.

BACKGROUND: Disproportionate exposure to poor food environments and food insecurity among Black Americans may partially explain critical chronic disease disparities by race and ethnicity. A complex set of structural factors and interactions between Black residents and their food environments, including store types, quantity, proximity, and quality of goods and consumer interactions within stores, may affect nutritional behaviors and contribute to higher cardiovascular and kidney disease risk. METHODS: We used the Photovoice methodology to explore the food environment in Baltimore, MD, through the perspectives of Black residents with hypertension between August and November 2019. Twenty-four participants were enrolled in the study (mean age: 65.1 years; 67% female). After a brief photography training, participants captured photos of their food environment, which they discussed in small focus groups over the course of 5 weeks. Discussions were audiotaped and analyzed for emergent themes using a line-by-line inductive approach. Themes were, then, organized into a collective narrative. RESULTS: Findings describe physical and social features of the food environment as well as participants' perceptions of its origins and holistic and generational health effects. The study illustrates the interrelationships among the broader socio-political environment, the quality and quantity of stores in the food landscape, and the ways in which they engage with the food environment as residents and consumers who have been marginalized due to their race and/or social class. The following meta-themes emerged from the data: (1) social injustice; (2) structural racism and classism; (3) interpersonal racism; (4) generational effects; (5) mistrust; (6) social programs; and (7) community asset-based approaches, including advocacy and civic engagement. CONCLUSIONS: Understanding residents' perceptions of the foundations and effects of the food environment on their health may help stakeholders to cocreate multilevel interventions alongside residents to improve access to healthy food and health outcomes among disparities affected populations.

Association of Perceived Stress and Discrimination on Medication Adherence among Diverse Patients with Uncontrolled Hypertension.

Background: Uncontrolled hypertension is a significant risk factor for cardiovascular morbidity and mortality. In the United States, many patients remain uncontrolled, in part, due to poor medication adherence. Efforts to improve hypertension control include not only attending to medical management of the disease but also the social determinants of health, which impact medication adherence, and ultimately blood pressure control. Purpose: To determine which social determinants - health care access or community and social stressors - explain medication adherence. Methods: In this cross-sectional analysis, we used baseline data (N=1820, collected August 2017 to October 2019) from a pragmatic trial, which compares the effectiveness of a multi-level intervention including collaborative care and a stepped approach with enhanced standard of care for improving blood pressure. We used logistic regression analyses to examine the association between patient experiences of care and community and social stressors with medication adherence. Results: The participants represented a diverse sample: mean age of 60 years; 59% female; 57.3% Black, 9.6% Hispanic, and 33.2% White. All participants had a blood pressure reading ≥140/90 mm Hg (mean blood pressure - 152/85 mm Hg). Half of the participants reported some level of non-adherence to medication. Regression analysis showed that, compared with Whites, Blacks (AOR .47; 95% CIs: .37-.60, P<.001) and Hispanics (AOR .48; 95% CIs: .32- .73, P<.001) were less likely to report medication adherence. Also part-time workers (AOR .57; 95% CIs: .38-.86, P<.05), and those who reported greater perceived stress (AOR .94; 95% CIs: .91 - .98, P<.001) and everyday discrimination (AOR .73; 95% CIs: .59 - .89; P<.001) had lower odds of medication adherence. Among Blacks, greater perceived stress (AOR .93; 95% CIs: .88-.98, P<.001) and everyday discrimination (AOR .63; 95% CIs: .49 - .82, P<.005) were negatively associated with medication adherence. Among Hispanics, greater report of everyday discrimination (AOR .36; 95% CIs: .14 - .89, P<.005) was associated with lower odds of medication adherence. Among Whites, the negative effect of perceived stress on medication adherence was attenuated by emotional support. Conclusions: Using the social determinants of health framework, we identified associations between stress, everyday discrimination and medication adherence among non-Hispanic Blacks and Hispanics that were independent of health status and other social determinants. Programs to enhance self-management for African American and Hispanic patients with uncontrolled blood pressure should include a specific focus on addressing social stressors.

Stress-Related Outcomes after a Period of Unrest in Two Low-Income African American Communities.

We examined the association of civil unrest with potentially stress-related outcomes among two low-income, African American communities in Baltimore following the death of Freddie Gray in police custody and whether neighborhood proximity to unrest moderated these associations. We leveraged data from a cross-sectional survey of randomly selected households in two public housing communities (n=342) collected before, during, and after the civil unrest (August 2014 to August 2015). We used multivariate regression to explore the association of unrest with depressive symptoms and elevated blood pressure adjusting for potential confounders and community attributes. After the 2015 civil unrest event in Baltimore, those living in a low-income community near the epicenter demonstrated higher rates of depressive symptoms, but not elevated blood pressure, compared with those living in a comparable neighborhood three miles away. Low-income communities in Baltimore could benefit from mental health services after periods of civil unrest.

Correlates of alcohol use disorder pharmacotherapy receipt in medically insured patients.

BACKGROUND: Alcohol use disorder is a highly prevalent disease with multiple medications available for treatment. The overall prevalence of patients receiving pharmacotherapy is believed to be low and the characteristics and comorbidities that affect receipt are not well-established. METHODS: We created a dataset from Truven Health Analytics MarketScan Commercial Claims and Encounters Database of patients with an outpatient encounter for alcohol abuse or dependence in 2014. We subsequently identified patient characteristics, comorbid medical, psychiatric, or substance use disorders, as well as encounter provider specialties and, using multivariable logistic regression, assessed which variables correlated with increased or decreased receipt of pharmacotherapy for alcohol use disorder for this population. RESULTS: In our dataset of 123,355 patients, patient receipt of pharmacotherapy for alcohol use disorder was 3.3 %, and 9.3 % when restricted to the former diagnosis of alcohol dependence only. Male sex, younger age, alcohol-related liver disease, and cannabis use disorders correlated with decreased receipt whereas comorbid major depressive disorders and anxiety disorders correlated with increased receipt. Compared to patients seen by psychiatrists, those seen by primary medical doctors had a lower odds of receiving pharmacotherapy. CONCLUSIONS: Pharmacotherapy for alcohol use disorder is an underutilized treatment modality with a low prevalence of prescription in insured individuals. Patients with specific characteristics and comorbidities are less likely to receive this treatment and greater focus on these patients and in the primary care setting can allow for increased prescribing of these medications.

Race, Vigilant Coping Strategy, and Hypertension in an Integrated Community.

BACKGROUND: Vigilant coping refers to individuals who, potentially as a result of experiencing discrimination in the past, proactively prepare for the possibility that they will be discriminated against or mistreated because of their race. The extent to which vigilant coping is linked with hypertension, a highly prevalent condition with well-documented racial/ethnic disparities, remains largely unknown. METHODS: We performed a cross-sectional analysis of data from the Exploring Health Disparities in Integrated Communities (EHDIC) study-Southwest Baltimore (n = 715). We used a series of multivariate logistic regression models to evaluate vigilance as a potential mediator or moderator of the association between race, discrimination, and hypertension within the context of a racially integrated community. RESULTS: There was no difference in prevalence of hypertension between African-Americans and Whites in this sample (66.8 vs. 66.2; P = 0.86). A higher proportion of African-Americans reported discrimination (41.1 vs. 22.9; P < 0.0001) and vigilance (67.3 vs. 46.9; P < 0.0001) compared to Whites; however, neither measure was associated with hypertension. In stratified analyses, bothersome discrimination alongside vigilant coping was associated with higher odds of hypertension among African-Americans and lower odds among Whites. CONCLUSIONS: Overall, prevalence of hypertension was high and there were no racial differences in this racially integrated community. Discrimination, vigilance, and hypertension were differently associated among African-Americans and Whites. Studying lived experiences in integrated communities may illuminate how structural inequalities impact the health of African-Americans more broadly. Further, raising awareness of social factors as they relate to hypertension may help to inform clinical management of low-income patients.

Informed and patient-centered decision-making in the primary care visits of African Americans with depression.

OBJECTIVE: We examined the prevalence and extent of informed decision-making (IDM) and patient-centered decision-making (PCDM) in primary care visits of African Americans with depression. METHODS: We performed a cross-sectional analysis of audiotaped clinical encounters and post-visit surveys of 76 patients and their clinicians. We used RIAS to characterize patient-centeredness of visit dialogue. IDM entailed discussion of 3 components: the nature of the decision, alternatives, and pros/cons. PCDM entailed discussion of: lifestyle/coping strategies, knowledge/beliefs, or treatment concerns. We examined the association of IDM and PCDM with visit duration, overall patient-centeredness, and patient/clinician interpersonal ratings. RESULTS: Approximately one-quarter of medication and counseling decisions included essential IDM elements and 40% included at least one PCDM element. In high patient-centered visits, IDM was associated with patients feeling respected in counseling and liking clinicians in medication decisions. IDM was not related to clinician ratings. In low patient-centered visits, PCDM in counseling decisions was positively associated with patients feeling respected and clinicians respecting patients. CONCLUSIONS: The associations between IDM and PCDM with interpersonal ratings was moderated by overall patient-centeredness of the visit, which may be indicative of broader cross-cultural communication issues. PRACTICE IMPLICATIONS: Strengthening partnerships between depressed African Americans and their clinicians may improve patient-engaged decision-making.