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Health Equity

Our researchers actively seek to understand and address racial and ethnic disparities, social determinants of health

From its founding 75 years ago, Kaiser Permanente has held equity and inclusiveness for all its members, and the health of its communities, as guiding principles. And for nearly 60 years, the Division of Research has sought answers to support those goals.

In recent years, our investigators have sought to illuminate the social, biological, and environmental factors that contribute to racial and ethnic health disparities. And going a step farther, they identify evidence-based interventions to eliminate those differences.

This research portfolio is consistent and expanding. Investigators across our organization have taken variation by race, ethnicity, and health into account on a wide variety of topics, from medication adherence to diabetes prevalence to access to advanced surgeries.

We have long been focused on understanding the social drivers of health that have led to an increased risk for chronic health conditions, decreased access to medical care, and poorer health outcomes for our most vulnerable populations.

We know that:

  • communities of historically underrepresented groups are disproportionately impacted by a lack of economic opportunity, living under sustained financial strain that creates barriers to good health.
  • inequities and disparities that have existed for people of historically underrepresented groups — women, people living in poverty, and other marginalized groups — have been made more visible by the COVID-19 pandemic, with data showing that Latinx and African Americans are disproportionately affected by the disease as well as by its economic impacts.

The Division of Research will continue this mission to provide the data that allows high-quality health care to be accessible to everyone, no matter their social, economic, racial, or ethnic background.

Defining Terms

Health Equity: The attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.

Health Disparity: A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

Source: HealthyPeople 2030

Health Disparities Examples

  • Black adults who were born in 1928 in states with the highest Black infant mortality rates faced a 86 percent higher risk of dementia than among white people born in states without high infant mortality rates.
  • Hypertension is devastating to communities of color, particularly among Black adults, where males have the highest hypertension death rates of any other racial, ethnic, or gender group.
  • Diabetes occurs 3 times more often among Native Hawaiian and Pacific Islander people with a normal BMI than white people with a normal BMI.

Resources on Equity

Equality for All: Greg Adams, chairman and CEO, Kaiser Permanente

Equity, Inclusion, and Diversity Permanente Medicine Fact Sheet

Racism and Health Centers for Disease Control and Prevention Health Equity


Perceived Discrimination, Nativity, and Cognitive Performance in a Multi-ethnic Study of Older Adults: Findings from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) Study

Despite growing research on the association between discrimination and disparities in cognitive aging, an evidence gap remains on how the association varies by racial/ethnic group. This study evaluates the associations of experiences of discrimination with cognitive function and whether these associations varied by race/ethnicity and nativity. Using the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) cohort (N = 1 712) with approximately equal groups of Black, White, Latino, and Asian community-dwelling older adults aged 65 years and older, we evaluated the associations between self-reported experiences of everyday and major lifetime discrimination with overall cognitive performance and domain-specific cognition (verbal episodic memory, semantic memory, and executive functioning) across race/ethnicity and nativity. Linear regression models examined the cross-sectional association between self-reported experiences of everyday and major lifetime discrimination with z-standardized coefficients for cognition. We tested for effect modification by race and nativity. All models controlled for age, sex, and education. Among KHANDLE participants (mean age: 76 years; SD: 6.8), everyday discrimination was not associated with cognitive scores. Major lifetime discrimination was associated with better average cognitive scores among Black participants but not among other racial/ethnic groups. Major lifetime discrimination was associated with better average cognitive scores among U.S.-born but not among non-U.S.-born individuals. Our findings do not imply that discrimination improves cognition, but rather suggest that future research should include more detailed measures on discrimination and unfair treatment that could help disentangle the extent to which relationships are causal or reflect some other underlying factor.

Authors: Meza, Erika; Peterson, Rachel; Gilsanz, Paola; George, Kristen M; Miles, Sunita J; Eng, Chloe W; Mungas, Dan M; Mayeda, Elizabeth Rose; Glymour, M Maria; Whitmer, Rachel A

J Gerontol A Biol Sci Med Sci. 2022 02 03;77(2):e65-e73.

PubMed abstract

Measuring cognitive health in ethnically diverse older adults

Understanding racial/ethnic disparities in late-life cognitive health is a public health imperative. We used baseline data from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study to examine how age, education, gender, and clinical diagnosis, a proxy for brain health, are associated with cross-sectional measures of cognition in diverse racial/ethnic groups. Comprehensive measures of cognition were obtained using the Spanish and English Neuropsychological Assessment Scales and the National Institutes of Health Toolbox Cognitive Health Battery in a sample of 1,695 KHANDLE participants (Asians 24%, Blacks 26%, Latinos 20%, Whites 29%). A 25% random subsample was clinically evaluated and diagnosed with normal cognition, mild cognitive impairment (MCI), or dementia. Cognitive test scores were regressed on core demographic variables and diagnosis in the combined sample and in multiple group analyses stratified by racial/ethnic group. Race/ethnicity and education were variably associated with test scores with strongest associations with tests of vocabulary and semantic memory. Older age was associated with poorer performance on all measures, and gender differences varied across cognitive tests. Clinical diagnosis of MCI or dementia was associated with average decrements in test scores that ranged from -0.41 to -0.84 SD, with largest differences on tests of executive function and episodic memory. With few exceptions, associations of demographic variables and clinical diagnosis did not differ across racial/ethnic groups. The robust associations of cognitive test results with clinical diagnosis independent of core demographic variables and race/ethnicity support the validity of cognitive tests as indicators for brain health in diverse older adults.

Authors: Hernandez Saucedo, Hector; Whitmer, Rachel A; Glymour, Maria; DeCarli, Charles; Mayeda, Elizabeth-Rose; Gilsanz, Paola; Miles, Sunita Q; Bhulani, Nihal; Farias, Sarah Tomaszewski; Olichney, John; Mungas, Dan

J Gerontol B Psychol Sci Soc Sci. 2022 02 03;77(2):261-271.

PubMed abstract

Contributions of COVID-19 Pandemic-Related Stressors to Racial and Ethnic Disparities in Mental Health During Pregnancy

This study aimed to identify racial and ethnic disparities in prenatal mental health and identify COVID-19 pandemic-related health/healthcare and economic contributors to these disparities, using an established framework for disparity investigation. This cross-sectional study includes 10,930 pregnant people at Kaiser Permanente Northern California who completed an online survey between June 22, 2020 and April 28, 2021 on COVID-19 pandemic-related health/healthcare and economic stressors, depression, and anxiety. Self-reported race and ethnicity were extracted from electronic health records. Weighted analyses were used to evaluate the association between racial and ethnic category and prenatal depression and anxiety; the prevalence of each stressor by race and ethnicity; and the relationship between each stressor and prenatal depression and anxiety in each racial and ethnic category. The sample was 22% Asian, 3% Black, 20% Hispanic, 5% Other/Multiracial/Unknown, and 49% White. Compared to White people, Black and Hispanic people had a higher prevalence of prenatal depression (aPR: 1.85, 95% CI: 1.45, 2.35 and aPR: 1.17, 95% CI: 1.00, 1.37, respectively) and anxiety (aPR: 1.71, 95% CI: 1.34, 2.18 and aPR: 1.10, 95% CI: 0.94, 1.29, respectively). Compared to White people, Black and Hispanic people had a higher prevalence of moderate/severe distress due to changes in prenatal care (24 vs. 34 and 31%), and food insecurity (9 vs. 31 and 24%). Among Black and Hispanic people, distress due to changes in prenatal care was associated with a greater prevalence of prenatal depression (aPR: 2.27, 95% CI: 1.41, 3.64 and aPR: 2.76, 95% CI: 2.12, 3.58, respectively) and prenatal anxiety (aPR: 3.00, 95% CI: 1.85, 4.84 and aPR: 2.82, 95% CI: 2.15, 3.71, respectively). Additionally, among Hispanic people, high-risk employment and food insecurity were associated with a greater prevalence of prenatal depression and anxiety. This study identified racial and ethnic disparities in mental health for pregnant Black and Hispanic people. Distress due to prenatal care changes contributed to the observed disparities in prenatal depression and anxiety for Black and Hispanic people and food insecurity additionally contributed to the observed disparities for Hispanic people. Addressing distress due to changes to prenatal care and food insecurity specifically in Black and Hispanic people may help reduce the high burden of poor mental health and reduce observed disparities in these communities.

Authors: Avalos, Lyndsay A; Nance, Nerissa; Zhu, Yeyi; Croen, Lisa A; Young-Wolff, Kelly C; Zerbo, Ousseny; Hedderson, Monique M; Ferrara, Assiamira; Ames, Jennifer L; Badon, Sylvia E

Front Psychiatry. 2022;13:837659. Epub 2022-03-14.

PubMed abstract

Advancing Diversity, Equity, and Inclusion in Scientific Publishing

Authors: Doubeni, Chyke A; Corley, Douglas A; Peek, Richard M

Gastroenterology. 2022 01;162(1):59-62.e1. Epub 2021-11-03.

PubMed abstract

Regional and sociodemographic differences in average BMI among US children in the ECHO program

The aim of this study was to describe the association of individual-level characteristics (sex, race/ethnicity, birth weight, maternal education) with child BMI within each US Census region and variation in child BMI by region. This study used pooled data from 25 prospective cohort studies. Region of residence (Northeast, Midwest, South, West) was based on residential zip codes. Age- and sex-specific BMI z scores were the outcome. The final sample included 14,313 children with 85,428 BMI measurements, 49% female and 51% non-Hispanic White. Males had a lower average BMI z score compared with females in the Midwest (β = -0.12, 95% CI: -0.19 to -0.05) and West (β = -0.12, 95% CI: -0.20 to -0.04). Compared with non-Hispanic White children, BMI z score was generally higher among children who were Hispanic and Black but not across all regions. Compared with the Northeast, average BMI z score was significantly higher in the Midwest (β = 0.09, 95% CI: 0.05 to 0.14) and lower in the South (β = -0.12, 95% CI: -0.16 to -0.08) and West (β = -0.14, 95% CI: -0.19 to -0.09) after adjustment for age, sex, race/ethnicity, and birth weight. Region of residence was associated with child BMI z scores, even after adjustment for sociodemographic characteristics. Understanding regional influences can inform targeted efforts to mitigate BMI-related disparities among children.

Authors: Bekelman, Traci A; Ferrara, Assiamira; Program collaborators for Environmental influences on Child Health Outcomes (ECHO),; et al.

Obesity (Silver Spring). 2021 12;29(12):2089-2099. Epub 2021-08-31.

PubMed abstract

Racial and Ethnic Differences in Age at Diabetes Diagnosis-A Call for Action

Authors: Gopalan, Anjali; Habib, Anand R; Grant, Richard W

JAMA Intern Med. 2021 12 01;181(12):1560-1561.

PubMed abstract

Disparities in Risks of Inadequate and Excessive Intake of Micronutrients during Pregnancy

Inadequate or excessive intake of micronutrients in pregnancy has potential to negatively impact maternal/offspring health outcomes. The aim was to compare risks of inadequate or excessive micronutrient intake in diverse females with singleton pregnancies by strata of maternal age, race/ethnicity, education, and prepregnancy BMI. Fifteen observational cohorts in the US Environmental influences on Child Health Outcomes (ECHO) Consortium assessed participant dietary intake with 24-h dietary recalls (n = 1910) or food-frequency questionnaires (n = 7891) from 1999-2019. We compared the distributions of usual intake of 19 micronutrients from food alone (15 cohorts; n = 9801) and food plus dietary supplements (10 cohorts with supplement data; n = 7082) to estimate the proportion with usual daily intakes below their age-specific daily Estimated Average Requirement (EAR), above their Adequate Intake (AI), and above their Tolerable Upper Intake Level (UL), overall and within sociodemographic and anthropometric subgroups. Risk of inadequate intake from food alone ranged from 0% to 87%, depending on the micronutrient and assessment methodology. When dietary supplements were included, some women were below the EAR for vitamin D (20-38%), vitamin E (17-22%), and magnesium (39-41%); some women were above the AI for vitamin K (63-75%), choline (7%), and potassium (37-53%); and some were above the UL for folic acid (32-51%), iron (39-40%), and zinc (19-20%). Highest risks for inadequate intakes were observed among participants with age 14-18 y (6 nutrients), non-White race or Hispanic ethnicity (10 nutrients), less than a high school education (9 nutrients), or obesity (9 nutrients). Improved diet quality is needed for most pregnant females. Even with dietary supplement use, >20% of participants were at risk of inadequate intake of ≥1 micronutrients, especially in some population subgroups. Pregnancy may be a window of opportunity to address disparities in micronutrient intake that could contribute to intergenerational health inequalities.

Authors: Sauder, Katherine A; Avalos, Lyndsay A; Zhu, Yeyi; Breton, Carrie V; Program Collaborators for Environmental influences on Child Health Outcomes (ECHO),; et al.

J Nutr. 2021 11 02;151(11):3555-3569.

PubMed abstract

Disparities in Use of Video Telemedicine Among Patients With Limited English Proficiency During the COVID-19 Pandemic

Authors: Hsueh, Loretta; Huang, Jie; Millman, Andrea K; Gopalan, Anjali; Parikh, Rahul K; Teran, Silvia; Reed, Mary E

JAMA Netw Open. 2021 11 01;4(11):e2133129. Epub 2021-11-01.

PubMed abstract

Opportunities to Integrate Mobile App-Based Interventions Into Mental Health and Substance Use Disorder Treatment Services in the Wake of COVID-19

The COVID-19 pandemic has heightened concerns about the impact of depression, anxiety, alcohol, and drug use on public health. Mobile apps to address these problems were increasingly popular even before the pandemic, and may help reach people who otherwise have limited treatment access. In this review, we describe pandemic-related substance use and mental health problems, the growing evidence for mobile app efficacy, how health systems can integrate apps into patient care, and future research directions. If equity in access and effective implementation can be addressed, mobile apps are likely to play an important role in mental health and substance use disorder treatment.

Authors: Satre, Derek D; Meacham, Meredith C; Asarnow, Lauren D; Fisher, Weston S; Fortuna, Lisa R; Iturralde, Esti

Am J Health Promot. 2021 11;35(8):1178-1183. Epub 2021-10-15.

PubMed abstract

Attention-Deficit/Hyperactivity Disorder Medication Adherence in the Transition to Adulthood: Associated Adverse Outcomes for Females and Other Disparities

The purpose of this study was to assess the association between attention-deficit/hyperactivity disorder (ADHD) medication adherence and adverse health outcomes in older adolescents transitioning to adulthood. In a cohort of 17-year-old adolescents with ADHD at Kaiser Permanente Northern California, we assessed medication adherence (medication possession ratio ≥70%) and any medication use and associations with adverse outcomes at 18 and 19 years of age. We conducted bivariate tests of association and multivariable logistic regression models. Adherence declined from 17 to 19 years of age (36.7%-19.1%, p < .001). Non-white race/ethnicity, lower estimated income, and male sex were associated with nonadherence. Model results show nonadherent females experienced several adverse outcomes: Adherence at 18 years of age (referent: nonadherence) was associated with lower odds of pregnancy (adjusted odds ratio [AOR]: .13, 95% confidence interval [CI]: .03-.54). Any use (referent: nonuse) at 18 years of age was associated with lower odds of sexually transmitted infections among females (AOR: .39, 95% CI: .19-.83), pregnancies (AOR: .26, 95% CI: .13-.50), emergency department visits (AOR: .69, 95% CI: .55-.85), and greater odds of injuries (AOR: 1.16, 95% CI: 1.02-1.32). Adherence at 19 years of age was associated with lower odds of pregnancy (AOR: .13, 95% CI: .02-.95). Any use at 19 years of age was associated with lower odds of injury in females (AOR: .77, 95% CI: .60-.99) pregnancy (AOR: .35, 95% CI: .16-.78), and, in both sexes, substance use (AOR: .71, 95% CI: .55-.92). Late adolescence is associated with decline in ADHD medication use and adherence. ADHD medication adherence and any ADHD medication use is associated with fewer adverse health outcomes, particularly in females.

Authors: Rao, Kavitha; Carpenter, Diane M; Campbell, Cynthia I

J Adolesc Health. 2021 11;69(5):806-814. Epub 2021-05-28.

PubMed abstract

Cancer screening in the U.S. through the COVID-19 pandemic, recovery, and beyond

COVID-19 has proved enormously disruptive to the provision of cancer screening, which does not just represent an initial test but an entire process, including risk detection, diagnostic follow-up, and treatment. Successful delivery of services at all points in the process has been negatively affected by the pandemic. There is a void in empirical high-quality evidence to support a specific strategy for administering cancer screening during a pandemic and its resolution phase, but several pragmatic considerations can help guide prioritization efforts. Targeting guideline-eligible people who have never been screened, or those who are significantly out of date with screening, has the potential to maximize benefits now and into the future. Disruptions to care due to the pandemic could represent an unparalleled opportunity to reassess early detection programs towards an explicit, thoughtful, and just prioritization of populations historically experiencing cancer disparities. By focusing screening services on populations that have the most to gain, and by careful and deliberate planning for the period following the pandemic, we can positively affect cancer outcomes for all.

Authors: Croswell, Jennifer M; Corley, Douglas A; Lafata, Jennifer Elston; Haas, Jennifer S; Inadomi, John M; Kamineni, Aruna; Ritzwoller, Debra P; Vachani, Anil; Zheng, Yingye; National Cancer Institute Population-based Research to Optimize the Screening Process (PROSPR) II Consortium,

Prev Med. 2021 10;151:106595. Epub 2021-06-30.

PubMed abstract

Algorithmic prognostication in critical care: a promising but unproven technology for supporting difficult decisions

Patients, surrogate decision makers, and clinicians face weighty and urgent decisions under uncertainty in the ICU, which could be aided by risk prediction. Although emerging artificial intelligence/machine learning (AI/ML) algorithms could reduce uncertainty surrounding these life and death decisions, certain criteria must be met to ensure their bedside value. Although ICU severity of illness scores have existed for decades, these tools have not been shown to predict well or to improve outcomes for individual patients. Novel AI/ML tools offer the promise of personalized ICU care but remain untested in clinical trials. Ensuring that these predictive models account for heterogeneity in patient characteristics and treatments, are not only specific to a clinical action but also consider the longitudinal course of critical illness, and address patient-centered outcomes related to equity, transparency, and shared decision-making will increase the likelihood that these tools improve outcomes. Improved clarity around standards and contributions from institutions and critical care departments will be essential. Improved ICU prognostication, enabled by advanced ML/AI methods, offer a promising approach to inform difficult and urgent decisions under uncertainty. However, critical knowledge gaps around performance, equity, safety, and effectiveness must be filled and prospective, randomized testing of predictive interventions are still needed.

Authors: Weissman, Gary E; Liu, Vincent X

Curr Opin Crit Care. 2021 10 01;27(5):500-505.

PubMed abstract

Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System

Long-term follow-up is needed to evaluate gaps in HIV preexposure prophylaxis (PrEP) care delivery and to identify individuals at risk for falling out of care. To characterize the PrEP continuum of care, including prescription, initiation, discontinuation, and reinitiation, and evaluate incident HIV infections. This retrospective cohort study used data from the electronic health records (EHR) at Kaiser Permanente Northern California to identify individuals aged 18 years and older who received PrEP care between July 2012 and March 2019. Individuals were followed up from date of linkage (defined as a PrEP referral or PrEP-coded encounter) until March 2019, HIV diagnosis, discontinuation of health plan membership, or death. Data were analyzed from December 2019 to January 2021. Sociodemographic factors included age, sex, race and ethnicity, and neighborhood deprivation index, and clinical characteristics were extracted from the EHR. The primary outcomes were attrition at each step of the PrEP continuum of care and incident HIV infections. Among 13 906 individuals linked to PrEP care, the median (interquartile range [IQR]) age was 33 (27-43) years, 6771 individuals (48.7%) were White, and 13 227 (95.1%) were men. Total follow-up was 26 210 person-years (median [IQR], 1.6 [0.7-2.8] years). Of individuals linked to PrEP care, 88.1% (95% CI, 86.1%-89.9%) were prescribed PrEP and of these, 98.2% (95% CI, 97.2%-98.8%) initiated PrEP. After PrEP initiation, 52.2% (95% CI, 48.9%-55.7%) discontinued PrEP at least once during the study period, and 60.2% (95% CI, 52.2%-68.3%) of these individuals subsequently reinitiated. Compared with individuals aged 18 to 25 years, older individuals were more likely to receive a PrEP prescription (eg, age >45 years: hazard ratio [HR], 1.21 [95% CI, 1.14-1.29]) and initiate PrEP (eg, age >45 years: HR, 1.09 [95% CI, 1.02-1.16]) and less likely to discontinue (eg, age >45 years: HR, 0.46 [95% CI, 0.42-0.52]). Compared with White patients, African American and Latinx individuals were less likely to receive a PrEP prescription (African American: HR, 0.74 [95% CI, 0.69-0.81]; Latinx: HR, 0.88 [95% CI, 0.84-0.93]) and initiate PrEP (African American: HR, 0.87 [95% CI, 0.80-0.95]; Latinx: HR, 0.90 [95% CI, 0.86-0.95]) and more likely to discontinue (African American: HR, 1.36 [95% CI, 1.17-1.57]; Latinx: 1.33 [95% CI, 1.22-1.46]). Similarly, women, individuals with lower neighborhood-level socioeconomic status (SES), and persons with a substance use disorder (SUD) were less likely to be prescribed (women: HR, 0.56 [95% CI, 0.50-0.62]; lowest SES: HR, 0.72 [95% CI, 0.68-0.76]; SUD: HR, 0.88 [95% CI, 0.82-0.94]) and initiate PrEP (women: HR, 0.71 [95% CI, 0.64-0.80]; lower SES: HR, 0.93 [95% CI, 0.87-.0.99]; SUD: HR, 0.88 [95% CI, 0.81-0.95]) and more likely to discontinue (women: HR, 1.99 [95% CI, 1.67-2.38]); lower SES: HR, 1.40 [95% CI, 1.26-1.57]; SUD: HR, 1.23 [95% CI, 1.09-1.39]). HIV incidence was highest among individuals who discontinued PrEP and did not reinitiate PrEP (1.28 [95% CI, 0.93-1.76] infections per 100 person-years). These findings suggest that gaps in the PrEP care continuum were concentrated in populations disproportionately impacted by HIV, including African American individuals, Latinx individuals, young adults (aged 18-25 years), and individuals with SUD. Comprehensive strategies to improve PrEP continuum outcomes are needed to maximize PrEP impact and equity.

Authors: Hojilla, J Carlo; Hurley, Leo B; Marcus, Julia L; Silverberg, Michael J; Skarbinski, Jacek; Satre, Derek D; Volk, Jonathan E

JAMA Netw Open. 2021 08 02;4(8):e2122692. Epub 2021-08-02.

PubMed abstract

Sex Differences in Cardiovascular Outcomes in CKD: Findings From the CRIC Study

Cardiovascular events are less common in women than men in general populations; however, studies in chronic kidney disease (CKD) are less conclusive. We evaluated sex-related differences in cardiovascular events and death in adults with CKD. Prospective cohort study. 1,778 women and 2,161 men enrolled in the Chronic Renal Insufficiency Cohort (CRIC). Sex (women vs men). Atherosclerotic composite outcome (myocardial infarction, stroke, or peripheral artery disease), incident heart failure, cardiovascular death, and all-cause death. Cox proportional hazards regression. During a median follow-up period of 9.6 years, we observed 698 atherosclerotic events (women, 264; men, 434), 762 heart failure events (women, 331; men, 431), 435 cardiovascular deaths (women, 163; men, 274), and 1,158 deaths from any cause (women, 449; men, 709). In analyses adjusted for sociodemographic, clinical, and metabolic parameters, women had a lower risk of atherosclerotic events (HR, 0.71 [95% CI, 0.57-0.88]), heart failure (HR, 0.76 [95% CI, 0.62-0.93]), cardiovascular death (HR, 0.55 [95% CI, 0.42-0.72]), and death from any cause (HR, 0.58 [95% CI, 0.49-0.69]) compared with men. These associations remained statistically significant after adjusting for cardiac and inflammation biomarkers. Assessment of sex hormones, which may play a role in cardiovascular risk, was not included. In a large, diverse cohort of adults with CKD, compared with men, women had lower risks of cardiovascular events, cardiovascular mortality, and mortality from any cause. These differences were not explained by measured cardiovascular risk factors.

Authors: Toth-Manikowski, Stephanie M; Go, Alan S; Chronic Renal Insufficiency Cohort (CRIC) Study Investigators,; et al.

Am J Kidney Dis. 2021 08;78(2):200-209.e1. Epub 2021-04-20.

PubMed abstract

COVID-19 Vaccination Coverage Among Insured Persons Aged ≥16 Years, by Race/Ethnicity and Other Selected Characteristics – Eight Integrated Health Care Organizations, United States, December 14, 2020-May 15, 2021

COVID-19 vaccination is critical to ending the COVID-19 pandemic. Members of minority racial and ethnic groups have experienced disproportionate COVID-19-associated morbidity and mortality (1); however, COVID-19 vaccination coverage is lower in these groups (2). CDC used data from CDC’s Vaccine Safety Datalink (VSD)* to assess disparities in vaccination coverage among persons aged ≥16 years by race and ethnicity during December 14, 2020-May 15, 2021. Measures of coverage included receipt of ≥1 COVID-19 vaccine dose (i.e., receipt of the first dose of the Pfizer-BioNTech or Moderna COVID-19 vaccines or 1 dose of the Janssen COVID-19 vaccine [Johnson & Johnson]) and full vaccination (receipt of 2 doses of the Pfizer-BioNTech or Moderna COVID-19 vaccines or 1 dose of Janssen COVID-19 vaccine). Among 9.6 million persons aged ≥16 years enrolled in VSD during December 14, 2020-May 15, 2021, ≥1-dose coverage was 48.3%, and 38.3% were fully vaccinated. As of May 15, 2021, coverage with ≥1 dose was lower among non-Hispanic Black (Black) and Hispanic persons (40.7% and 41.1%, respectively) than it was among non-Hispanic White (White) persons (54.6%). Coverage was highest among non-Hispanic Asian (Asian) persons (57.4%). Coverage with ≥1 dose was higher among persons with certain medical conditions that place them at higher risk for severe COVID-19 (high-risk conditions) (63.8%) than it was among persons without such conditions (41.5%) and was higher among persons who had not had COVID-19 (48.8%) than it was among those who had (42.4%). Persons aged 18-24 years had the lowest ≥1-dose coverage (28.7%) among all age groups. Continued monitoring of vaccination coverage and efforts to improve equity in coverage are critical, especially among populations disproportionately affected by COVID-19.

Authors: Pingali, Cassandra; Klein, Nicola P; Fireman, Bruce; Zerbo, Ousseny; Patel, Suchita A; et al.

MMWR Morb Mortal Wkly Rep. 2021 Jul 16;70(28):985-990. Epub 2021-07-16.

PubMed abstract

Engagement in perinatal depression treatment: a qualitative study of barriers across and within racial/ethnic groups

To better understand previously observed racial/ethnic disparities in perinatal depression treatment rates we examined care engagement factors across and within race/ethnicity. Obstetric patients and women’s health clinician experts from a large healthcare system participated in this qualitative study. We conducted focus groups with 30 pregnant or postpartum women of Asian, Black, Latina, and White race/ethnicity with positive depression screens. Nine clinician experts in perinatal depression (obstetric, mental health, and primary care providers) were interviewed. A semi-structured format elicited treatment barriers, cultural factors, and helpful strategies. Discussion transcripts were coded using a general inductive approach with themes mapped to the Capability-Opportunity-Motivation-Behavior (COM-B) theoretical framework. Treatment barriers included social stigma, difficulties recognizing one’s own depression, low understanding of treatment options, and lack of time for treatment. Distinct factors emerged for non-White women including culturally specific messages discouraging treatment, low social support, trauma history, and difficulty taking time off from work for treatment. Clinician factors included knowledge and skill handling perinatal depression, cultural competencies, and language barriers. Participants recommended better integration of mental health treatment with obstetric care, greater treatment convenience (e.g., telemedicine), and programmatic attention to cultural factors and social determinants of health. Women from diverse backgrounds with perinatal depression encounter individual-level, social, and clinician-related barriers to treatment engagement, necessitating care strategies that reduce stigma, offer convenience, and attend to cultural and economic factors. Our findings suggest the importance of intervention and policy approaches effecting change at multiple levels to increase perinatal depression treatment engagement.

Authors: Iturralde, Esti; Hsiao, Crystal A; Nkemere, Linda; Kubo, Ai; Sterling, Stacy A; Flanagan, Tracy; Avalos, Lyndsay A

BMC Pregnancy Childbirth. 2021 Jul 16;21(1):512. Epub 2021-07-16.

PubMed abstract

Equitably Allocating Resources During Crises: Racial Differences in Mortality Prediction Models

Rationale: Crisis standards of care (CSCs) guide critical care resource allocation during crises. Most recommend ranking patients on the basis of their expected in-hospital mortality using the Sequential Organ Failure Assessment (SOFA) score, but it is unknown how SOFA or other acuity scores perform among patients of different races. Objectives: To test the prognostic accuracy of the SOFA score and version 2 of the Laboratory-based Acute Physiology Score (LAPS2) among Black and white patients. Methods: We included Black and white patients admitted for sepsis or acute respiratory failure at 27 hospitals. We calculated the discrimination and calibration for in-hospital mortality of SOFA, LAPS2, and modified versions of each, including categorical SOFA groups recommended in a popular CSC and a SOFA score without creatinine to reduce the influence of race. Measurements and Main Results: Of 113,158 patients, 27,644 (24.4%) identified as Black. The LAPS2 demonstrated higher discrimination (area under the receiver operating characteristic curve [AUC], 0.76; 95% confidence interval [CI], 0.76-0.77) than the SOFA score (AUC, 0.68; 95% CI, 0.68-0.69). The LAPS2 was also better calibrated than the SOFA score, but both underestimated in-hospital mortality for white patients and overestimated in-hospital mortality for Black patients. Thus, in a simulation using observed mortality, 81.6% of Black patients were included in lower-priority CSC categories, and 9.4% of all Black patients were erroneously excluded from receiving the highest prioritization. The SOFA score without creatinine reduced racial miscalibration. Conclusions: Using SOFA in CSCs may lead to racial disparities in resource allocation. More equitable mortality prediction scores are needed.

Authors: Ashana, Deepshikha Charan; Anesi, George L; Liu, Vincent X; Escobar, Gabriel J; Chesley, Christopher; Eneanya, Nwamaka D; Weissman, Gary E; Miller, William Dwight; Harhay, Michael O; Halpern, Scott D

Am J Respir Crit Care Med. 2021 07 15;204(2):178-186.

PubMed abstract

Operationalizing Social Environments in Cognitive Aging and Dementia Research: A Scoping Review

Social environments are a contributing determinant of health and disparities. This scoping review details how social environments have been operationalized in observational studies of cognitive aging and dementia. A systematic search in PubMed and Web of Science identified studies of social environment exposures and late-life cognition/dementia outcomes. Data were extracted on (1) study design; (2) population; (3) social environment(s); (4) cognitive outcome(s); (5) analytic approach; and (6) theorized causal pathways. Studies were organized using a 3-tiered social ecological model at interpersonal, community, or policy levels. Of 7802 non-duplicated articles, 123 studies met inclusion criteria. Eighty-four studies were longitudinal (range 1-28 years) and 16 examined time-varying social environments. When sorted into social ecological levels, 91 studies examined the interpersonal level; 37 examined the community/neighborhood level; 3 examined policy level social environments; and 7 studies examined more than one level. Most studies of social environments and cognitive aging and dementia examined interpersonal factors measured at a single point in time. Few assessed time-varying social environmental factors or considered multiple social ecological levels. Future studies can help clarify opportunities for intervention by delineating if, when, and how social environments shape late-life cognitive aging and dementia outcomes.

Authors: Peterson, Rachel L; George, Kristen M; Tran, Duyen; Malladi, Pallavi; Gilsanz, Paola; Kind, Amy J H; Whitmer, Rachel A; Besser, Lilah M; Meyer, Oanh L

Int J Environ Res Public Health. 2021 07 04;18(13). Epub 2021-07-04.

PubMed abstract

The Role of Community-Based Organizations in Improving Chronic Care for Safety-Net Populations

Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts. Varied qualitative inquiry methods – in-depth interviews, participant-led neighborhood tours, and clinic visit observations – involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco’s public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM). Several key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients’ self-management. Health service providers leveraged these resources to address patients’ social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated. The results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.

Authors: Nguyen, Kim Hanh; Fields, Jessica D; Cemballi, Anupama G; Desai, Riya; Gopalan, Anjali; Cruz, Tessa; Shah, Aekta; Akom, Antwi; Brown, William; Sarkar, Urmimala; Lyles, Courtney Rees

J Am Board Fam Med. 2021 Jul-Aug;34(4):698-708.

PubMed abstract

Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005-2015

To examine recent trends and differences in all-cause and cause-specific hospitalization rates by race, ethnicity, and gender among persons with HIV (PWH) in the United States and Canada. HIV clinical cohort consortium. We followed PWH at least 18 years old in care 2005-2015 in six clinical cohorts. We used modified Clinical Classifications Software to categorize hospital discharge diagnoses. Incidence rate ratios (IRR) were estimated using Poisson regression with robust variances to compare racial and ethnic groups, stratified by gender, adjusted for cohort, calendar year, injection drug use history, and annually updated age, CD4+, and HIV viral load. Among 27 085 patients (122 566 person-years), 80% were cisgender men, 1% transgender, 43% White, 33% Black, 17% Hispanic of any race, and 1% Indigenous. Unadjusted all-cause hospitalization rates were higher for Black [IRR 1.46, 95% confidence interval (CI) 1.32-1.61] and Indigenous (1.99, 1.44-2.74) versus White cisgender men, and for Indigenous versus White cisgender women (2.55, 1.68-3.89). Unadjusted AIDS-related hospitalization rates were also higher for Black, Hispanic, and Indigenous versus White cisgender men (all P < 0.05). Transgender patients had 1.50 times (1.05-2.14) and cisgender women 1.37 times (1.26-1.48) the unadjusted hospitalization rate of cisgender men. In adjusted analyses, among both cisgender men and women, Black patients had higher rates of cardiovascular and renal/genitourinary hospitalizations compared to Whites (all P < 0.05). Black, Hispanic, Indigenous, women, and transgender PWH in the United States and Canada experienced substantially higher hospitalization rates than White patients and cisgender men, respectively. Disparities likely have several causes, including differences in virologic suppression and chronic conditions such as diabetes and renal disease.

Authors: Davy-Mendez, Thibaut; Silverberg, Michael J; North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of IeDEA,; et al.

AIDS. 2021 07 01;35(8):1229-1239.

PubMed abstract

Mediation analysis of racial disparities in triple-negative breast cancer incidence among postmenopausal women

Triple-negative breast cancer (TNBC) is disproportionately higher in Black women relative to White women. The objective of this study was to examine to what extent the association between race/ethnicity and risk of TNBC is mediated by potentially modifiable factors. A total of 128,623 Black and White women aged 50-79 years from the Women’s Health Initiative were followed for a mean of 15.8 years. 643 incident TNBC cases (92 Black women and 551 White women) were confirmed by medical record review. Mediation analyses were conducted using an approach under a counterfactual framework. Black women had approximately twofold higher risk of TNBC compared with white women (HR = 1.93, 95% CI 1.52-2.45). We observed that 48% of the racial disparity was mediated by metabolic dysfunction defined by having 3 or more cardiometabolic risk factors including elevated waist circumference, having history of diabetes, high cholesterol and hypertension. The racial disparity was not significantly mediated by other factors studied, including socioeconomic, lifestyle or reproductive factors. Our study observed that approximately half of the racial disparity between postmenopausal Black and White women in TNBC incidence was driven by metabolic dysfunction.

Authors: Luo, Juhua; Kroenke, Candyce H; Wactawski-Wende, Jean; et al.

Breast Cancer Res Treat. 2021 Jul;188(1):283-293. Epub 2021-03-07.

PubMed abstract

Is Shelter-in-Place Policy Related to Mail Order Pharmacy Use and Racial/Ethnic Disparities for Patients With Diabetes?

Authors: Thomas, Tainayah W; Dyer, Wendy T; Yassin, Maher; Neugebauer, Romain; Karter, Andrew J; Schmittdiel, Julie A

Diabetes Care. 2021 06;44(6):e113-e114. Epub 2021-04-13.

PubMed abstract

Racial Disparities in COVID-19 Testing and Outcomes : Retrospective Cohort Study in an Integrated Health System

Racial disparities exist in outcomes after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. To evaluate the contribution of race/ethnicity in SARS-CoV-2 testing, infection, and outcomes. Retrospective cohort study (1 February 2020 to 31 May 2020). Integrated health care delivery system in Northern California. Adult health plan members. Age, sex, neighborhood deprivation index, comorbid conditions, acute physiology indices, and race/ethnicity; SARS-CoV-2 testing and incidence of positive test results; and hospitalization, illness severity, and mortality. Among 3 481 716 eligible members, 42.0% were White, 6.4% African American, 19.9% Hispanic, and 18.6% Asian; 13.0% were of other or unknown race. Of eligible members, 91 212 (2.6%) were tested for SARS-CoV-2 infection and 3686 had positive results (overall incidence, 105.9 per 100 000 persons; by racial group, White, 55.1; African American, 123.1; Hispanic, 219.6; Asian, 111.7; other/unknown, 79.3). African American persons had the highest unadjusted testing and mortality rates, White persons had the lowest testing rates, and those with other or unknown race had the lowest mortality rates. Compared with White persons, adjusted testing rates among non-White persons were marginally higher, but infection rates were significantly higher; adjusted odds ratios [aORs] for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 2.01 (95% CI, 1.75 to 2.31), 3.93 (CI, 3.59 to 4.30), 2.19 (CI, 1.98 to 2.42), and 1.57 (CI, 1.38 to 1.78), respectively. Geographic analyses showed that infections clustered in areas with higher proportions of non-White persons. Compared with White persons, adjusted hospitalization rates for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 1.47 (CI, 1.03 to 2.09), 1.42 (CI, 1.11 to 1.82), 1.47 (CI, 1.13 to 1.92), and 1.03 (CI, 0.72 to 1.46), respectively. Adjusted analyses showed no racial differences in inpatient mortality or total mortality during the study period. For testing, comorbid conditions made the greatest relative contribution to model explanatory power (77.9%); race only accounted for 8.1%. Likelihood of infection was largely due to race (80.3%). For other outcomes, age was most important; race only contributed 4.5% for hospitalization, 12.8% for admission illness severity, 2.3% for in-hospital death, and 0.4% for any death. The study involved an insured population in a highly integrated health system. Race was the most important predictor of SARS-CoV-2 infection. After infection, race was associated with increased hospitalization risk but not mortality. The Permanente Medical Group, Inc.

Authors: Escobar, Gabriel J; Adams, Alyce S; Liu, Vincent X; Soltesz, Lauren; Chen, Yi-Fen Irene; Parodi, Stephen M; Ray, G Thomas; Myers, Laura C; Ramaprasad, Charulata M; Dlott, Richard; Lee, Catherine

Ann Intern Med. 2021 06;174(6):786-793. Epub 2021-02-09.

PubMed abstract

Initiation and adherence to adjuvant endocrine therapy among urban, insured American Indian/Alaska Native breast cancer survivors

It has been shown that racial/ethnic disparities exist with regard to initiation of and adherence to adjuvant endocrine therapy (AET). However, the relationship among American Indian/Alaska Native (AIAN) individuals is poorly understood, particularly among those who reside in urban areas. We evaluated whether AET initiation and adherence were lower among AIAN individuals than those of other races/ethnicities who were enrolled in the Kaiser Permanente of Northern California (KPNC) health system. We identified 23,680 patients from the period 1997 to 2014 who were eligible for AET (first primary, stage I-III, hormone receptor-positive breast cancer) and used KPNC pharmacy records to identify AET prescriptions and refill dates. We assessed AET initiation (≥1 filled prescription within 1 year of diagnosis) and AET adherence (proportion of days covered ≥80%) every year up to 5 years after AET initiation. At the end of the 5-year follow-up period, 83% of patients were AET initiators, and 58% were AET adherent. Compared with other races/ethnicities, AIAN women had the second-lowest rate of AET initiation (non-Hispanic Black [NHB], 78.0%; AIAN, 78.6%; Hispanic, 83.0%; non-Hispanic White [NHW], 82.5%; Asian/Pacific Islander [API], 84.7%), the lowest rate of AET adherence after 1 year and 5 years of follow-up (70.3% and 50.8%, respectively), and the greatest annual decline in AET adherence during the 4- to 5-year period of follow-up (a 13.8% decrease in AET adherence [from 64.6% to 50.8%]) after initiation of AET. In adjusted multivariable models, AIAN, Hispanic, and NHB women were less likely than NHW women to be AET adherent. At the end of the 5-year period, total underutilization (combining initiation and adherence) in AET-eligible patients was greatest among AIAN (70.6%) patients, followed by NHB (69.6%), Hispanic (63.2%), NHW (58.7%), and API (52.3%) patients, underscoring the AET treatment gap. Our results suggest that AET initiation and adherence are particularly low for insured AIAN women.

Authors: Emerson, Marc A; Achacoso, Ninah S; Benefield, Halei C; Troester, Melissa A; Habel, Laurel A

Cancer. 2021 06 01;127(11):1847-1856. Epub 2021-02-23.

PubMed abstract

Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association

This statement summarizes evidence that adverse pregnancy outcomes (APOs) such as hypertensive disorders of pregnancy, preterm delivery, gestational diabetes, small-for-gestational-age delivery, placental abruption, and pregnancy loss increase a woman’s risk of developing cardiovascular disease (CVD) risk factors and of developing subsequent CVD (including fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, and heart failure). This statement highlights the importance of recognizing APOs when CVD risk is evaluated in women, although their value in reclassifying risk may not be established. A history of APOs is a prompt for more vigorous primordial prevention of CVD risk factors and primary prevention of CVD. Adopting a heart-healthy diet and increasing physical activity among women with APOs, starting in the postpartum setting and continuing across the life span, are important lifestyle interventions to decrease CVD risk. Lactation and breastfeeding may lower a woman’s later cardiometabolic risk. Black and Asian women experience a higher proportion APOs, with more severe clinical presentation and worse outcomes, than White women. More studies on APOs and CVD in non-White women are needed to better understand and address these health disparities. Future studies of aspirin, statins, and metformin may better inform our recommendations for pharmacotherapy in primary CVD prevention among women who have had an APO. Several opportunities exist for health care systems to improve transitions of care for women with APOs and to implement strategies to reduce their long-term CVD risk. One proposed strategy includes incorporation of the concept of a fourth trimester into clinical recommendations and health care policy.

Authors: Parikh, Nisha I; Gonzalez, Juan M; Anderson, Cheryl A M; Judd, Suzanne E; Rexrode, Kathryn M; Hlatky, Mark A; Gunderson, Erica P; Stuart, Jennifer J; Vaidya, Dhananjay; American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and the Stroke Council,

Circulation. 2021 05 04;143(18):e902-e916. Epub 2021-03-29.

PubMed abstract

Evaluation of sex differences in preschool children with and without autism spectrum disorder enrolled in the study to explore early development

Research in school-aged children, adolescents, and adults with autism spectrum disorder (ASD) has found sex-based differences in behavioral, developmental, and diagnostic outcomes. These findings have not been consistently replicated in preschool-aged children. We examined sex-based differences in a large sample of 2-5-year-old children with ASD symptoms in a multi-site community-based study. Based on a comprehensive evaluation, children were classified as having ASD (n = 1480, 81.55 % male) or subthreshold ASD characteristics (n = 593, 70.15 % male). Outcomes were behavior problems, developmental abilities, performance on ASD screening and diagnostic tests, and parent-reported developmental conditions diagnosed before study enrollment. We found no statistically significant sex differences in behavioral functioning, developmental functioning, performance on an ASD screening test, and developmental conditions diagnosed before study enrollment among children with ASD or subthreshold ASD characteristics. Males in both study groups had more parent reported restricted interests and repetitive behaviors than females, but these differences were small in magnitude and not clinically meaningful. Preschool males and females who showed risk for ASD were more similar than different in the outcomes assessed in our study. Future research could examine sex-based differences in ASD phenotypes as children age.

Authors: Wiggins, Lisa D; Croen, Lisa; Schieve, Laura; et al.

Res Dev Disabil. 2021 May;112:103897. Epub 2021-02-17.

PubMed abstract

Influence of patient immigrant status on physician trainee diabetes treatment decisions: a virtual patient experimental study

To determine the effect of patient immigrant status on physician trainees’ diabetes treatment decisions. Participants were 140 physician trainees (‘providers’). Providers viewed videos and vignettes of virtual patients differing in immigrant status (born in Mexico or U.S.; other characteristics held constant). Analyses were completed at the group and individual levels. Providers were less likely to refer foreign-born (vs. U.S.-born) patients to endocrinology. Individual-level results showed an almost even split between treatment ratings for foreign-born vs. U.S.-born patients for three decisions (take no action, add oral hypoglycemic agent, add/switch to insulin), explaining why group-level differences for these ratings did not emerge (i.e., they were cancelled out). Physician trainees are less likely to refer foreign-born patients to endocrinology. Half of individual-level decisions were influenced by patient immigrant status, but group-level analyses mask these differences. Systematic treatment differences based on non-relevant factors could lead to adverse outcomes for immigrants.

Authors: Hsueh L; Hirsh AT; Zapolski T; de Groot M; Mather KJ; Stewart JC

J Behav Med. 2021 Apr 16.

PubMed abstract

Improving adherence to guideline-directed medical therapies and outcomes in the developing world: A call to end global inequities in heart failure

Authors: Chioncel, Ovidiu; Ambrosy, Andrew P

Int J Cardiol. 2021 04 15;329:74-76. Epub 2020-12-02.

PubMed abstract

Racial/Ethnic Disparities in Young Adulthood and Midlife Cardiovascular Risk Factors and Late-life Cognitive Domains: The Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) Study

Midlife cardiovascular risk factors (CVRF) increase dementia risk. Less is known about whether CVRF identified before midlife impact late-life cognition in diverse populations. Linear regression models examined hypertension, hyperlipidemia, and overweight/obesity at ages 30 to 59 with late-life executive function, semantic memory, verbal episodic memory, and global cognition in a cohort of Asians, blacks, Latinos, and whites (n=1127; mean age=75.8, range=65 to 98). Models adjusted for age at CVRF, age at cognitive assessment, sex, race/ethnicity, participant education, and parental education. Overall, 34% had 1 CVRF at ages 30 to 59; 19% had 2+. Blacks (26%) and Latinos (23%) were more likely to have 2+ CVRF than Asians (14%) or whites (13%). Having 2+ CVRF was associated with lower global cognition [β=-0.33; 95% confidence interval (CI)=-0.45, -0.21], executive function (β=-0.26; 95% CI=-0.39, -0.13), verbal episodic memory (β=-0.34; 95% CI=-0.48, -0.20), and semantic memory (β=-0.20; 95% CI=-0.33, -0.07). Interaction by age (P=0.06) indicated overweight/obesity was negatively associated with executive function at ages 30 to 39 but not at ages 40 to 59. Race/ethnic-specific effects showed disparities in CVRF prevalence impact population disparities in late-life cognition. Being overweight/obese in early adulthood and having 2+ CVRF in early adulthood/midlife are modifiable targets to redress racial/ethnic disparities in cognitive impairment and dementia.

Authors: Peterson, Rachel L; George, Kristen M; Gilsanz, Paola; Ackley, Sarah; Mayeda, Elizabeth R; Glymour, M M; Mungas, Dan M; DeCarli, Charles; Whitmer, Rachel A

Alzheimer Dis Assoc Disord. 2021 Apr-Jun 01;35(2):99-105.

PubMed abstract

Age-Related Development of Cardiac Remodeling and Dysfunction in Young Black and White Adults: the Coronary Artery Risk Development in Young Adults Study

Little is known about the timing of preclinical heart failure (HF) development, particularly among blacks. The primary aims of this study were to delineate age-related left ventricular (LV) structure and function evolution in a biracial cohort and to test the hypothesis that young-adult LV parameters within normative ranges would be associated with incident stage B-defining LV abnormalities over 25 years, independent of cumulative risk factor burden. Data from the Coronary Artery Risk Development in Young Adults study were analyzed. Participants (n = 2,833) had a mean baseline age of 30.1 years; 45% were black, and 56% were women. Generalized estimating equation logistic regression was used to estimate age-related probabilities of stage B LV abnormalities (remodeling, hypertrophy, or dysfunction) and logistic regression to examine risk factor-adjusted associations between baseline LV parameters and incident abnormalities. Cox regression was used to assess whether baseline LV parameters associated with incident stage B LV abnormalities were also associated with incident clinical (stage C/D) HF events over >25 years’ follow-up. Probabilities of stage B LV abnormalities at ages 25 and 60 years were 10.5% (95% CI, 9.4%-11.8%) and 45.0% (95% CI, 42.0%-48.1%), with significant race-sex disparities (e.g., at age 60, black men 52.7% [95% CI, 44.9%-60.3%], black women 59.4% [95% CI, 53.6%-65.0%], white men 39.1% [95% CI, 33.4%-45.0%], and white women 39.1% [95% CI, 33.9%-44.6%]). Over 25 years, baseline LV end-systolic dimension indexed to height was associated with incident systolic dysfunction (adjusted odds ratio per 1 SD higher, 2.56; 95% CI, 1.87-3.52), eccentric hypertrophy (1.34; 95% CI, 1.02-1.75), concentric hypertrophy (0.69; 95% CI, 0.51-0.91), and concentric remodeling (0.68; 95% CI, 0.58-0.79); baseline LV mass indexed to height2.7 was associated with incident eccentric hypertrophy (1.70; 95% CI, 1.25-2.32]), concentric hypertrophy (1.63; 95% CI, 1.19-2.24), and diastolic dysfunction (1.24; 95% CI, 1.01-1.52). Among the entire cohort with baseline echocardiographic data available (n = 4,097; 72 HF events), LV end-systolic dimension indexed to height and LV mass indexed to height2.7 were significantly associated with incident clinical HF (adjusted hazard ratios per 1 SD higher, 1.56 [95% CI, 1.26-1.93] and 1.42 [95% CI, 1.14-1.75], respectively). Stage B LV abnormalities and related racial disparities were present in young adulthood, increased with age, and were associated with baseline variation in indexed LV end-systolic dimension and mass. Baseline indexed LV end-systolic dimension and mass were also associated with incident clinical HF. Efforts to prevent the LV abnormalities underlying clinical HF should start from a young age.

Authors: Perak, Amanda M; Khan, Sadiya S; Colangelo, Laura A; Gidding, Samuel S; Armstrong, Anderson C; Lewis, Cora E; Reis, Jared P; Schreiner, Pamela J; Sidney, Stephen; Lima, Joao A C; Lloyd-Jones, Donald M

J Am Soc Echocardiogr. 2021 04;34(4):388-400. Epub 2020-11-17.

PubMed abstract

Do the Benefits of Educational Attainment for Late-life Cognition Differ by Racial/Ethnic Group?: Evidence for Heterogenous Treatment Effects in the Kaiser Healthy Aging and Diverse Life Experience (KHANDLE) Study

Educational attainment is associated with late-life cognitive performance and dementia; few studies have examined diverse racial/ethnic groups to assess whether the association differs by race/ethnicity. We investigated whether the association between educational attainment and cognition differed between White, Black, Asian, and Latino participants in the Kaiser Healthy Aging and Diverse Life Experiences study (n=1348). Covariate-adjusted multivariable linear regression models examined domains of verbal episodic memory, semantic memory, and executive functioning. We observed significant effect heterogeneity by race/ethnicity only for verbal episodic memory (P=0.0198), for which any schooling between high school and college was beneficial for White, Asian, and Black participants, but not Latino participants. We found no evidence of heterogeneity for semantic memory or executive function. With the exception of Latino performance on verbal episodic memory, more education consistently predicted better cognitive scores to a similar extent across racial/ethnic groups, despite likely heterogenous educational and social experiences.

Authors: Eng, Chloe W; Glymour, Medellena Maria; Gilsanz, Paola; Mungas, Dan M; Mayeda, Elizabeth R; Meyer, Oanh L; Whitmer, Rachel A

Alzheimer Dis Assoc Disord. 2021 Apr-Jun 01;35(2):106-113.

PubMed abstract

Disparities in Preventable Mortality from Colorectal Cancer: are they the result of structural racism?

Authors: Doubeni, Chyke A; Selby, Kevin; Levin, Theodore R

Gastroenterology. 2021 03;160(4):1022-1025. Epub 2021-01-05.

PubMed abstract

Racial/ethnic disparities in survival after breast cancer diagnosis by estrogen and progesterone receptor status: A pooled analysis

Limited studies have investigated racial/ethnic survival disparities for breast cancer defined by estrogen receptor (ER) and progesterone receptor (PR) status in a multiethnic population. Using multivariable Cox proportional hazards models, we assessed associations of race/ethnicity with ER/PR-specific breast cancer mortality in 10,366 California women diagnosed with breast cancer from 1993 to 2009. We evaluated joint associations of race/ethnicity, health care, sociodemographic, and lifestyle factors with mortality. Among women with ER/PR+ breast cancer, breast cancer-specific mortality was similar among Hispanic and Asian American women, but higher among African American women [HR, 1.31; 95% confidence interval (CI), 1.05-1.63] compared with non-Hispanic White (NHW) women. Breast cancer-specific mortality was modified by surgery type, hospital type, education, neighborhood socioeconomic status (SES), smoking history, and alcohol consumption. Among African American women, breast cancer-specific mortality was higher among those treated at nonaccredited hospitals (HR, 1.57; 95% CI, 1.21-2.04) and those from lower SES neighborhoods (HR, 1.48; 95% CI, 1.16-1.88) compared with NHW women without these characteristics. Breast cancer-specific mortality was higher among African American women with at least some college education (HR, 1.42; 95% CI, 1.11-1.82) compared with NHW women with similar education. For ER-/PR- disease, breast cancer-specific mortality did not differ by race/ethnicity and associations of race/ethnicity with breast cancer-specific mortality varied only by neighborhood SES among African American women. Racial/ethnic survival disparities are more striking for ER/PR+ than ER-/PR- breast cancer. Social determinants and lifestyle factors may explain some of the survival disparities for ER/PR+ breast cancer. Addressing these factors may help reduce the higher mortality of African American women with ER/PR+ breast cancer.

Authors: John, Esther M; Kwan, Marilyn L; Wu, Anna H; et al.

Cancer Epidemiol Biomarkers Prev. 2021 02;30(2):351-363. Epub 2020-12-18.

PubMed abstract

Urban-Rural Disparities and Temporal Trends in Peptic Ulcer Disease Epidemiology, Treatment, and Outcomes in the United States

The incidence of peptic ulcer disease (PUD) has been decreasing over time with Helicobacter pylori eradication and use of acid-suppressing therapies. However, PUD remains a common cause of hospitalization in the United States. We aimed to evaluate contemporary national trends in the incidence, treatment patterns, and outcomes for PUD-related hospitalizations and compare care delivery by hospital rurality. Data from the National Inpatient Sample were used to estimate weighted annual rates of PUD-related hospitalizations. Temporal trends were evaluated by joinpoint regression and expressed as annual percent change with 95% confidence intervals (CIs). We determined the proportion of hospitalizations requiring endoscopic and surgical interventions, stratified by clinical presentation and rurality. Multivariable logistic regression was used to assess independent predictors of in-hospital mortality and postoperative morbidity. There was a 25.8% reduction (P < 0.001) in PUD-related hospitalizations from 2005 to 2014, although the rate of decline decreased from -7.2% per year (95% CI: 13.2% to -0.7%) before 2008 to -2.1% per year (95% CI: 3.0% to -1.1%) after 2008. In-hospital mortality was 2.4% (95% CI: 2.4%-2.5%). Upper endoscopy (84.3% vs 78.4%, P < 0.001) and endoscopic hemostasis (26.1% vs 16.8%, P < 0.001) were more likely to be performed in urban hospitals, whereas surgery was performed less frequently (9.7% vs 10.5%, P < 0.001). In multivariable logistic regression, patients managed in urban hospitals were at higher risk for postoperative morbidity (odds ratio 1.16 [95% CI: 1.04-1.29]), but not death (odds ratio 1.11 [95% CI: 1.00-1.23]). The rate of decline in hospitalization rates for PUD has stabilized over time, although there remains significant heterogeneity in treatment patterns by hospital rurality.

Authors: Guo, Howard; Ma, Christopher; Ma, Christopher; et al.

Am J Gastroenterol. 2021 02 01;116(2):296-305.

PubMed abstract

COVID-19 prevalence, symptoms, and sociodemographic disparities in infection among insured pregnant women in Northern California

Research on COVID-19 during pregnancy has mainly focused on women hospitalized for COVID-19 or other reasons during their pregnancy. Little is known about COVID-19 in the general population of pregnant women. To describe the prevalence of COVID-19, symptoms, consequent healthcare use, and possible sources of COVID-19 exposure among a population-based sample of pregnant women residing in Northern California. We analyzed data from 19,458 members of Kaiser Permanente Northern California who were pregnant between January 2020 and April 2021 and responded to an online survey about COVID-19 testing, diagnosis, symptoms, and their experiences during the COVID-19 pandemic. Medical diagnosis of COVID-19 during pregnancy was defined separately by self-report and by documentation in electronic health records (EHR). We examined relationships of COVID-19 with sociodemographic factors, underlying comorbidities, and survey measures of COVID-19-like symptoms, consequent healthcare utilization, and possible COVID-19 exposures. Among 19,458 respondents, the crude prevalence of COVID-19 was 2.5% (n = 494) according to self-report and 1.4% (n = 276) according to EHR. After adjustment, the prevalence of self-reported COVID-19 was higher among women aged <25 years compared with women aged ≥35 years (prevalence ratio [PR], 1.75, 95% CI: 1.23, 2.49) and among Hispanic women compared with White women (PR, 1.91, 95% CI: 1.53, 2.37). Prevalence of self-reported COVID-19 was higher among women affected by personal or partner job loss during the pandemic (PR, 1.23, 95% CI: 1.02, 1.47) and among women living in areas of high vs. low neighborhood deprivation (PR, 1.74, 95% CI: 1.33, 2.27). We did not observe differences in self-reported COVID-19 between women with and without underlying comorbidities. Results were similar for EHR-documented COVID-19. Loss of smell or taste was a unique and common symptom reported among women with COVID-19 (42.3% in self-reported; 54.0% in EHR-documented). Among women with symptomatic COVID-19, approximately 2% were hospitalized, 71% had a telehealth visit, and 75% quarantined at home. Over a third of women with COVID-19 reported no known exposure to someone with COVID-19. Observed COVID-19 prevalence differences by sociodemographic and socioeconomic factors underscore social and health inequities among reproductive-aged women. Women with COVID-19 reported unique symptoms and low frequency of hospitalization. Many were not aware of an exposure to someone with COVID-19.

Authors: Ames, Jennifer L; Ferrara, Assiamira; Avalos, Lyndsay A; Badon, Sylvia E; Greenberg, Mara B; Hedderson, Monique M; Kuzniewicz, Michael W; Young-Wolff, Kelly C; Zerbo, Ousseny; Zhu, Yeyi; Croen, Lisa A; et al.

PLoS One. 2021;16(9):e0256891. Epub 2021-09-03.

PubMed abstract

Trans-ancestry genome-wide association meta-analysis of prostate cancer identifies new susceptibility loci and informs genetic risk prediction

Prostate cancer is a highly heritable disease with large disparities in incidence rates across ancestry populations. We conducted a multiancestry meta-analysis of prostate cancer genome-wide association studies (107,247 cases and 127,006 controls) and identified 86 new genetic risk variants independently associated with prostate cancer risk, bringing the total to 269 known risk variants. The top genetic risk score (GRS) decile was associated with odds ratios that ranged from 5.06 (95% confidence interval (CI), 4.84-5.29) for men of European ancestry to 3.74 (95% CI, 3.36-4.17) for men of African ancestry. Men of African ancestry were estimated to have a mean GRS that was 2.18-times higher (95% CI, 2.14-2.22), and men of East Asian ancestry 0.73-times lower (95% CI, 0.71-0.76), than men of European ancestry. These findings support the role of germline variation contributing to population differences in prostate cancer risk, with the GRS offering an approach for personalized risk prediction.

Authors: Conti, David V; Van Den Eeden, Stephen K; Haiman, Christopher A; et al.

Nat Genet. 2021 01;53(1):65-75. Epub 2021-01-04.

PubMed abstract

Community Health Behaviors and Geographic Variation in Early-Onset Colorectal Cancer Survival Among Women

Despite overall reductions in colorectal cancer (CRC) morbidity and mortality, survival disparities by sex persist among young patients (age <50 years). Our study sought to quantify variance in early-onset CRC survival accounted for by individual/community-level characteristics among a population-based cohort of US women. Geographic hot spots-counties with high early-onset CRC mortality rates among women-were derived using 3 geospatial autocorrelation approaches with Centers for Disease Control and Prevention national mortality data. We identified women (age: 15-49 years) diagnosed with CRC from 1999 to 2016 in the National Institutes of Health/National Cancer Institute's Surveillance, Epidemiology, and End Results program. Patterns of community health behaviors by hot spot classification were assessed by Spearman correlation (ρ). Generalized R values were used to evaluate variance in survival attributed to individual/community-level features. Approximately 1 in every 16 contiguous US counties identified as hot spots (191 of 3,108), and 52.9% of hot spot counties (n = 101) were located in the South. Among 28,790 women with early-onset CRC, 13.7% of cases (n = 3,954) resided in hot spot counties. Physical inactivity and fertility were community health behaviors that modestly correlated with hot spot residence among women with early-onset CRC (ρ = 0.21 and ρ = -0.23, respectively; P < 0.01). Together, individual/community-level features accounted for distinct variance patterns in early-onset CRC survival among women (hot spot counties: 33.8%; non-hot spot counties: 34.1%). Individual/community-level features accounted for approximately one-third of variation in early-onset CRC survival among women and differed between hot spot vs non-hot spot counties. Understanding the impact of community health behaviors-particularly in regions with high early-onset CRC mortality rates-is critical for tailoring strategies to reduce early-onset CRC disparities.

Authors: Holowatyj AN; Langston ME; Han Y; Viskochil R; Perea J; Cao Y; Rogers CR; Lieu CH; Moore JX

Clin Transl Gastroenterol. 2020 Dec;11(12):e00266.

PubMed abstract

Impact of nulliparity, hypertensive disorders of pregnancy, and gestational diabetes on vasomotor symptoms in midlife women

To determine whether women with a history of nulliparity, hypertensive disorders of pregnancy (HDP), or gestational diabetes mellitus (GDM) have a higher odds of reporting vasomotor symptoms (VMS) at midlife. A longitudinal analysis was performed with 2,249 women with pregnancy history data in the Study of Women’s Health Across the Nation. Women were classified as nulliparous, no HDP/GDM, or a history of HDP/GDM. VMS (hot flashes, night sweats) were assessed separately at baseline and at each follow-up visit. VMS was recorded as any versus none; 0 , 1-5 , 6+ days in past 2 weeks. Pregnancy history was examined in relation to each VMS (hot flashes, night sweats) using generalized estimating equations adjusting for age (time-varying), site, race/ethnicity, education, financial strain, smoking, and body mass index. Models excluded women with hysterectomy/bilateral oophorectomy and observations with hormone therapy use. Women in the HDP/GDM group (n = 208, 9%) were more likely to be Black, financially strained, and overweight. Compared to women with no HDP/GDM, women with HDP/GDM had greater odds of reporting any hot flashes (OR:1.27; 95% CI:1.05-1.53). Nulliparous women had lower odds of any hot flashes (OR:0.64; 95% CI:0.51-0.80) and night sweats (OR:0.73; 95% CI:0.58-0.93) in age-adjusted models. Similar patterns were observed for frequency of hot flashes and night sweats; associations were attenuated to nonsignificance after adjusting for covariates. History of HDP/GDM may be associated with more VMS and nulliparity with fewer VMS, but not independently of sociodemographic factors. Our findings underscore the importance of social and economic disparities in both reproductive outcomes and VMS. VIDEO SUMMARY::

Authors: Cortés, Yamnia I; Conant, Rhoda; Catov, Janet M; Matthews, Karen A; Crawford, Sybil L; Hedderson, Monique M; Thurston, Rebecca C

Menopause. 2020 12;27(12):1363-1370.

PubMed abstract

Health care utilization and HIV clinical outcomes among newly enrolled patients following Affordable Care Act implementation in a California integrated health system: a longitudinal study

The Affordable Care Act (ACA) has increased insurance coverage for people with HIV (PWH) in the United States. To inform health policy, it is useful to investigate how enrollment through ACA Exchanges, deductible levels, and demographic factors are associated with health care utilization and HIV clinical outcomes among individuals newly enrolled in insurance coverage following implementation of the ACA. Among PWH newly enrolled in an integrated health care system (Kaiser Permanente Northern California) in 2014 (N = 880), we examined use of health care and modeled associations between enrollment mechanisms (enrolled in a Qualified Health Plan through the California Exchange vs. other sources), deductibles (none, $1-$999 and > = $1000), receipt of benefits from the California AIDS Drug Assistance Program (ADAP), demographic factors, and three-year patterns of health service utilization (primary care, psychiatry, substance treatment, emergency, inpatient) and HIV outcomes (CD4 counts; viral suppression at HIV RNA < 75 copies/mL). Health care use was greatest immediately after enrollment and decreased over 3 years. Those with high deductibles were less likely to use primary care (OR = 0.64, 95% CI = 0.49-0.84, p < 0.01) or psychiatry OR = 0.59, 95% CI = 0.37, 0.94, p = 0.03) than those with no deductible. Enrollment via the Exchange was associated with fewer psychiatry visits (rate ratio [RR] = 0.40, 95% CI = 0.18-0.86; p = 0.02), but ADAP was associated with more psychiatry visits (RR = 2.22, 95% CI = 1.24-4.71; p = 0.01). Those with high deductibles were less likely to have viral suppression (OR = 0.65, 95% CI = 0.42-1.00; p = 0.05), but ADAP enrollment was associated with viral suppression (OR = 2.20, 95% CI = 1.32-3.66, p < 0.01). Black (OR = 0.35, 95% CI = 0.21-0.58, p < 0.01) and Hispanic (OR = 0.50, 95% CI = 0.29-0.85, p = 0.01) PWH were less likely to be virally suppressed. In this sample of PWH newly enrolled in an integrated health care system in California, findings suggest that enrollment via the Exchange and higher deductibles were negatively associated with some aspects of service utilization, high deductibles were associated with worse HIV outcomes, but support from ADAP appeared to help patients achieve viral suppression. Race/ethnic disparities remain important to address even among those with access to insurance coverage.

Authors: Satre, Derek D; Parthasarathy, Sujaya; Silverberg, Michael J; Horberg, Michael; Young-Wolff, Kelly C; Williams, Emily C; Volberding, Paul; Campbell, Cynthia I

BMC Health Serv Res. 2020 Nov 11;20(1):1030. Epub 2020-11-11.

PubMed abstract

Interventions Targeting Racial/Ethnic Disparities in Stroke Prevention and Treatment

Systemic racism is a public health crisis. Systemic racism and racial/ethnic injustice produce racial/ethnic disparities in health care and health. Substantial racial/ethnic disparities in stroke care and health exist and result predominantly from unequal treatment. This special report aims to summarize selected interventions to reduce racial/ethnic disparities in stroke prevention and treatment. It reviews the social determinants of health and the determinants of racial/ethnic disparities in care. It provides a focused summary of selected interventions aimed at reducing stroke risk factors, increasing awareness of stroke symptoms, and improving access to care for stroke because these interventions hold the promise of reducing racial/ethnic disparities in stroke death rates. It also discusses knowledge gaps and future directions.

Authors: Levine, Deborah A; Duncan, Pamela W; Nguyen-Huynh, Mai N; Ogedegbe, Olugbenga G

Stroke. 2020 11;51(11):3425-3432. Epub 2020-10-26.

PubMed abstract

Long-term follow-up of a racially and ethnically diverse population of men with localized prostate cancer who did not undergo initial active treatment

There is limited research on the racial/ethnic differences in long-term outcomes for men with untreated, localized prostate cancer. Men diagnosed with localized, Gleason ≤7 prostate cancer who were not treated within 1 year of diagnosis from 1997-2007 were identified. Cumulative incidence rates of the following events were calculated; treatment initiation, metastasis, death due to prostate cancer and all-cause mortality, accounting for competing risks. The Cox model of all-cause mortality and Fine-Gray sub distribution model to account for competing risks were used to test for racial/ethnic differences in outcomes adjusted for clinical factors. There were 3925 men in the study, 749 Hispanic, 2415 non-Hispanic white, 559 non-Hispanic African American, and 202 non-Hispanic Asian/Pacific Islander (API). Median follow-up was 9.3 years. At 19 years, overall cumulative incidence of treatment, metastasis, death due to prostate cancer, and all-cause mortality was 25.0%, 14.7%, 11.7%, and 67.8%, respectively. In adjusted models compared to non-Hispanic whites, African Americans had higher rates of treatment (HR = 1.39, 95% CI = 1.15-1.68); they had an increased risk of metastasis beyond 10 years after diagnosis (HR = 4.70, 95% CI = 2.30-9.61); API and Hispanic had lower rates of all-cause mortality (HR = 0.66, 95% CI = 0.52-0.84, and HR = 0.72, 95% CI = 0.62-0.85, respectively), and API had lower rates of prostate cancer mortality in the first 10 years after diagnosis (HR = 0.29, 95% CI = 0.09-0.90) and elevated risks beyond 10 years (HR = 5.41, 95% CI = 1.39-21.11). Significant risks of metastasis and prostate cancer mortality exist in untreated men beyond 10 years after diagnosis, but are not equally distributed among racial/ethnic groups.

Authors: Slezak, Jeff M; Van Den Eeden, Stephen K; Cannavale, Kimberly L; Chien, Gary W; Jacobsen, Steven J; Chao, Chun R

Cancer Med. 2020 11;9(22):8530-8539. Epub 2020-09-23.

PubMed abstract

Understanding Racial/Ethnic Disparities in Physical Performance in Mid-Life Women: Findings from SWAN (Study of Women’s Health Across the Nation)

Evaluate degree to which racial/ethnic differences in physical performance are mediated by sociodemographic, health, behavioral, and psychosocial factors. Physical performance was evaluated using a decile score derived from grip strength, timed 4 m walk, and timed repeat chair stand in 1,855 African American, Caucasian, Chinese, Hispanic, and Japanese women, mean age = 61.8 (SD = 2.7) in the Study of Women’s Health Across the Nation. Mediators included education, financial strain, comorbidities, pain, body mass index (BMI), physical activity, and perceived stress. Structural equation models provided estimates of the total difference in physical performance between Caucasians and each race/ethnic groups and differences due to direct effects of race/ethnicity and indirect effects through mediators. The mean decile score for Caucasian women was 16.9 (SD = 5.6), 1.8, 2.6, and 2.1 points higher than the model-estimated scores in African Americans, Hispanics and Chinese, respectively, and 1.3 points lower than the Japanese. Differences between Caucasians and the Chinese and Japanese were direct effects of race/ethnicity whereas in African Americans and Hispanics 75% or more of that disparity was through mediators, particularly education, financial strain, BMI, physical activity, and pain. Addressing issues of poverty, racial inequality, pain, and obesity could reduce some racial/ethnic disparity in functional limitations as women age.

Authors: Sternfeld B; Colvin A; Stewart A; Appelhans BM; Cauley JA; Dugan SA; El Khoudary SR; Greendale GA; Strotmeyer E; Karvonen-Gutierrez C

J Gerontol B Psychol Sci Soc Sci. 2020 10 16;75(9):1961-1971.

PubMed abstract

Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement

Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.

Authors: Rivera, M Patricia; Sakoda, Lori C; Aldrich, Melinda C; et al.

Am J Respir Crit Care Med. 2020 10 01;202(7):e95-e112.

PubMed abstract

Body mass index versus bioelectrical impedance analysis for classifying physical function impairment in a racially diverse cohort of midlife women: the Study of Women’s Health Across the Nation (SWAN)

Body composition strongly influences physical function in older adults. Bioelectrical impedance analysis (BIA) differentiates fat mass from skeletal muscle mass, and may be more useful than body mass index (BMI) for classifying women on their likelihood of physical function impairment. This study tested whether BIA-derived estimates of percentage body fat (%BF) and height-normalized skeletal muscle mass (skeletal muscle mass index; SMI) enhance classification of physical function impairment relative to BMI. Black, White, Chinese, and Japanese midlife women (N = 1482) in the Study of Women’s Health Across the Nation (SWAN) completed performance-based measures of physical function. BMI (kg/m2) was calculated. %BF and SMI were derived through BIA. Receiver-operating characteristic (ROC) curve analysis, conducted in the overall sample and stratified by racial group, evaluated optimal cutpoints of BMI, %BF, and SMI for classifying women on moderate-severe physical function impairment. In the overall sample, a BMI cutpoint of ≥ 30.1 kg/m2 correctly classified 71.1% of women on physical function impairment, and optimal cutpoints for %BF (≥ 43.4%) and SMI (≥ 8.1 kg/m2) correctly classified 69% and 62% of women, respectively. SMI did not meaningfully enhanced classification relative to BMI (change in area under the ROC curve = 0.002; net reclassification improvement = 0.021; integrated discrimination improvement = - 0.003). Optimal cutpoints for BMI, %BF, and SMI varied substantially across race. Among Black women, a %BF cutpoint of 43.9% performed somewhat better than BMI (change in area under the ROC curve = 0.017; sensitivity = 0.69, specificity = 0.64). Some race-specific BMI and %BF cutpoints have moderate utility for identifying impaired physical function among midlife women.

Authors: Appelhans BM; Lange-Maia BS; Pettee Gabriel K; Karvonen-Gutierrez C; Karavolos K; Dugan SA; Greendale GA; Avery EF; Sternfeld B; Janssen I; Kravitz HM

Aging Clin Exp Res. 2020 Sep;32(9):1739-1747. Epub 2019-10-04.

PubMed abstract

Heterogeneous trends in burden of heart disease mortality by subtypes in the United States, 1999-2018: observational analysis of vital statistics

To describe trends in the burden of mortality due to subtypes of heart disease from 1999 to 2018 to inform targeted prevention strategies and reduce disparities. Serial cross sectional analysis of cause specific heart disease mortality rates using national death certificate data in the overall population as well as stratified by race-sex, age, and geography. United States, 1999-2018. 12.9 million decedents from total heart disease (49% women, 12% black, and 19% <65 years old). Age adjusted mortality rates (AAMR) and years of potential life lost (YPLL) for each heart disease subtype, and respective mean annual percentage change. Deaths from total heart disease fell from 752 192 to 596 577 between 1999 and 2011, and then increased to 655 381 in 2018. From 1999 to 2018, the proportion of total deaths from heart disease attributed to ischemic heart disease decreased from 73% to 56%, while the proportion attributed to heart failure increased from 8% to 13% and the proportion attributed to hypertensive heart disease increased from 4% to 9%. Among heart disease subtypes, AAMR was consistently highest for ischemic heart disease in all subgroups (race-sex, age, and region). After 2011, AAMR for heart failure and hypertensive heart disease increased at a faster rate than for other subtypes. The fastest increases in heart failure mortality were in black men (mean annual percentage change 4.9%, 95% confidence interval 4.0% to 5.8%), whereas the fastest increases in hypertensive heart disease occurred in white men (6.3%, 4.9% to 9.4%). The burden of years of potential life lost was greatest from ischemic heart disease, but black-white disparities were driven by heart failure and hypertensive heart disease. Deaths from heart disease in 2018 resulted in approximately 3.8 million potential years of life lost. Trends in AAMR and years of potential life lost for ischemic heart disease have decelerated since 2011. For almost all other subtypes of heart disease, AAMR and years of potential life lost became stagnant or increased. Heart failure and hypertensive heart disease account for the greatest increases in premature deaths and the largest black-white disparities and have offset declines in ischemic heart disease. Early and targeted primary and secondary prevention and control of risk factors for heart disease, with a focus on groups at high risk, are needed to avoid these suboptimal trends beginning earlier in life.

Authors: Shah, Nilay S; Molsberry, Rebecca; Rana, Jamal S; Sidney, Stephen; Capewell, Simon; O'Flaherty, Martin; Carnethon, Mercedes; Lloyd-Jones, Donald M; Khan, Sadiya S

BMJ. 2020 08 13;370:m2688. Epub 2020-08-13.

PubMed abstract

Social Relationships and Risk of Type 2 Diabetes Among Postmenopausal Women

We examined whether social relationship variables (social support, social strain, social network size, and stressful life events) were associated with risk of developing type 2 diabetes among postmenopausal women. 139,924 postmenopausal women aged 50-79 years without prevalent diabetes at baseline were followed for a mean of 14 years. 19,240 women developed diabetes. Multivariable Cox proportional hazard models tested associations between social relationship variables and diabetes incidence after consideration of demographics, depressive symptoms, and lifestyle behaviors. We also examined moderating effects of obesity and race/ethnicity, and we tested whether social variable associations were mediated by lifestyle or depressive symptoms. Compared with the lowest quartile, women in the highest social support quartile had lower risk of diabetes after adjusting for demographic factors, health behaviors, and depressive symptoms (hazard ratio [HR] = 0.93, 95% confidence interval [CI] = 0.89-0.97). Social strain (HR = 1.09, 95% CI = 1.04-1.13) and stressful life events (HR = 1.10, 95% CI = 1.05-1.15) were associated with higher diabetes risks. The association between diabetes and social strain was stronger among African American women. Social relationship variables had direct relationships to diabetes, as well as indirect effects partially mediated by lifestyle and depressive symptoms. Social support, social strain, and stressful life events were associated with diabetes risk among postmenopausal women independently of demographic factors and health behaviors. In addition to healthy behaviors such as diet and physical activity, healthy social relationships among older women may be important in the prevention of diabetes.

Authors: Hendryx M; Nicholson W; Manson JE; Kroenke CH; Lee J; Weitlauf JC; Garcia L; Jonasson JM; Wactawski-Wende J; Luo J

J Gerontol B Psychol Sci Soc Sci. 2020 08 13;75(7):1597-1608.

PubMed abstract

Obesity and Mortality Among Patients Diagnosed With COVID-19: Results From an Integrated Health Care Organization

Obesity, race/ethnicity, and other correlated characteristics have emerged as high-profile risk factors for adverse coronavirus disease 2019 (COVID-19)-associated outcomes, yet studies have not adequately disentangled their effects. To determine the adjusted effect of body mass index (BMI), associated comorbidities, time, neighborhood-level sociodemographic factors, and other factors on risk for death due to COVID-19. Retrospective cohort study. Kaiser Permanente Southern California, a large integrated health care organization. Kaiser Permanente Southern California members diagnosed with COVID-19 from 13 February to 2 May 2020. Multivariable Poisson regression estimated the adjusted effect of BMI and other factors on risk for death at 21 days; models were also stratified by age and sex. Among 6916 patients with COVID-19, there was a J-shaped association between BMI and risk for death, even after adjustment for obesity-related comorbidities. Compared with patients with a BMI of 18.5 to 24 kg/m2, those with BMIs of 40 to 44 kg/m2 and greater than 45 kg/m2 had relative risks of 2.68 (95% CI, 1.43 to 5.04) and 4.18 (CI, 2.12 to 8.26), respectively. This risk was most striking among those aged 60 years or younger and men. Increased risk for death associated with Black or Latino race/ethnicity or other sociodemographic characteristics was not detected. Deaths occurring outside a health care setting and not captured in membership files may have been missed. Obesity plays a profound role in risk for death from COVID-19, particularly in male patients and younger populations. Our capitated system with more equalized health care access may explain the absence of effect of racial/ethnic and socioeconomic disparities on death. Our data highlight the leading role of severe obesity over correlated risk factors, providing a target for early intervention. Roche-Genentech.

Authors: Tartof SY; Skarbinski J; Murali SB; et al.

Ann Intern Med. 2020 Aug 12.

PubMed abstract

Association of Racial Residential Segregation Throughout Young Adulthood and Cognitive Performance in Middle-aged Participants in the CARDIA Study

Neighborhood-level residential segregation is implicated as a determinant for poor health outcomes in black individuals, but it is unclear whether this association extends to cognitive aging, especially in midlife. To examine the association between cumulative exposure to residential segregation during 25 years of young adulthood among black individuals and cognitive performance in midlife. The ongoing prospective cohort Coronary Artery Risk Development in Young Adults (CARDIA) Study recruited 5115 black and white participants aged 18 to 30 years from 4 field centers at the University of Alabama, Birmingham; University of Minnesota, Minneapolis; Northwestern University, Chicago, Illinois; and Kaiser Permanente, Oakland, California. Data were acquired from February 1985 to May 2011. Among the surviving CARDIA cohort, 3671 (71.8%) attended examination year 25 of the study in 2010, when cognition was measured, and 3008 (81.9%) of those completed the cognitive assessments. To account for time-varying confounding and differential censoring, marginal structural models using inverse probability weighting were applied. Data were analyzed from April 16 to July 20, 2019. Racial residential segregation was measured using the Getis-Ord Gi* statistic, and the mean cumulative exposure to segregation was calculated across 6 follow-up visits from baseline to year 25 of the study, then categorized into high, medium, and low segregation. Cognitive function was measured at year 25 of the study, using the Digit Symbol Substitution Test (DSST), Stroop color test (reverse coded), and Rey Auditory Verbal Learning Test. To facilitate comparison of estimates, z scores were calculated for all cognitive tests. A total of 1568 black participants with available cognition data were included in the analysis. At baseline, participants had a mean (SD) age of 25 (4) years and consisted of 936 women (59.7%). Greater cumulative exposure to segregated neighborhoods was associated with a worse DSST z score (for high segregation, β = -0.37 [95% CI, -0.61 to -0.13]; for medium segregation, β = -0.25 [95% CI, -0.51 to 0.0002]) relative to exposure to low segregation. In this cohort study, exposure to residential segregation throughout young adulthood was associated with worse processing speed among black participants as early as in midlife. This association may potentially explain black-white disparities in dementia risk at older age.

Authors: Caunca MR; Odden MC; Glymour MM; Elfassy T; Kershaw KN; Sidney S; Yaffe K; Launer L; Zeki Al Hazzouri A

JAMA Neurol. 2020 08 01;77(8):1000-1007.

PubMed abstract

Neighborhood socioeconomic status and risk of hospitalization in patients with chronic kidney disease: A chronic renal insufficiency cohort study

Patients with chronic kidney disease (CKD) experience significantly greater morbidity than the general population. The hospitalization rate for patients with CKD is significantly higher than the general population. The extent to which neighborhood-level socioeconomic status (SES) is associated with hospitalization has been less explored, both in the general population and among those with CKD.We evaluated the relationship between neighborhood SES and hospitalizations for adults with CKD participating in the Chronic Renal Insufficiency Cohort Study. Neighborhood SES quartiles were created utilizing a validated neighborhood-level SES summary measure expressed as z-scores for 6 census-derived variables. The relationship between neighborhood SES and hospitalizations was examined using Poisson regression models after adjusting for demographic characteristics, individual SES, lifestyle, and clinical factors while taking into account clustering within clinical centers and census block groups.Among 3291 participants with neighborhood SES data, mean age was 58 years, 55% were male, 41% non-Hispanic white, 49% had diabetes, and mean estimated glomerular filtration rate (eGFR) was 44 ml/min/1.73 m. In the fully adjusted model, compared to individuals in the highest SES neighborhood quartile, individuals in the lowest SES neighborhood quartile had higher risk for all-cause hospitalization (rate ratio [RR], 1.28, 95% CI, 1.09-1.51) and non-cardiovascular hospitalization (RR 1.30, 95% CI, 1.10-1.55). The association with cardiovascular hospitalization was in the same direction but not statistically significant (RR 1.21, 95% CI, 0.97-1.52).Neighborhood SES is associated with risk for hospitalization in individuals with CKD even after adjusting for individual SES, lifestyle, and clinical factors.

Authors: Saunders MR; Go AS; CRIC Study Investigators; et al.

Medicine (Baltimore). 2020 Jul 10;99(28):e21028.

PubMed abstract

Remission From Unhealthy Drinking Among Patients With an Alcohol Use Disorder: A Longitudinal Study Using Systematic, Primary Care-Based Alcohol Screening Data

Using electronic health record (EHR) data from a systematic, primary care-based alcohol screening, brief intervention, and referral to treatment (SBIRT) initiative within a health system, we examined correlates of remission from unhealthy drinking among patients with an alcohol use disorder (AUD). We conducted a longitudinal study of 4,078 adults with AUD who screened positive for unhealthy drinking between October 1, 2015, and September 30, 2016. We extracted EHR data up to 3 years after screening until October 1, 2018. We used survival analysis to examine associations between remission (i.e., reporting abstinence or low-risk drinking at a subsequent screening) and patient characteristics, comorbidities, and treatment utilization. The median time to remission from unhealthy drinking was 1.7 years. Factors significantly associated with greater odds of remitting from unhealthy drinking during follow-up were female gender; older age (50-64 years); Black or Latino/Hispanic race/ethnicity; having more medical comorbidities; not having a comorbid drug use disorder; lower alcohol consumption levels; and receiving addiction medicine treatment before the index screening. In the first follow-up year, individuals with mental health comorbidities were more likely to remit, but those in psychiatric treatment were less likely. Receiving addiction treatment during follow-up was not associated with remission. Ethnic minorities and individuals with mental illness were more likely to remit, which is encouraging given the health disparities observed among these clinically important subgroups and warrants further research. Our findings may inform research on AUD recovery and clinical practice, as remission from unhealthy drinking is a crucial component of the early stages of recovery.

Authors: Palzes, Vanessa A; Kline-Simon, Andrea H; Satre, Derek D; Sterling, Stacy; Weisner, Constance; Chi, Felicia W

J Stud Alcohol Drugs. 2020 07;81(4):436-445.

PubMed abstract

Hospital Characteristics and Breast Cancer Survival in the California Breast Cancer Survivorship Consortium

Racial/ethnic disparities in breast cancer survival are well documented, but the influence of health care institutions is unclear. We therefore examined the effect of hospital characteristics on survival. Harmonized data pooled from 5 case-control and prospective cohort studies within the California Breast Cancer Survivorship Consortium were linked to the California Cancer Registry and the California Neighborhoods Data System. The study included 9,701 patients with breast cancer who were diagnosed between 1993 and 2007. First reporting hospitals were classified by hospital type-National Cancer Institute (NCI) -designated cancer center, American College of Surgeons (ACS) Cancer Program, other-and hospital composition of the neighborhood socioeconomic status and race/ethnicity of patients with cancer. Multivariable Cox proportional hazards models adjusted for clinical and patient-level prognostic factors were used to examine the influence of hospital characteristics on survival. Fewer than one half of women received their initial care at an NCI-designated cancer center (5%) or ACS program (38%) hospital. Receipt of initial care in ACS program hospitals varied by race/ethnicity-highest among non-Latina White patients (45%), and lowest among African Americans (21%). African-American women had superior breast cancer survival when receiving initial care in ACS hospitals versus other hospitals (non-ACS program and non-NCI-designated cancer center; hazard ratio, 0.67; 95% CI, 0.55 to 0.83). Other hospital characteristics were not associated with survival. African American women may benefit significantly from breast cancer care in ACS program hospitals; however, most did not receive initial care at such facilities. Future research should identify the aspects of ACS program hospitals that are associated with higher survival and evaluate strategies by which to enhance access to and use of high-quality hospitals, particularly among African American women.

Authors: Shariff-Marco S; Kwan ML; Kurian AW; et al.

JCO Oncol Pract. 2020 06;16(6):e517-e528.

PubMed abstract

Racial and Ethnic Disparities in Diabetes Care Quality among Women of Reproductive Age in an Integrated Delivery System

Diabetes is increasingly prevalent among women of reproductive age, yet little is known about quality of diabetes care for this population at increased risk of diabetes complications and poor maternal and infant health outcomes. Previous studies have identified racial/ethnic disparities in diabetes care, but patterns among women of reproductive age have not been examined. This retrospective cohort study analyzed 2016 data from Kaiser Permanente Northern California, a large integrated delivery system. Outcomes were quality of diabetes care measures-glycemic testing, glycemic control, and medication adherence-among women ages 18 to 44 with type 1 or type 2 diabetes (N = 9,923). Poisson regression was used to estimate the association between patient race/ethnicity and each outcome, adjusting for other patient characteristics and health care use. In this cohort, 83% of participants had type 2 diabetes; 31% and 36% of women with type 2 and type 1 diabetes, respectively, had poor glycemic control (hemoglobin A1c of ≥9%), and approximately one-third of women with type 2 diabetes exhibited nonadherence to diabetes medications. Compared with non-Hispanic White women with type 2 diabetes, non-Hispanic Black women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) and Hispanic women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) were more likely to have poor control. Findings among women with type 1 diabetes were similar. Our findings indicate opportunities to decrease disparities and improve quality of diabetes care for reproductive-aged women. Elucidating the contributing factors to poor glycemic control and medication adherence in this population, particularly among Black, Hispanic, and Asian women, should be a high research and practice priority.

Authors: Marshall CJ; Rodriguez HP; Dyer W; Schmittdiel JA

Womens Health Issues. 2020 May - Jun;30(3):191-199. Epub 2020-04-25.

PubMed abstract

Association Between Blood Pressure and Later-Life Cognition Among Black and White Individuals

Black individuals are more likely than white individuals to develop dementia. Whether higher blood pressure (BP) levels in black individuals explain differences between black and white individuals in dementia risk is uncertain. To determine whether cumulative BP levels explain racial differences in cognitive decline. Individual participant data from 5 cohorts (January 1971 to December 2017) were pooled from the Atherosclerosis Risk in Communities Study, Coronary Artery Risk Development in Young Adults Study, Cardiovascular Health Study, Framingham Offspring Study, and Northern Manhattan Study. Outcomes were standardized as t scores (mean [SD], 50 [10]); a 1-point difference represented a 0.1-SD difference in cognition. The median (interquartile range) follow-up was 12.4 (5.9-21.0) years. Analysis began September 2018. The primary outcome was change in global cognition, and secondary outcomes were change in memory and executive function. Race (black vs white). Among 34 349 participants, 19 378 individuals who were free of stroke and dementia and had longitudinal BP, cognitive, and covariate data were included in the analysis. The mean (SD) age at first cognitive assessment was 59.8 (10.4) years and ranged from 5 to 95 years. Of 19 378 individuals, 10 724 (55.3%) were female and 15 526 (80.1%) were white. Compared with white individuals, black individuals had significantly faster declines in global cognition (-0.03 points per year faster [95% CI, -0.05 to -0.01]; P = .004) and memory (-0.08 points per year faster [95% CI, -0.11 to -0.06]; P 

Authors: Levine DA; Sidney S; Galecki AT; et al.

JAMA Neurol. 2020 Apr 13.

PubMed abstract

Characterizing the Human Immunodeficiency Virus Care Continuum Among Transgender Women and Cisgender Women and Men in Clinical Care: A Retrospective Time-series Analysis

Prior studies suggest that transgender women (TW) with human immunodeficiency virus (HIV) are less likely to be virally suppressed than cisgender women (CW) and cisgender men (CM). However, prior data are limited by small sample sizes and cross-sectional designs. We sought to characterize the HIV care continuum comparing TW to CW and CM in the United States and Canada. We analyzed annual HIV care continuum outcomes by gender status from January 2001 through December 2015 among adults (aged ≥18 years) in 15 clinical cohorts. Outcomes were retention in care and viral suppression. The study population included TW (n = 396), CW (n = 14 094), and CM (n = 101 667). TW had lower proportions retained in care than CW and CM (P < .01). Estimates of retention in care were consistently lower in TW, with little change over time within each group. TW and CW had similar proportions virally suppressed over time (TW, 36% in 2001 and 80% in 2015; CW, 35% in 2001 and 83% in 2015) and were lower than CM (41% in 2001 and 87% in 2015). These differences did not reach statistical significance after adjusting for age, race, HIV risk group, and cohort. TW experience challenges with retention in HIV care. However, TW who are engaged in care achieve viral suppression that is comparable to that of CW and CM of similar age, race, and HIV risk group. Further research is needed to understand care engagement disparities.

Authors: Poteat T; Silverberg MJ; Althoff KN; et al.

Clin Infect Dis. 2020 03 03;70(6):1131-1138.

PubMed abstract

Sedentary Time and Physical Activity Across Occupational Classifications

To examine differences in activity patterns across employment and occupational classifications. Cross-sectional. A 2005-2006 Coronary Artery Risk Development in Young Adults (CARDIA) study. Participants with valid accelerometry data (n = 2068). Uniaxial accelerometry data (ActiGraph 7164), accumulated during waking hours, were summarized as mean activity counts (counts/min) and time spent (min/d) in long-bout sedentary (≥30 minutes, SED≥30), short-bout sedentary (<30 minutes, SED<30), light physical activity (LPA), short-bout moderate-to-vigorous physical activity (<10 minutes, MVPA<10), and long-bout MVPA (≥10 minutes, MVPA≥10) using Freedson cut-points. Employment status was self-reported as full time, part time, unemployed, keeping house, or raising children. Self-reported job duties were categorized into 23 major groups using the 2010 Standard Occupational Classification. Omnibus differences were analyzed using adjusted analysis of covariance and repeated after stratification by race (black/white) and sex (female/male). SED≥30, SED<30, LPA, and MVPA<10 differed significantly by employment and occupational categories (P ≤ .05), while MVPA≥10 did not (P ≥ .50). SED≥30, SED<30, and LPA differed by occupational classification in men, women, blacks, and whites (P < .05). Mean activity counts, MVPA<10, and MVPA≥10 were significantly different across occupational classifications in whites (P ≤ .05), but not in blacks (P > .05). Significant differences in mean activity counts and MVPA<10 across occupational classifications were found in males (P ≤ .001), but not in females (P > .05). Time within activity intensity categories differs across employment and occupational classifications and by race and sex.

Authors: Quinn TD; Pettee Gabriel K; Siddique J; Aaby D; Whitaker KM; Lane-Cordova A; Sidney S; Sternfield B; Barone Gibbs B

Am J Health Promot. 2020 03;34(3):247-256. Epub 2019-11-14.

PubMed abstract

Race and Mortality in CKD and Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy. Retrospective cohort study. 3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment. Race. Mortality. Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC. During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28). Residual confounding. The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.

Authors: Ku E; Go AS; CRIC Study Investigators; et al.

Am J Kidney Dis. 2020 03;75(3):394-403. Epub 2019-11-12.

PubMed abstract

Prevalence and treatment of opioid use disorders among primary care patients in six health systems

The U.S. experienced nearly 48,000 opioid overdose deaths in 2017. Treatment of opioid use disorder (OUD) with buprenorphine is a recommended part of primary care, yet little is known about current U.S. practices in this setting. This observational study reports the prevalence of documented OUD and OUD treatment with buprenorphine among primary care patients in six large health systems. Adults with ≥2 primary care visits during a three-year period (10/1/2013-9/30/2016) in six health systems were included. Data were obtained from electronic health record and claims data, with measures, assessed over the three-year period, including indicators for documented OUD from ICD 9 and 10 codes and OUD treatment with buprenorphine. The prevalence of OUD treatment was adjusted for age, gender, race/ethnicity, and health system. Among 1,368,604 primary care patients, 13,942 (1.0 %) had documented OUD, and among these, 21.0 % had OUD treatment with buprenorphine. For those with documented OUD, the adjusted prevalence of OUD treatment with buprenorphine varied across demographic and clinical subgroups. OUD treatment was lower among patients who were older, women, Black/African American and Hispanic (compared to white), non-commercially insured, and those with non-cancer pain, mental health disorders, greater comorbidity, and more opioid prescriptions, emergency department visits or hospitalizations. Among primary care patients in six health systems, one in five with an OUD were treated with buprenorphine, with disparities across demographic and clinical characteristics. Less buprenorphine treatment among those with greater acute care utilization highlights an opportunity for systems-level changes to increase OUD treatment.

Authors: Lapham G; Campbell CI; PROUD Collaborative Investigators; et al.

Drug Alcohol Depend. 2020 02 01;207:107732. Epub 2019-11-15.

PubMed abstract

Cervical cancer risk in women living with HIV across four continents: A multicohort study

We compared invasive cervical cancer (ICC) incidence rates in Europe, South Africa, Latin and North America among women living with HIV who initiated antiretroviral therapy (ART) between 1996 and 2014. We analyzed cohort data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) and the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in EuroCoord. We used flexible parametric survival models to determine regional ICC rates and risk factors for incident ICC. We included 64,231 women from 45 countries. During 320,141 person-years (pys), 356 incident ICC cases were diagnosed (Europe 164, South Africa 156, North America 19 and Latin America 17). Raw ICC incidence rates per 100,000 pys were 447 in South Africa (95% confidence interval [CI]: 382-523), 136 in Latin America (95% CI: 85-219), 76 in North America (95% CI: 48-119) and 66 in Europe (95% CI: 57-77). Compared to European women ICC rates at 5 years after ART initiation were more than double in Latin America (adjusted hazard ratio [aHR]: 2.43, 95% CI: 1.27-4.68) and 11 times higher in South Africa (aHR: 10.66, 95% CI: 6.73-16.88), but similar in North America (aHR: 0.79, 95% CI: 0.37-1.71). Overall, ICC rates increased with age (>50 years vs. 16-30 years, aHR: 1.57, 95% CI: 1.03-2.40) and lower CD4 cell counts at ART initiation (per 100 cell/μl decrease, aHR: 1.25, 95% CI: 1.15-1.36). Improving access to early ART initiation and effective cervical cancer screening in women living with HIV should be key parts of global efforts to reduce cancer-related health inequities.

Authors: Rohner E; Silverberg MJ; Bohlius J; et al.

Int J Cancer. 2020 02 01;146(3):601-609. Epub 2019-06-19.

PubMed abstract

Variation in Colorectal Cancer Stage and Mortality across Large Community-Based Populations: PORTAL Colorectal Cancer Cohort

Colorectal cancer (CRC) incidence and mortality can be reduced by effective screening and/or treatment. However, the influence of health care systems on disparities among insured patients is largely unexplored. To evaluate insured patients with CRC diagnosed between 2010 and 2014 across 6 diverse US health care systems in the Patient-Centered Outcomes Research Institute (PCORI) Patient Outcomes Research To Advance Learning (PORTAL) CRC cohort, we contrasted CRC stage; CRC mortality; all-cause mortality; and influences of demographics, stage, comorbidities, and treatment between health systems. Among 16,211 patients with CRC, there were significant differences between health care systems in CRC stage at diagnosis, CRC-specific mortality, and all-cause mortality. The unadjusted risk of CRC mortality varied from 27% lower to 21% higher than the reference system (hazard ratio [HR] = 0.73, 95% confidence interval = 0.66-0.80 to HR = 1.21, 95% confidence interval = 1.05-1.40; p < 0.01 across systems). Significant differences persisted after adjustment for demographics and comorbidities (p < 0.01); however, adjustment for stage eliminated significant differences (p = 0.24). All-cause mortality among patients with CRC differed approximately 30% between health care systems (HR = 0.89-1.17; p < 0.01). Adjustment for age eliminated significant differences (p = 0.48). Differences in CRC survival between health care systems were largely explained by stage at diagnosis, not demographics, comorbidity, or treatment. Given that stage is strongly related to early detection, these results suggest that variation in CRC screening systems represents a modifiable systems-level factor for reducing disparities in CRC survival.

Authors: Schneider, Jennifer L; Feigelson, Heather Spencer; Quinn, Virginia P; McMullen, Carmit; Pawloski, Pamela A; Powers, John D; Sterrett, Andrew T; Arterburn, David; Corley, Douglas A

Perm J. 2020;24.

PubMed abstract

Racial-ethnic differences in prevalence of social determinants of health and social risks among middle-aged and older adults in a Northern California health plan

Social determinants of health (SDoHs) and social risks (SRs) have been associated with adverse health and healthcare utilization and racial/ethnic disparities. However, there is limited information about the prevalence of SRs in non-“safety net” adult populations and how SRs differ by race/ethnicity, age, education, and income. We analyzed weighted survey data for 16,247 White, 1861 Black, 2895 Latino, 1554 Filipino, and 1289 Chinese adults aged 35 to 79 who responded to the 2011 or 2014/2015 Kaiser Permanente Northern California Member Health Survey. We compared age-standardized prevalence estimates of SDoHs (education, household income, marital status) and SRs (financial worry, cost-related reduced medication use and fruit/vegetable consumption, chronic stress, harassment/discrimination, health-related beliefs) across racial/ethnic groups for ages 35 to 64 and 65 to 79. SDoHs and SRs differed by race/ethnicity and age group, and SRs differed by levels of education and income. In both age groups, Blacks, Latinos, and Filipinos were more likely than Whites to be in the lower income category and be worried about their financial situation. Compared to Whites, cost-related reduced medication use was higher among Blacks, and cost-related reduced fruit/vegetable consumption was higher among Blacks and Latinos. Younger adults were more likely than older adults to experience chronic stress and financial worry. Racial/ethnic disparities in income were observed within similar levels of education. Differences in prevalence of SRs by levels of education and income were wider within than across racial/ethnic groups. In this non-“safety net” adult health plan population, Blacks, Latinos, and Filipinos had a higher prevalence of social risks than Whites and Chinese, and prevalence of social risks differed by age group. Our results support the assessment and EHR documentation of SDoHs and social risks and use of this information to understand and address drivers of racial/ethnic disparities in health and healthcare use.

Authors: Gordon, Nancy P; Banegas, Matthew P; Tucker-Seeley, Reginald D

PLoS One. 2020;15(11):e0240822. Epub 2020-11-04.

PubMed abstract

The South Asian Paradox

For several decades we have studied health outcomes in identified Asian American (ASAM) ethnic groups, comparing ASAM subgroups to whites and to each other. The most striking disparities we found involved South Asians (SAs). The SA individuals had higher coronary artery disease (CAD) risk and lower cancer risk than whites or any other ASAM group. The SA individuals also did not share the lower venous thromboembolism risk of all other ASAM groups. The relatively low prevalence of CAD risk traits in SAs with high CAD incidence defines a paradox. Exploration of these data might help the search for therapeutic and preventive medical benefits.

Authors: Klatsky, Arthur L; Tran, H Nicole

Perm J. 2020;24. Epub 2020-04-03.

PubMed abstract

Racial/Ethnic Differences in Sleep Quality among Older Adults: Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) Study

We assessed cross-sectional differences in sleep quality and risk factors among Asian, Black, Latino, and White participants in the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) Study. KHANDLE enrolled community-dwelling adults aged ≥65 years living in northern California. Participants completed a modified Pittsburgh Sleep Quality Index to measure six sleep components and a global sleep score (scored 0-24). Covariates included age, sex, central adiposity, education, income, alcohol consumption, ever smoking, physical activity, and depression. Ordinal logistic regression was used to model sleep component scores across race/ethnic groups. Linear regression was used to assess racial/ethnic differences in global sleep score and the association between risk factors and global sleep score. 1,664 participants with a mean age of 76 (SD=7) and mean global sleep score of 6 (SD=4) were analyzed. Using Latinos as reference (highest average sleep score), Blacks had an average .96 (.37, 1.54) unit higher global sleep score (worse sleep) while Asians [β: .04 (-.56, .63)] and Whites [β: .28 (-.29, .84)] did not significantly differ. Compared with Latinos, Blacks and Asians had greater odds of a worse score on the sleep duration component; Blacks and Whites had greater odds of a worse score on the sleep disturbances component; and, Whites had greater odds of a worse score on the medication component. Risk factors for poor sleep did not differ by race/ethnicity except alcohol consumption (interaction P=.04), which was associated with poor sleep in Blacks only. In this cohort, racial/ethnic differences in sleep quality were common.

Authors: George, Kristen M; Peterson, Rachel L; Gilsanz, Paola; Mungas, Dan M; Glymour, M Maria; Mayeda, Elizabeth Rose; Whitmer, Rachel A

Ethn Dis. 2020 Summer;30(3):469-478. Epub 2020-07-09.

PubMed abstract

Genetic ancestry does not explain increased atopic dermatitis susceptibility or worse disease control among African American subjects in 2 large US cohorts

Atopic dermatitis (AD) is more common among African American children. Whether there are racial/ethnic difference among adults with AD and the causes for those disparities are unclear. We sought to examine the relationship between self-reported race/ethnicity and AD and determine whether African genetic ancestry is predictive of these outcomes among African American subjects. We analyzed data from 2 independent multiethnic longitudinal studies: 86,893 subjects aged 18 to 100 years from the Kaiser Permanente Genetic Epidemiology Research on Adult Health and Aging (GERA) cohort and 5467 subjects aged 2 to 26 years from the national Pediatric Eczema Elective Registry (PEER) cohort. The primary outcomes were physician-diagnosed AD in GERA and repeated measures of self-reported disease control among patients with physician-diagnosed AD at 6-month intervals in PEER. We examined whether self-identified African American race/ethnicity was predictive of these outcomes and then tested whether a continuous measure of African genetic ancestry was associated with outcomes within the African American group. AD was more common among self-identified African American subjects than non-Hispanic white subjects in GERA (4.4% vs 2.1%; odds ratio, 2.06; 95% CI, 1.70-2.48) and less well-controlled in PEER subjects (odds of 1-level worse control, 1.91; 95% CI, 1.64-2.22). However, African genetic ancestry was not associated with AD risk or control among self-identified African American subjects in either cohort, nor did an AD polygenic risk score or genetic skin pigment score explain the AD disparities in patients with AD. Ancestry-related genetic effects do not explain increased AD prevalence or poorer disease control among African American subjects.

Authors: Abuabara K; You Y; Margolis DJ; Hoffmann TJ; Risch N; Jorgenson E

J Allergy Clin Immunol. 2020 01;145(1):192-198.e11. Epub 2019-07-29.

PubMed abstract


Improvements in life expectancy among people living with human immunodeficiency virus (PLWH) receiving antiretroviral treatment in the United States and Canada might differ among key populations. Given the difference in substance use among key populations and the current opioid epidemic, drug- and alcohol-related deaths might be contributing to the disparities in life expectancy. We sought to estimate life expectancy at age 20 years in key populations (and their comparison groups) in 3 time periods (2004-2007, 2008-2011, and 2012-2015) and the potential increase in expected life expectancy with a simulated 20% reduction in drug- and alcohol-related deaths using the novel Lives Saved Simulation model. Among 92,289 PLWH, life expectancy increased in all key populations and comparison groups from 2004-2007 to 2012-2015. Disparities in survival of approximately a decade persisted among black versus white men who have sex with men and people with (vs. without) a history of injection drug use. A 20% reduction in drug- and alcohol-related mortality would have the greatest life-expectancy benefit for black men who have sex with men, white women, and people with a history of injection drug use. Our findings suggest that preventing drug- and alcohol-related deaths among PLWH could narrow disparities in life expectancy among some key populations, but other causes of death must be addressed to further narrow the disparities.

Authors: Althoff KN; Silverberg MJ; North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of IeDEA; et al.

Am J Epidemiol. 2019 12 31;188(12):2097-2109.

PubMed abstract

The associations of anthropometric, behavioural and sociodemographic factors with circulating concentrations of IGF-I, IGF-II, IGFBP-1, IGFBP-2, and IGFBP-3 in a pooled analysis of 16,024 men from 22 studies

Insulin-like growth factors (IGFs) and insulin-like growth factor binding proteins (IGFBPs) have been implicated in the aetiology of several cancers. To better understand whether anthropometric, behavioural and sociodemographic factors may play a role in cancer risk via IGF signalling, we examined the cross-sectional associations of these exposures with circulating concentrations of IGFs (IGF-I and IGF-II) and IGFBPs (IGFBP-1, IGFBP-2 and IGFBP-3). The Endogenous Hormones, Nutritional Biomarkers and Prostate Cancer Collaborative Group dataset includes individual participant data from 16,024 male controls (i.e. without prostate cancer) aged 22-89 years from 22 prospective studies. Geometric means of protein concentrations were estimated using analysis of variance, adjusted for relevant covariates. Older age was associated with higher concentrations of IGFBP-1 and IGFBP-2 and lower concentrations of IGF-I, IGF-II and IGFBP-3. Higher body mass index was associated with lower concentrations of IGFBP-1 and IGFBP-2. Taller height was associated with higher concentrations of IGF-I and IGFBP-3 and lower concentrations of IGFBP-1. Smokers had higher concentrations of IGFBP-1 and IGFBP-2 and lower concentrations of IGFBP-3 than nonsmokers. Higher alcohol consumption was associated with higher concentrations of IGF-II and lower concentrations of IGF-I and IGFBP-2. African Americans had lower concentrations of IGF-II, IGFBP-1, IGFBP-2 and IGFBP-3 and Hispanics had lower IGF-I, IGF-II and IGFBP-3 than non-Hispanic whites. These findings indicate that a range of anthropometric, behavioural and sociodemographic factors are associated with circulating concentrations of IGFs and IGFBPs in men, which will lead to a greater understanding of the mechanisms through which these factors influence cancer risk.

Authors: Watts EL; Habel LA; Schaefer CA; Van Den Eeden SK; Travis RC; et al.

Int J Cancer. 2019 12 15;145(12):3244-3256. Epub 2019-04-04.

PubMed abstract

Racial Disparities in Route of Hysterectomy for Benign Indications Within an Integrated Health Care System

Authors: Zaritsky E; Ojo A; Tucker LY; Raine-Bennett TR

JAMA Netw Open. 2019 Dec 02;2(12):e1917004. Epub 2019-12-02.

PubMed abstract

Use of >100,000 NHLBI Trans-Omics for Precision Medicine (TOPMed) Consortium whole genome sequences improves imputation quality and detection of rare variant associations in admixed African and Hispanic/Latino populations

Most genome-wide association and fine-mapping studies to date have been conducted in individuals of European descent, and genetic studies of populations of Hispanic/Latino and African ancestry are limited. In addition, these populations have more complex linkage disequilibrium structure. In order to better define the genetic architecture of these understudied populations, we leveraged >100,000 phased sequences available from deep-coverage whole genome sequencing through the multi-ethnic NHLBI Trans-Omics for Precision Medicine (TOPMed) program to impute genotypes into admixed African and Hispanic/Latino samples with genome-wide genotyping array data. We demonstrated that using TOPMed sequencing data as the imputation reference panel improves genotype imputation quality in these populations, which subsequently enhanced gene-mapping power for complex traits. For rare variants with minor allele frequency (MAF) < 0.5%, we observed a 2.3- to 6.1-fold increase in the number of well-imputed variants, with 11-34% improvement in average imputation quality, compared to the state-of-the-art 1000 Genomes Project Phase 3 and Haplotype Reference Consortium reference panels. Impressively, even for extremely rare variants with minor allele count <10 (including singletons) in the imputation target samples, average information content rescued was >86%. Subsequent association analyses of TOPMed reference panel-imputed genotype data with hematological traits (hemoglobin (HGB), hematocrit (HCT), and white blood cell count (WBC)) in ~21,600 African-ancestry and ~21,700 Hispanic/Latino individuals identified associations with two rare variants in the HBB gene (rs33930165 with higher WBC [p = 8.8×10-15] in African populations, rs11549407 with lower HGB [p = 1.5×10-12] and HCT [p = 8.8×10-10] in Hispanics/Latinos). By comparison, neither variant would have been genome-wide significant if either 1000 Genomes Project Phase 3 or Haplotype Reference Consortium reference panels had been used for imputation. Our findings highlight the utility of the TOPMed imputation reference panel for identification of novel rare variant associations not previously detected in similarly sized genome-wide studies of under-represented African and Hispanic/Latino populations.

Authors: Kowalski MH; Choquet H; Li Y; et al.

PLoS Genet. 2019 12;15(12):e1008500. Epub 2019-12-23.

PubMed abstract

Racial/Ethnic Disparities in the Prevalence of Diabetes and Prediabetes by BMI: Patient Outcomes Research To Advance Learning (PORTAL) Multisite Cohort of Adults in the U.S

To examine racial/ethnic disparities in the prevalence of diabetes and prediabetes by BMI category. In a consortium of three U.S. integrated health care systems, 4,906,238 individuals aged ≥20 years during 2012-2013 were included. Diabetes and prediabetes were ascertained by diagnosis and laboratory results; antihyperglycemic medications were also included for diabetes ascertainment. The age-standardized diabetes and prediabetes prevalence estimates were 15.9% and 33.4%, respectively. Diabetes but not prediabetes prevalence increased across BMI categories among all racial/ethnic groups (P for trend < 0.001). Racial/ethnic minorities reached a given diabetes prevalence at lower BMIs than whites; Hawaiians/Pacific Islanders and Asians had a diabetes prevalence of 24.6% (95% CI 24.1-25.2%) in overweight and 26.5% (26.3-26.8%) in obese class 1, whereas whites had a prevalence of 23.7% (23.5-23.8%) in obese class 2. The age-standardized prediabetes prevalence estimates in overweight among Hispanics (35.6% [35.4-35.7%]), Asians (38.1% [38.0-38.3%]), and Hawaiians/Pacific Islanders (37.5% [36.9-38.2%]) were similar to those in obese class 4 among whites (35.3% [34.5-36.0%]), blacks (36.8% [35.5-38.2%]), and American Indians/Alaskan Natives (34.2% [29.6-38.8%]). In adjusted models, the strength of association between BMI and diabetes was highest among whites (relative risk comparing obese class 4 with normal weight 7.64 [95% CI 7.50-7.79]) and lowest among blacks (3.16 [3.05-3.27]). The association between BMI and prediabetes was less pronounced. Racial/ethnic minorities had a higher burden of diabetes and prediabetes at lower BMIs than whites, suggesting the role of factors other than obesity in racial/ethnic disparities in diabetes and prediabetes risk and highlighting the need for tailored screening and prevention strategies.

Authors: Zhu Y; Ferrara A; et al.

Diabetes Care. 2019 12;42(12):2211-2219. Epub 2019-09-19.

PubMed abstract

Effect of Sex, Age and Positivity Threshold on Fecal Immunochemical Test Accuracy: a Systematic Review and Meta-Analysis

Quantitative fecal immunochemical tests (FITs) for hemoglobin are commonly used for colorectal cancer (CRC) screening. We aimed to quantify the change in CRC and advanced adenoma detection and number of positive test results at different positivity thresholds and by sex and age. We searched MEDLINE and EMBASE, selecting articles of FIT for CRC detection in asymptomatic adults undergoing screening. We calculated sensitivity and specificity, as well as detected number of cancers, advanced adenomas, and positive test results at positivity thresholds ≤10 μg hemoglobin/g feces, 10 to ≤20 μg/g, 20 to ≤30 μg/g, and >30 μg/g. We also analyzed results from stratified by patient sex, age, and reference standard. Our meta-analysis comprised 46 studies with 2.4 million participants and 6478 detected cancers. Sensitivity for detection of CRC increased from 69% (95% confidence interval [CI], 63%-75%) at thresholds >10 μg/g and ≤20 μg/g to 80% (95% CI, 76%-83%) at thresholds ≤10 μg/g. At these threshold values, sensitivity for detection of advanced adenomas increased from 21% (95% CI, 18%-25%) to 31% (95% CI, 27%-35%), whereas specificity decreased from 94% (95% CI, 93%-96%) to 91% (95% CI, 89%-93%). In 3 studies stratified by sex, sensitivity of CRC detection was 77% in men (95% CI, 75%-79%) and 81% in women (95% CI, 60%-100%) (P = .68). In 3 studies stratified by age groups, sensitivity of CRC detection was 85% for ages 50-59 years (95% CI, 71%-99%) and 73% for ages 60-69 years (95% CI, 71%-75%) (P = .10). All studies with colonoscopy follow-up had similar sensitivity levels for detection of CRC to studies that analyzed 2-year registry follow-up data (74%; 95% CI, 68%-78% vs 75%; 95% CI, 73%-77%). In a meta-analysis of studies that analyzed detection of CRC and advanced adenomas at different FIT positivity thresholds, we found the sensitivity and specificity of detection to vary with positive cutoff value. It might be possible to decrease positive threshold values for centers with sufficient follow-up colonoscopy resources. More research is needed to precisely establish FIT thresholds for each sex and age subgroup. PROSPERO CRD42017068760.

Authors: Selby K; Levine EH; Doan C; Gies A; Brenner H; Quesenberry C; Lee JK; Corley DA

Gastroenterology. 2019 12;157(6):1494-1505. Epub 2019-08-22.

PubMed abstract

Is breast cancer in Asian and Asian American women a different disease?

Authors: Gomez SL; Yao S; Kushi LH; Kurian AW

J Natl Cancer Inst. 2019 12 01;111(12):1243-1244.

PubMed abstract

Understanding racial disparities in renal cell carcinoma incidence: estimates of population attributable risk in two US populations

Renal cell carcinoma (RCC) incidence is higher among black than white Americans. The reasons for this disparity remain unclear. We calculated race- and sex-specific population attributable risk percentages (PAR%) and their 95% confidence intervals (CI) for hypertension and chronic kidney disease (CKD) among black and white subjects ≥  50 years of age from the US Kidney Cancer Study (USKC; 965 cases, 953 controls), a case-control study in Chicago and Detroit, and a nested case-control study in the Kaiser Permanente Northern California health care network (KPNC; 2,162 cases, 21,484 controls). We also estimated PAR% for other modifiable RCC risk factors (cigarette smoking, obesity) in USKC. In USKC, the PAR% for hypertension was 50% (95% CI 24-77%) and 44% (95% CI 25-64%) among black women and men, respectively, and 29% (95% CI 13-44%) and 27% (95% CI 14-39%) for white women and men, respectively. In KPNC, the hypertension PAR% was 40% (95% CI 18-62%) and 23% (95% CI 2-44%) among black women and men, and 27% (95% CI 20-35%) and 19% (95% CI 14-24%) among white women and men, respectively. The PAR% for CKD in both studies ranged from 7 to 10% for black women and men but was negligible (

Authors: Callahan CL; Corley DA; Zhao WK; Hofmann JN; et al.

Cancer Causes Control. 2019 Nov 28.

PubMed abstract

Rural-urban differences e-cigarette ever use, the perception of harm, and e-cigarette information seeking behaviors among U.S. adults in a nationally representative study.

Adults living in rural areas, compared to their urban counterparts, are at an increased risk of using tobacco-related products and mortality due to tobacco-related diseases. The harms and benefits of e-cigarette use are mixed, and similarly obscure messaging about these harms and benefits have a critical influence on e-cigarette uptake and perceptions. However, little is known about rural-urban differences in the prevalence of adult e-cigarette daily usage. Using the Health Information National Trends Survey-Food and Drug Administration (HINTS-FDA) cycles 1 and 2, we conducted weighted logistic regressions to assess rural-urban differences in the prevalence of adult e-cigarette daily usage, perceived harm, and e-cigarette information seeking behaviors. This analysis included adults aged 18 years and older in the United States (N = 4229). Both rural and urban respondents reported a similar history of e-cigarette use. Rural respondents were significantly more likely than urban respondents to trust religious organizations and leaders and tobacco companies for information about e-cigarettes. Rural and urban respondents were equally as likely to believe e-cigarettes are addictive, perceive e-cigarette use as harmful, and believe e-cigarettes are more harmful than tobacco cigarettes. Respondents were equally as likely to look for information on e-cigarettes, the health effects of e-cigarettes, and cessation; and, to seek e-cigarette information from healthcare professionals, family and friends, and health organizations and groups. Given our findings, it will be pertinent to continue to research the potential harms of e-cigarette use and develop accurate health communication messages to avoid rural-urban disparities observed for cigarette smoking-related outcomes.

Authors: Lewis-Thames, Marquita W; Langston, Marvin E; Fuzzell, Lindsay; Khan, Saira; Moore, Justin X; Han, Yunan

Preventive medicine. 2020 Jan ;130():105898. Epub 2019-11-21.

PubMed abstract

“They were just waiting for me to mess up”: A critical discourse analysis of immigrant Latinx teens’ perceptions of power dynamics.

This paper explores Latinx adolescents’ perceptions of power dynamics with authority around them. We seek to inform how community-based professionals engage with and seek to understand members of this population. We conducted a critical discourse analysis of data collected during a community action photovoice project with 13 Latinx adolescents living in a metropolitan region of the southeastern United States. Participants felt they were under greater surveillance scrutiny by authority figures in social and academic spaces than their non-Latino peers. They discussed ways their movements were at times constrained because others presumed they were deviant, and how that affected their identity development. Judgments and assumptions held by both powerful adults and oppressed groups alike serve to reinscribe social stratification that places Latinx adolescents at a power disadvantage relative to their white peers. These experiences and understandings of power relations shape the circuitous racial dispossession of youth.

Authors: Merino, Yesenia Y; Thomas, Tainayah T; Lightfoot, Alexandra A; Eng, Eugenia E; Simán, Florence F; Thatcher, Kari K; Chapman, Mimi M

Journal of community psychology. 2019 Nov 09;():. Epub 2019-11-09.

PubMed abstract

Environmental Tobacco Smoke Exposure in Relation to Family Characteristics, Stressors and Chemical Co-Exposures in California Girls

Childhood environmental tobacco smoke (ETS) exposure is a risk factor for adverse health outcomes and may disproportionately burden lower socioeconomic status groups, exacerbating health disparities. We explored associations of demographic factors, stressful life events, and chemical co-exposures, with cotinine levels, among girls in the CYGNET Study. Data were collected from families of girls aged 6-8 years old in Northern California, through clinic exams, questionnaires and biospecimens (n = 421). Linear regression and factor analysis were conducted to explore predictors of urinary cotinine and co-exposure body burdens, respectively. In unadjusted models, geometric mean cotinine concentrations were higher among Black (0.59 ug/g creatinine) than non-Hispanic white (0.27), Asian (0.32), or Hispanic (0.34) participants. Following adjustment, living in a rented home, lower primary caregiver education, and lack of two biologic parents in the home were associated with higher cotinine concentrations. Girls who experienced parental separation or unemployment in the family had higher unadjusted cotinine concentrations. Higher cotinine was also associated with higher polybrominated diphenyl ether and metals concentrations. Our findings have environmental justice implications as Black and socio-economically disadvantaged young girls experienced higher ETS exposure, also associated with higher exposure to other chemicals. Efforts to reduce ETS and co-exposures should account for other disparity-related factors.

Authors: Windham GC; Soriano JW; Dobraca D; Sosnoff CS; Hiatt RA; Kushi LH

Int J Environ Res Public Health. 2019 10 30;16(21). Epub 2019-10-30.

PubMed abstract

Locus of Control and Cognition in Older Adults With Type I Diabetes: Evidence For Sex Differences From the Study of Longevity in Diabetes (SOLID)

Life expectancy for individuals with type 1 diabetes mellitus (T1DM) has increased recently; however, it is unknown how diabetes care attitudes affect late-life brain health. The Study of Longevity in Diabetes (SOLID) consists of 734 older adults with T1DM, reporting diabetes locus of control (dLOC), age of diabetes diagnosis and other demographics, history of hypoglycemic episodes, and depressive symptoms. Global and domain-specific (language, executive function, episodic memory, simple attention) cognitive functioning was assessed at in-person interviews. Cross-sectional associations between dLOC and cognition were estimated using covariate-adjusted linear regression models in pooled and sex-stratified models. In pooled analyses, a 1-point increase in dLOC (more internal) was positively associated with global cognition [β=0.05, 95% confidence interval (CI): 0.02, 0.07], language (β=0.04, 95% CI: 0.01, 0.07), and executive function (β=0.04, 95% CI: 0.01, 0.07), but not episodic memory or simple attention. However, in sex-stratified analyses, this effect was seen only in males and not females. In elderly individuals with T1DM, we found associations between dLOC and cognition overall and in men but not women. Underlying sex differences should be considered in future research or interventions on psychosocial characteristics for cognition.

Authors: Eng CW; Gilsanz P; Lacy ME; Beeri M; Whitmer RA

Alzheimer Dis Assoc Disord. 2019 Oct 17.

PubMed abstract

Prevalence of human papillomavirus (HPV)-vaccine types by race/ethnicity and sociodemographic factors in women with high-grade cervical intraepithelial neoplasia (CIN2/3/AIS), Alameda County, California, United States

We evaluated racial/ethnic differences in prevalence of oncogenic HPV types targeted by the quadrivalent HPV vaccine (16/18) and nonavalent HPV vaccine (31/33/45/52/58) in women diagnosed with CIN2/3/AIS after quadrivalent HPV vaccine introduction (2008-2015). Typing data from 1810 cervical tissue specimen from HPV-IMPACT (Alameda County, California, US), a population-based CIN2/3/AIS surveillance effort, were analyzed. Using log-binomial regression, we calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) comparing type prevalence by race/ethnicity, adjusted for health insurance, age, CIN2/3/AIS grade, and time period, overall and in the "early vaccine era" (2008-2011) and "later vaccine era" (2012-2015). Overall, oncogenic HPV16/18 prevalence was significantly lower among black (43%) and Hispanic (43%) women compared with white (52%) women (aPR (95% CI): 0.80 (0.70, 0.93) and 0.80 (0.70, 0.91), respectively). In 2008-2011, proportion of HPV16/18 detected was significantly lower in black (47%), Hispanic (46%), and Asian (42%) women compared to white (58%) women (aPR (95% CI): 0.80 (0.67, 0.96), 0.75 (0.63, 0.90), and 0.73 (0.58, 0.90), respectively). There were no significant differences in 2012-2015. Between the two eras, HPV16/18 prevalence declined in white (-11%), black (-9%), and Hispanic (-6%) women, and increased in Asian women (12%). Decreasing HPV 16/18 prevalence in CIN2/3/AIS lesions in white, black, and Hispanic women may suggest benefit from quadrivalent vaccination. In our unadjusted analysis of HPV31/33/45/52/58, prevalence did not differ significantly by race/ethnicity, but was significantly higher among Hispanic women (32%) compared to white women (27%) after adjustment (aPR (95%CI): 1.22 (1.02, 1.47). Prevalence was also non-significantly higher among black (32%) and Asian (33%) women. This analysis suggests that the nonavalent vaccine’s potential for impact against cervical precancers will not be lower in women of color compared to white women. These data underscore the importance of equitable vaccination in facilitating continued declines of vaccine-preventable HPV types among all women.

Authors: Saadeh K; Park I; Gargano JW; Whitney E; Querec TD; Hurley L; Silverberg M

Vaccine. 2019 Oct 11.

PubMed abstract

Is it possible to overcome the ‘long arm’ of childhood socioeconomic disadvantage through upward socioeconomic mobility?

Socioeconomically disadvantaged children have worse adult health; we test if this ‘long arm’ of childhood disadvantage can be overcome through upward socioeconomic mobility in adulthood. Four SES trajectories (stable low, upwardly mobile, downwardly mobile and stable high) were created from median dichotomized childhood socioeconomic status (SES; childhood human and financial capital) and adult SES (wealth at age 67) from Health and Retirement Study respondents (N = 6669). Healthy ageing markers, in tertiles, were walking speed, peak expiratory flow (PEF), and grip strength measured in 2008 and 2010. Multinomial logistic regression models, weighted to be nationally representative, controlled for age, gender, race, birthplace, outcome year and childhood health and social capital. Upwardly mobile individuals were as likely as the stable high SES group to be in the best health tertile for walking speed (OR = 0.81; 95% CI: 0.63, 1.05; P = 0.114), PEF (OR = 0.97; 95% CI: 0.78, 1.21; P = 0.810) and grip strength (OR = 0.97; 95%CI: 0.74, 1.27; P = 0.980). Findings suggest the ‘long arm’ of childhood socioeconomic disadvantage can be overcome for these markers of healthy ageing through upward socioeconomic mobility.

Authors: Vable AM; Gilsanz P; Kawachi I

J Public Health (Oxf). 2019 09 30;41(3):566-574.

PubMed abstract

Mental and Physical Quality of Life by Age Groups in People Living With HIV

Quality of life (QoL) is relevant to people living with HIV (PLWH) with increased life expectancy because of antiretroviral therapy. Our cross-sectional study examined associations between sociodemographic, HIV-related and psychological variables, and QoL, overall and by age. PLWH (n = 614) completed questionnaires at enrollment in an alcohol treatment study. QoL was assessed by the 12-item Short Form Survey, which includes physical and mental domains. Linear regression models evaluated the association of age and other factors with mental and physical QoL. PLWH younger than 50 years (n = 310) reported poorer mental QoL but better physical QoL compared to older PLWH (n = 304). Poorer mental QoL was associated with substance use, depression, and anxiety. Poorer physical QoL was associated with depression and history of injection drug use. We identified age-group differences in QoL for this primary care-based sample. Health care providers can use our findings to guide patient-centered care.

Authors: Jang HJ; Satre DD; Leyden W; Leibowitz A; Silverberg MJ

J Assoc Nurses AIDS Care. 2019 Sep-Oct;30(5):500-510.

PubMed abstract

Do breast quadrants explain racial disparities in breast cancer outcomes?

PURPOSE: Tumors of the inner quadrants of the breast are associated with poorer survival than those of the upper-outer quadrant. It is unknown whether racial differences in breast cancer outcomes are modified by breast quadrant, in addition to comparisons among Asian subgroups.METHODS: Using the Surveillance, Epidemiology, and End Results database, we analyzed data among women diagnosed with non-metastatic invasive breast cancer between 1990 and 2014. We performed Cox proportional hazards regression models to assess the associations of race with breast cancer-specific survival and overall survival, stratified by breast quadrants. The models were adjusted for age, year of the diagnosis, tumor size, grade, histological type, tumor laterality, lymph node, estrogen receptor, progesterone receptor, and treatments.RESULTS: Among 454,154 patients (73.0% White, 10.0% Black, 7.8% Asian/PI, and 9.2% Hispanic), 54.3% had tumors diagnosed in the upper-outer quadrant of the breast. Asian/PI women were more likely than White to have tumors diagnosed in the nipple/central portion of the breast and were less likely to have diagnosed in the upper-outer quadrant (P CONCLUSIONS: Differences in breast cancer survival by race could not be attributed to tumor locations. Understanding the cultural, biological, and lifestyle factors that vary between White, African American, and ethnic subgroups of Asian American women may help explain these survival differences.

Authors: Han, Yunan Y; Moore, Justin Xavier JX; Langston, Marvin M; Fuzzell, Lindsay L; Khan, Saira S; Lewis, Marquita W MW; Colditz, Graham A GA; Liu, Ying Y

Cancer causes & control : CCC. 2019 Nov ;30(11):1171-1182. Epub 2019-08-27.

PubMed abstract

A Seat at the Table: Strategic Engagement in Service Activities for Early Career Faculty From Underrepresented Groups in the Academy

Many academic institutions strive to promote more diverse and inclusive campuses for faculty, staff, and students. As part of this effort, these institutions seek to include individuals from historically underrepresented groups (URGs)-such as women, people from racial/ethnic minority populations, persons with disabilities-on committees and in other service activities. However, given the low number of faculty members from URGs at many institutions, these faculty members tend to receive more requests to provide service to the institution or department (e.g., serving on committees, mentoring) than their counterparts from majority groups. Faculty members from URGs, especially early-career faculty, thus risk becoming overburdened with providing service at the expense of working on other scholarly activities required for promotion and tenure (i.e., conducting research, publishing). Although many scholars and others have written about this “minority tax” and its implications for early-career faculty from underrepresented racial/ethnic minority groups, fewer have published about how this tax extends beyond racial/ethnic minorities to women and persons with disabilities. Further, the literature provides scant practical advice on how to avoid overburdening early-career faculty from URGs. Here, a group of multidisciplinary early- and mid-career faculty members from URGs seek to provide their peers from URGs with practical strategies for both evaluating the appropriateness of service requests and declining those that are not a good fit. The authors also provide institutional leaders with actionable recommendations to prevent early-career faculty from URGs from becoming overburdened with service.

Authors: Carson TL; Aguilera A; Brown SD; Peña J; Butler A; Dulin A; Jonassaint CR; Riley I; Vanderbom K; Molina KM; Cené CW

Acad Med. 2019 08;94(8):1089-1093.

PubMed abstract

A Systematic Review and Meta-analysis of Associations between Clinical Prostatitis and Prostate Cancer: New Estimates Accounting for Detection Bias.

BACKGROUND: Previous meta-analyses have estimated summary positive associations between clinical prostatitis and prostate cancer. However, none have accounted for detection bias, the possibility for increased prostate cancer screening and detection in men with clinical prostatitis, in their pooled estimates.METHODS: We searched for studies that investigated the relation between clinical prostatitis and prostate cancer through November 2018. Random effects meta-analysis was used to calculate summary odds ratios (OR) among all studies and in strata defined by methods used to reduce detection bias.Results: Although an increased odds of prostate cancer was seen among men with a history of clinical prostatitis in all 38 eligible studies combined [OR, 2.05; 95% confidence interval (CI), 1.64-2.57], this estimate attenuated to null among studies that performed the most rigorous analyses to limit detection bias (OR, 1.16; 95% CI, 0.77-1.74).CONCLUSIONS: Our findings indicate that previously reported positive associations between clinical prostatitis and prostate cancer are likely due to detection bias.IMPACT: Studies using rigorous detection bias methods are warranted to replicate these findings, as well as to examine the possible relation between prostate inflammation and prostate cancer directly, rather than indirectly through the diagnosis of "prostatitis," which includes a large proportion of men without evidence of prostate inflammation.

Authors: Langston, Marvin E ME; Horn, Mara M; Khan, Saira S; Pakpahan, Ratna R; Doering, Michelle M; Dennis, Leslie K LK; Sutcliffe, Siobhan S

Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2019 Oct ;28(10):1594-1603. Epub 2019-07-23.

PubMed abstract

Stressors in Midlife and Risk of Dementia: The Role of Race and Education

Posttraumatic stress disorder is associated with increased dementia risk but less is known about stress because of everyday problems in diverse populations. A total of 9605 health care plan members who provided information regarding midlife stressors in 1972 to 1973 (ages, 40 to 55 y) were followed for dementia diagnosis between 1996 and 2017. Cox proportional hazard models evaluated associations between midlife stressors and dementia adjusting for demographics and lifecourse health indicators. Reporting at least 1 midlife stressor was associated with 17% greater dementia risk [hazard ratio (HR), 1.17; 95% confidence interval (CI),1.07-1.27] versus 0 midlife stressors and 26% increased risk among those with less than equal to high school education (HR, 1.26; 95% CI,1.09-1.44) adjusting for demographics. Compared with whites without stressors, whites with ≥1 stressor had 13% greater dementia risk (HR, 1.13; 95% CI, 1.02-1.24), blacks without stressors 19% greater risk (HR, 1.19; 95% CI,1.08-1.32), and blacks with ≥1 stressors 47% greater risk (HR, 1.47; 95% CI,1.27-1.69) in fully adjusted models. Resource problems were associated with 20% greater risk (HR, 1.20; 95% CI, 1.01-1.42) than interpersonal problems. Reporting ≥1 serious midlife stressor was associated with elevated dementia risk, especially stressors related to resources problems and for those with less than equal to high school education. Everyday stressors can impact brain health over the long term and may contribute to racial inequities in dementia rates, though education can be a mitigating factor.

Authors: Gilsanz P; Quesenberry CP; Mayeda ER; Glymour MM; Farias ST; Whitmer RA

Alzheimer Dis Assoc Disord. 2019 Jul-Sep;33(3):200-205.

PubMed abstract

Association of Fitness With Racial Differences in Chronic Kidney Disease

Non-white minorities are at higher risk for chronic kidney disease than non-Hispanic whites. Better cardiorespiratory fitness is associated with slower declines in estimated glomerular filtration rate and a lower incidence of chronic kidney disease. Little is known regarding associations of fitness with racial disparities in chronic kidney disease. A prospective cohort of 3,842 young adults without chronic kidney disease completed a maximal treadmill test at baseline in 1985-1986. Chronic kidney disease status was defined as estimated glomerular filtration rate of <60 mL/min/1.73 m2 during 10-, 15-, 20-, 25-, and 30-year follow-up assessments (through 2006). Analyses were completed in 2019. Multivariable Cox models were used to determine hazard ratios and 95% CI for incidence of chronic kidney disease. Multivariable models included race, gender, age, field center, education, baseline estimated glomerular filtration rate, and time-varying covariates of healthy diet index, smoking status, alcohol intake, BMI, systolic blood pressure, and fasting glucose. Percent attenuation quantified the association of fitness to racial disparities in chronic kidney disease. Chronic kidney disease incidence was higher among blacks (n=83/1,941, 1.61 per 1,000 person years) than whites (43/1,901, 0.82 per 1,000 person years). Every 1-minute shorter treadmill duration was associated with 1.14 (95% CI=1.04, 1.25) times higher risk of chronic kidney disease. Blacks were 1.72 (95% CI=1.13, 2.63) times more likely to develop chronic kidney disease compared with whites. The risk was reduced to 1.54 (95% CI=1.01, 2.39) with fitness added. This suggests that fitness is associated with 20.4% (95% CI=5.8, 43.0%) of the excess risk of chronic kidney disease attributable to race. Low fitness is a modifiable factor that may contribute to the racial disparity in chronic kidney disease.

Authors: Paluch AE; Pool LR; Isakova T; Lewis CE; Mehta R; Schreiner PJ; Sidney S; Wolf M; Carnethon MR

Am J Prev Med. 2019 07;57(1):68-76. Epub 2019-05-21.

PubMed abstract

Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform

The Affordable Care Act (ACA) promised to narrow smoking disparities by expanding access to healthcare and mandating comprehensive coverage for tobacco treatment starting in 2014. We examined whether two years after ACA implementation disparities in receiving clinician advice to quit and smokers’ knowledge and use of treatment resources remained. We conducted telephone interviews in 2016 with a stratified random sample of self-reported smokers newly enrolled in the Kaiser Permanente Northern California’s (KPNC) integrated healthcare delivery system in 2014 (N = 491; 50% female; 53% non-white; 6% Spanish language). We used Poisson regression with robust standard errors to test whether sociodemographics, insurance type, comorbidities, smoking status in 2016 (former, light/nondaily [<5 cigarettes per day], daily), and preferred language (English or Spanish) were associated with receiving clinician advice to quit and knowledge and use of tobacco treatment. We included an interaction between smoking status and language to test whether the relation between smoking status and key outcomes varied with preferred language. Overall, 80% of respondents received clinician advice to quit, 84% knew that KPNC offers cessation counseling, 54% knew that cessation pharmacotherapy is free, 54% used pharmacotherapy, and 6% used counseling. In multivariate models, Spanish-speaking light/nondaily smokers had significantly lower rates of all outcomes, while there was no association with other demographic and clinical characteristics. Following ACA implementation, most smokers newly enrolled in KPNC received clinician advice to quit and over half used pharmacotherapy, yet counseling utilization was low. Spanish-language outreach efforts and treatment services are recommended, particularly for adults who are light/nondaily smokers.

Authors: Young-Wolff KC; Adams SR; Tan ASL; Adams AS; Klebaner D; Campbell CI; Satre DD; Salloum RG; Carter-Harris L; Prochaska JJ

Prev Med Rep. 2019 Jun;14:100847. Epub 2019-03-15.

PubMed abstract

Perceived and objective characteristics of the neighborhood environment are associated with accelerometer-measured sedentary time and physical activity, the CARDIA Study

We investigated cross-sectional and longitudinal associations of neighborhood environment characteristics with accelerometer-measured sedentary time (SED), light-intensity physical activity (LPA), and moderate-to-vigorous intensity physical activity (MVPA). Participants were 2120 men and women in the year 20 (2005-2006) and year 30 CARDIA exams (2015-2016). Year 20 neighborhood characteristics included neighborhood cohesion, resources for physical activity, poverty, and racial residential segregation. Physical activity was measured by accelerometer at years 20 and 30. Multivariable linear regression models examined associations of standardized neighborhood measures at year 20 with SED, LPA, and MVPA assessed that year, and with 10-year changes in SED, LPA, and MVPA. Cross-sectionally, a one standard deviation (SD) increase in cohesion was associated with 4.06 less SED min/day (95% CI: -7.98, -0.15), and 4.46 more LPA min/day (95% CI: 0.88, 8.03). Each one SD increase in resources was associated with 1.19 more MVPA min/day (95% CI: 0.06, 2.31). A one SD increase in poverty was associated with 11.18 less SED min/day (95% CI: -21.16, -1.18) and 10.60 more LPA min/day (95% CI: 1.79, 19.41) among black men. No neighborhood characteristic was associated with 10-year changes in physical activity in the full sample; however, a one SD increase in cohesion was associated with a 10-year decrease of 25.44 SED min/day (95% CI: -46.73, -4.14) and an increase of 19.0 LPA min/day (95% CI, 1.89, 36.10) in black men. Characteristics of the neighborhood environment are associated with accelerometer-measured physical activity. Differences were observed by race and sex, with more robust findings observed in black men.

Authors: Whitaker KM; Xiao Q; Pettee Gabriel K; Gordon Larsen P; Jacobs DR; Sidney S; Reis JP; Barone Gibbs B; Sternfeld B; Kershaw K

Prev Med. 2019 06;123:242-249. Epub 2019-03-30.

PubMed abstract

Strategies for Building Delivery Science in an Integrated Health Care System

Health systems today have increasing opportunities and imperatives to conduct delivery science, which is applied research that evaluates clinical or organizational practices that systems can implement or encourage. Examples include research on eliminating racial/ethnic disparities in hypertension management and on identifying the types of patients who can successfully use video visits. Clinical leaders and researchers often face barriers to delivery science, including limited funding, insufficient leadership support, lack of engagement between operational and research leaders, limited pools of research expertise, and lack of pathways to identify and develop ideas. We describe five key strategies we employed to address these barriers and develop a portfolio of delivery science programs in Kaiser Permanente Northern California. This portfolio now includes small and medium-sized grant programs, training programs for postdoctoral research fellows and experienced physician researchers, and a dedicated team that partners with clinicians to develop high-priority ideas and conduct small projects. Most of our approaches are consistent with frameworks used to develop delivery science by other health systems; some are innovative. Most of these strategies are adaptable by other health systems prepared to make long-range organizational commitments to mechanisms that foster partnerships between clinical leaders and researchers.

Authors: Lieu TA; Madvig PR

J Gen Intern Med. 2019 06;34(6):1043-1047. Epub 2019-01-25.

PubMed abstract

Disparities in Health Information-Seeking Behaviors and Fatalistic Views of Cancer by Sexual Orientation Identity: A Nationally Representative Study of Adults in the United States.

Purpose: A lack of national data makes it difficult to estimate, but LGB adults appear to have a higher risk of cancer. Although limited research exists to explain the disparity, we aimed to explore potential differences in access to and utilization of health information and in cancer-related beliefs and behaviors. Methods: We used data from the Health Information National Trends Survey 5, Cycle 1 conducted from January 25 through May 5, 2017. Using survey-weighted logistic regression, we explored potential differences in health information-seeking behavior, trusted sources of health care information, engagement with the health care system, awareness of cancer risk factors, cancer fatalism, cancer-related health behaviors, and historical cancer screening between 117 LGB and 2857 heterosexual respondents. Results: LGB respondents were more likely to report looking for information about health or medical topics than heterosexual respondents (adjusted odds ratio [aOR]: 3.12; confidence interval [95% CI]: 1.07-9.06), but less likely to seek health information first from a doctor (aOR: 0.17; 95% CI: 0.06-0.50) after adjusting for age, race, and sex. LGB persons were less likely to report that they trust receiving health or medical information from friends and family and more likely to be worried about getting cancer (aOR: 2.30; 95% CI: 1.04-5.05). Conclusions: Our findings indicate a growing need for the production of tailored cancer prevention and control materials for members of sexual minority groups. More work is needed to understand barriers that LGB populations face in accessing this health information and building informative social support networks.

Authors: Langston, Marvin E ME; Fuzzell, Lindsay L; Lewis-Thames, Marquita W MW; Khan, Saira S; Moore, Justin X JX

LGBT health. 2019 Oct ;6(4):192-201. Epub 2019-05-20.

PubMed abstract

Time to Follow-up After Colorectal Cancer Screening by Health Insurance Type

The purpose of this study was to test the hypothesis that patients with Medicaid insurance or Medicaid-like coverage would have longer times to follow-up and be less likely to complete colonoscopy compared with patients with commercial insurance within the same healthcare systems. A total of 35,009 patients aged 50-64years with a positive fecal immunochemical test were evaluated in Northern and Southern California Kaiser Permanente systems and in a North Texas safety-net system between 2011 and 2012. Kaplan-Meier estimation was used between 2016 and 2017 to calculate the probability of having follow-up colonoscopy by coverage type. Among Kaiser Permanente patients, Cox regression was used to estimate hazard ratios and 95% CIs for the association between coverage type and receipt of follow-up, adjusting for sociodemographics and health status. Even within the same integrated system with organized follow-up, patients with Medicaid were 24% less likely to complete follow-up as those with commercial insurance. Percentage receiving colonoscopy within 3 months after a positive fecal immunochemical test was 74.6% for commercial insurance, 63.10% for Medicaid only, and 37.5% for patients served by the integrated safety-net system. This study found that patients with Medicaid were less likely than those with commercial insurance to complete follow-up colonoscopy after a positive fecal immunochemical test and had longer average times to follow-up. With the future of coverage mechanisms uncertain, it is important and timely to assess influences of health insurance coverage on likelihood of follow-up colonoscopy and identify potential disparities in screening completion.

Authors: Breen N; Corley DA; PROSPR consortium; et al.

Am J Prev Med. 2019 05;56(5):e143-e152.

PubMed abstract

Barriers to preexposure prophylaxis use among individuals with recently acquired HIV infection in Northern California

Barriers to HIV preexposure prophylaxis (PrEP) use have not been well-characterized in people who became HIV-infected, all of whom could have benefited from PrEP. We invited Kaiser Permanente Northern California members diagnosed with HIV during 2014-2016, following a negative HIV test in the prior year, to complete a survey assessing barriers to PrEP use before HIV diagnosis. Of 268 patients surveyed, 122 (46%) responded. Median age was 36, most (84%) were men who have sex with men, and 64% were of minority racial/ethnic background. Thirty-six (30%) had discussed PrEP with a provider, of whom 10 were diagnosed with HIV at PrEP intake. Overall, only 5 (4.1%) had used PrEP, and all 5 discontinued before diagnosis. Among all respondents, the most common barrier to PrEP use was lack of PrEP awareness (51%). Among those aware of PrEP, the most common barriers were cost/insurance concerns (36%) and perceived low risk for HIV (24%). Lack of PrEP awareness ranged from 39% among those aged 25-34 to 88% among those aged <25 (P?=?0.011), and from 33% among Hispanics to 69% among Blacks (P?=?0.055). Increasing awareness and affordability of PrEP, and facilitating accurate assessment of HIV risk, are critical to reducing missed opportunities for PrEP.

Authors: Marcus JL; Hurley LB; Dentoni-Lasofsky D; Ellis CG; Silverberg MJ; Slome S; Snowden JM; Volk JE

AIDS Care. 2019 05;31(5):536-544. Epub 2018-10-10.

PubMed abstract

Early-onset triple-negative breast cancer in multiracial/ethnic populations: Distinct trends of prevalence of truncation mutations

Young black women are at higher risk of triple-negative breast cancer (TNBC); however, a majority of the genetic studies on cancer predisposition were carried out in White populations. The underrepresentation of minority racial/ethnic populations in cancer genetic studies may have led to disproportionate gaps in our knowledge of cancer predisposition genes in these populations. We surveyed the protein-truncating mutations at the exome-wide scale and in known breast cancer predisposition genes among 170 patients of multiple racial/ethnic groups with early-onset (≤age 50) TNBC from two independent cohorts. Black patients, on average, had a higher number of truncating mutations than Whites at the exome-wide level, but fewer truncating mutations in the panel of known breast cancer genes. White TNBC patients showed a strong enrichment of truncating variants in known breast cancer genes, whereas no such enrichment was found among Black patients. Our findings indicate likely more breast cancer disposition genes yet to be discovered in minority racial/ethnic groups, and the current multigene panels may result in unequal benefits from cancer genetic testing.

Authors: Liu Q; Yao S; Zhao H; Hu Q; Kwan ML; Roh JM; Ambrosone CB; Kushi LH; Liu S; Zhu Q

Cancer Med. 2019 04;8(4):1845-1853. Epub 2019-03-12.

PubMed abstract

Incidence of dementia after age 90 in a multiracial cohort

Little is known about dementia incidence in diverse populations of oldest-old, the age group with highest dementia incidence. Incident dementia diagnoses from 1/1/2010 to 9/30/2015 were abstracted from medical records for 2350 members of an integrated health care system in California (n = 1702 whites, n = 375 blacks, n = 105 Latinos, n = 168 Asians) aged ≥90 in 2010. We estimated race/ethnicity-specific age-adjusted dementia incidence rates and implemented Cox proportional hazards models and Fine and Gray competing risk of death models adjusted for demographics and comorbidities in midlife and late-life. Dementia incidence rates (n = 771 cases) were lowest among Asians (89.9/1000 person-years), followed by whites (96.9/1000 person-years), Latinos (105.8/1000 person-years), and blacks (121.5/1000 person-years). Cox regression and competing risk models estimated 28% and 36% higher dementia risk for blacks versus whites adjusting for demographics and comorbidities. Patterns of racial/ethnic disparities in dementia seen in younger older adults continue after the age of 90 years, though smaller in magnitude.

Authors: Gilsanz P; Corrada MM; Kawas CH; Mayeda ER; Glymour MM; Quesenberry CP; Lee C; Whitmer RA

Alzheimers Dement. 2019 04;15(4):497-505. Epub 2019-02-20.

PubMed abstract

Large-scale, multi-ethnic genome-wide association study identifies novel loci contributing to asthma susceptibility in adults

Authors: Dahlin A; Iribarren C; Wu AC; et al.

J Allergy Clin Immunol Pract. 2020 05;8(5):1475-1476. Epub 2020-04-06.

PubMed abstract

Poor diet quality in pregnancy is associated with increased risk of excess fetal growth: a prospective multi-racial/ethnic cohort study

Nutritional perturbations during pregnancy may impact fetal and long-term childhood growth, although there are limited data on overall diet quality. We investigated whether diet quality, measured by the Healthy Eating Index-2010 (HEI-2010), during pregnancy was related to birthweight z-score (BWZ) and the clinically relevant birth outcomes of large- and small-for-gestational age (LGA and SGA). In a prospective cohort of 2269 multi-racial/ethnic women from the Pregnancy Environment and Lifestyle Study (2014-2017), dietary intake was assessed by a food frequency questionnaire during early pregnancy. Offspring BWZ and LGA or SGA were derived based on gestational age-, sex-, and racial/ethnic-specific birthweight distributions. Multivariable linear and Poisson regression with robust standard errors were used. About 80% of women did not achieve good diet quality (HEI-2010?

Authors: Zhu Y; Hedderson MM; Sridhar S; Xu F; Feng J; Ferrara A

Int J Gynaecol Obstet. 2020 Jan;148 Suppl 1:42-58.

PubMed abstract

Prevalence and Factors Influencing Use of Internet and Electronic Health Resources by Middle-Aged and Older Adults in a US Health Plan Population: Cross-Sectional Survey Study

Health care organizations are increasingly using electronic health (eHealth) platforms to provide and exchange health information and advice (HIA). There is limited information about how factors beyond internet access affect use of eHealth resources by middle-aged and older adults. We aimed to estimate prevalence of use of the internet, health plan patient portal, and Web-based HIA among middle-aged and older adults; investigate whether similar sociodemographic-related disparities in eHealth resource use are found among middle-aged and older adults; and examine how sociodemographic and internet access factors drive disparities in eHealth resource use among adults who use the internet. We analyzed cross-sectional survey data for 10,920 Northern California health plan members aged 45 to 85 years who responded to a mailed and Web-based health survey (2014-2015). We used bivariate and multivariable analyses with weighted data to estimate prevalence of and identify factors associated with internet use and self-reported past year use of the health plan’s patient portal and Web-based HIA resources by middle-aged adults (aged 45 to 65 years; n=5520), younger seniors (aged 65 to 75 years; n=3014), and older seniors (aged 76 to 85 years; n=2389). Although approximately 96% of middle-aged adults, 92% of younger seniors, and 76% of older seniors use the internet to obtain information, about 4%, 9%, and 16%, respectively, require someone’s help to do so. The percentages who used the patient portal and Web-based HIA resources were similar for middle-aged adults and younger seniors but lower among older seniors (59.6%, 61.4%, and 45.0% and 47.9%, 48.4%, and 37.5%, respectively). Disparities in use of the internet, patient portal, and Web-based HIA across levels of education and between low and higher income were observed in all age groups, with wider disparities between low and high levels of education and income among seniors. Multivariable analyses showed that for all 3 age groups, educational attainment, ability to use the internet without help, and having 1 or more chronic condition were significant predictors of patient portal and Web-based HIA use after controlling for gender, race/ethnicity, and internet use. Internet use, and especially use without help, significantly declines with age, even within a middle-aged group. Educational attainment is significantly associated with internet use, ability to use the internet without help, and use of patient portal and Web-based HIA resources by middle-aged and older adults. Even among middle-aged and older adult internet users, higher educational attainment and ability to use the internet without help are positively associated with patient portal and Web-based HIA use. Organizations serving middle-aged and older adults should take into account target population characteristics when developing and evaluating uptake of eHealth resources and should consider offering instruction and support services to boost patient engagement.

Authors: Crouch E; Gordon NP

JMIR Aging. 2019 Mar 26;2(1):e11451. Epub 2019-03-26.

PubMed abstract

Racial Differences in Maintaining Optimal Health Behaviors Into Middle Age

Earlier development of cardiovascular disease risk factors in blacks versus whites may result from differences in maintaining health behaviors. Age-specific racial differences in maintaining health behaviors from ages 18 to 50 years were determined. In 1985-1986, the population-based Coronary Artery Risk Development in Young Adults study enrolled 5,115 participants aged 18-30 years. In 2017, a total of 2,485 blacks and 2,407 whites with one or more optimal health behaviors at baseline who attended one or more of seven follow-up exams over 25 years (i.e., through 2010-2011) were analyzed. The primary outcome, maintaining four or more optimal health behaviors, included BMI <25; never smoking; ≥150 minutes/week of moderate to vigorous physical activity; no/moderate alcohol intake (women/men: zero to seven/zero to 14 drinks per week); and Dietary Approaches to Stop Hypertension diet adherence score ≥15 (i.e., baseline highest quartile). Hazard ratios comparing blacks with whites for maintaining optimal health behaviors were calculated among participants with each optimal behavior at baseline. From ages 18 to 50 years, 2.6% of blacks and 9.2% of whites maintained four or more optimal health behaviors (for optimal BMI: 16.0% and 30.1%, smoking status: 74.6% and 78.4%, physical activity: 17.7% and 21.4%, alcohol intake: 68.4% and 64.6%, diet adherence: 3.9% and 10.3%, respectively). The multivariable adjusted hazard ratio comparing blacks with whites was 0.63 (95% CI=0.56, 0.72) for maintaining four or more optimal health behaviors (for optimal BMI: 0.82 [95% CI=0.66, 1.01], smoking status: 0.57 [95% CI=0.52, 0.62], physical activity: 0.83 [95% CI=0.75, 0.91], alcohol intake: 1.19 [95% CI=1.03, 1.37], diet adherence: 0.71 [95% CI=0.61, 0.82]). Fewer blacks than whites maintained four or more optimal health behaviors until age 50 years, but maintenance was low among both races.

Authors: Booth JN; Spring B; Muntner P; et al.

Am J Prev Med. 2019 03;56(3):368-375.

PubMed abstract

One Size Fits (n)One: The Influence of Sex, Age, and Sexual Human Immunodeficiency Virus (HIV) Acquisition Risk on Racial/Ethnic Disparities in the HIV Care Continuum in the United States

The United States National HIV/AIDS Strategy established goals to reduce disparities in retention in human immunodeficiency virus (HIV) care, antiretroviral therapy (ART) use, and viral suppression. The impact of sex, age, and sexual HIV acquisition risk (ie, heterosexual vs same-sex contact) on the magnitude of HIV-related racial/ethnic disparities is not well understood. We estimated age-stratified racial/ethnic differences in the 5-year restricted mean percentage of person-time spent in care, on ART, and virally suppressed among 19 521 women (21.4%), men who have sex with men (MSM; 59.0%), and men who have sex with women (MSW; 19.6%) entering HIV care in the North American AIDS Cohort Collaboration on Research and Design between 2004 and 2014. Among women aged 18-29 years, whites spent 12.0% (95% confidence interval [CI], 1.1%-20.2%), 9.2% (95% CI, .4%-20.4%), and 13.5% (95% CI, 2.7%-22.5%) less person-time in care, on ART, and virally suppressed, respectively, than Hispanics. Black MSM aged ≥50 years spent 6.3% (95% CI, 1.3%-11.7%), 11.0% (95% CI, 4.6%-18.1%), and 9.7% (95% CI, 3.6%-16.8%) less person-time in these stages, respectively, than white MSM ≥50 years of age. Among MSM aged 40-49 years, blacks spent 9.8% (95% CI, 2.4%-16.5%) and 11.9% (95% CI, 3.8%-19.3%) less person-time on ART and virally suppressed, respectively, than whites. Racial/ethnic differences in HIV care persist in specific populations defined by sex, age, and sexual HIV acquisition risk. Clinical and public health interventions that jointly target these demographic factors are needed.

Authors: Desir FA; Silverberg M; North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) Region of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium; et al.

Clin Infect Dis. 2019 02 15;68(5):795-802.

PubMed abstract

Sexual Orientation Disparities in Physical Activity: Results From Insured Adults in California

The majority of adults in the United States fail to meet the Centers for Disease Control and Prevention (CDC) physical activity (PA) guideline recommendations for health promotion. Despite evidence of disparities by sexual orientation in adverse health outcomes related to PA, little is known about whether PA patterns and the likelihood of meeting these guidelines differ between heterosexual and sexual minority (SM) men and women. In 2018, we pooled unweighted respondent data from Kaiser Permanente Northern California Member Health Surveys conducted in 2008, 2011, and 2014/15 (N=42,534) to compare PA patterns among heterosexual and SM men and women. In total, 38.8% of heterosexual men, 43.4% of SM men, 32.9% of heterosexual women, and 40.0% of SM women meet the CDC PA guidelines, yet there was no statistically significant difference in the adjusted odds of meeting these guidelines. Compared with heterosexual women, SM women engage in PA more frequently [odds ratio=0.81; 95% confidence interval (CI), 0.74-0.89], for more minutes per week on average (12.71; 95% CI, 4.85-20.57), and at higher levels of intensity (relative risk ratio=1.26; 95% CI, 1.02-1.56). Compared with heterosexual men, SM men engage in PA more frequently (OR=0.85; 95% CI, 0.74-0.98), for fewer minutes per week on average (-12.89; 95% CI, -25.84 to 0.06), and at lower levels of intensity (relative risk ratio=0.83; 95% CI, 0.67-0.99). We find that SMs get more frequent PA than their heterosexual peers, which suggests that the higher prevalence of obesity and other PA-related adverse health outcomes among SMs may be due to factors other than PA patterns.

Authors: Fricke J; Gordon N; Downing J

Med Care. 2019 02;57(2):138-144.

PubMed abstract

Racial discrimination in medical care settings and opioid pain reliever misuse in a U.S. cohort: 1992 to 2015

In the United States whites are more likely to misuse opioid pain relievers (OPRs) than blacks, and blacks are less likely to be prescribed OPRs than whites. Our objective is to determine whether racial discrimination in medical settings is protective for blacks against OPR misuse, thus mediating the black-white disparities in OPR misuse. We used data from 3528 black and white adults in the Coronary Artery Risk Development in Young Adults (CARDIA) study, an ongoing multi-site cohort. We employ causal mediation methods, with race (black vs white) as the exposure, lifetime discrimination in medical settings prior to year 2000 as the mediator, and OPR misuse after 2000 as the outcome. We found black participants were more likely to report discrimination in a medical setting (20.3% vs 0.9%) and less likely to report OPR misuse (5.8% vs 8.0%, OR = 0.71, 95% CI = 0.55, 0.93, adjusted for covariates). Our mediation models suggest that when everyone is not discriminated against, the disparity is wider with black persons having even lower odds of reporting OPR misuse (OR = 0.63, 95% CI = 0.45, 0.89) compared to their white counterparts, suggesting racial discrimination in medical settings is a risk factor for OPR misuse rather than protective. These results suggest that racial discrimination in a medical setting is a risk factor for OPR misuse rather than being protective, and thus could not explain the seen black-white disparity in OPR misuse.

Authors: Swift SL; Glymour MM; Elfassy T; Lewis C; Kiefe CI; Sidney S; Calonico S; Feaster D; Bailey Z; Zeki Al Hazzouri A

PLoS One. 2019;14(12):e0226490. Epub 2019-12-20.

PubMed abstract

Patterns of Health Care Utilization Before First Episode Psychosis in Racial and Ethnic Groups

To compare patterns of health care utilization associated with first presentation of psychosis among different racial and ethnic groups of patients. The study was a retrospective observational design. The study was conducted in five health care systems in the western United States. All sites were also part of the National Institute of Mental Health-funded Mental Health Research Network (MHRN). Patients (n = 852) were aged 15 – 59 years (average 26.9 ± 12.2 years), 45% women, and primarily non-Hispanic White (53%), with 16% Hispanic, 10% non-Hispanic Black, 6% Asian, 1% Native Hawaiian/Pacific Islander, 1% Native American/ Alaskan Native, and 12% unknown race/ethnicity. Variables examined were patterns of health care utilization, type of comorbid mental health condition, and type of treatment received in the three years before first presentation of psychosis. Data abstracted from electronic medical records and insurance claims data were organized into a research virtual data warehouse (VDW) and used for analysis. Compared with non-Hispanic Whites, Asian patients (16% vs 34%; P=.007) and non-Hispanic Black patients (20% vs 34%; P=.009) were less likely to have a visit with specialty mental health care before their first presentation of psychosis. Early detection of first episode psychosis should start with wider screening for symptoms outside of any indicators for mental health conditions for non-Hispanic Black and Asian patients.

Authors: Coleman KJ; Yarborough BJ; Beck A; Lynch FL; Stewart C; Penfold RS; Hunkeler EM; Operskalski BH; Simon GE

Ethn Dis. 2019 Fall;29(4):609-616. Epub 2019-10-17.

PubMed abstract

Sociodemographic Determinants of Health and Well-Being Among Adults Residing in the Combined Kaiser Permanente Regions

Kaiser Permanente commissioned a health and well-being (HWB) survey of adult members and nonmembers in its 8 Regions. To estimate the prevalence of HWB indicators and evaluate differences in prevalence of excellent/very good (E/VG) health and thriving overall in life (thriving) by race/ethnicity, age group, sex, education, and financial situation. Cross-sectional survey conducted by email and phone during Winter 2016-2017 with a racial/ethnic group-stratified quota sample. Participants (N = 26,304) provided sociodemographic characteristics and ratings for 6 HWB indicators. Using population-weighted data, we estimated the prevalence of HWB indicators and used logistic regression models to test for differences in E/VG health and thriving by sociodemographic factors. Overall health and overall life evaluation. Of adults, 52% were in E/VG health and 63% were thriving. Blacks were less likely to be in E/VG health than whites, Hispanics, and Asian/Pacific Islanders, but there was little racial/ethnic variation in those who were thriving. E/VG health and thriving varied significantly by level of education and financial situation. Across all racial/ethnic groups, large differences in percentages were observed in E/VG health and thriving between the lowest and highest levels of education and financial situation but little racial/ethnic variation within education and financial situation strata. Differences in health status and life evaluation are associated very strongly with financial situation and educational attainment, and these social determinants partially explain racial/ethnic disparities in HWB. The lack of strong correlation of health status and life evaluation suggests these are different domains of well-being.

Authors: Stiefel MC; Gordon NP; Wilson-Anumudu FJ; Arsen EL

Perm J. 2019;23.

PubMed abstract

Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study

Latinos face unique challenges engaging with their health care providers for risk management of cardiovascular disease (CVD). To better understand differences in how Latinos and non-Latino whites (NLWs) experience CVD care. We examined self-reported activation, engagement, confidence, and communication comparing Latinos (n = 194) and NLWs (n = 208). Data were taken from baseline survey assessments of participants in the CREATE Wellness Study (NCT02302612), designed to help patients with poorly controlled CVD risk factors more actively engage in their care. The groups were compared using ?2 tests and separate logistic regression models adjusting for age, age and income, and age and educational attainment. Latinos in this cohort were younger, were less educated, and had lower incomes than did NLWs. In age-adjusted models, Latinos were significantly less likely to report knowing how to ask good questions about their health (71.1% vs 83.7% for NLW, p < 0.01; adjusted odds ratio = 0.49, 95% confidence interval = 0.29-0.83). Further adjustment by educational attainment or income did not attenuate this association. Latinos were also significantly more likely to report positive experiences and confidence with several measures of chronic illness care (adjusted odds ratio range = 1.57-2.01). Further adjustment by educational attainment eliminated these associations. We found notable differences between Latinos and NLWs in their experience of health care. These results provide insights into how CVD risk management programs can be tailored for Latinos. Interventions to improve patient activation and engagement for Latinos with CVD should emphasize question-asking skills.

Authors: Torres DX; Lu WY; Uratsu CS; Sterling SA; Grant RW

Perm J. 2019;23.

PubMed abstract

Links between age at menarche, antral follicle count, and body mass index in African American and European American women

To examine the relationships between age at menarche, antral follicle count (AFC), and body mass index (BMI) in a multi-ethnic population of women. Community-based, cross-sectional study. Academic setting. A total of 245 African American women and 273 European American women, aged 25-45 years, with regular menstrual cycles and no reproductive disorders. The ethnicity of these women was self-reported and genetically validated. The AFCs were measured by transvaginal ultrasound during the early follicular phase. Anthropometric measurements were taken, and age at menarche was gathered by questionnaire. Determination of the associations between age of menarche and adult AFC and BMI. Earlier age of menarche was associated with both higher BMIs and higher AFCs in adulthood, with control for female age. The antral follicle difference between early (<12 years) vs. late (?15 years) initiation of menarche in both white and black women was +3.81 and +3.34 follicles, respectively, which is equivalent to an approximately 20% difference in AFC. This study provides the first evidence that timing of menarche may influence AFC. Because of limited studies on African American women, this work provides additional needed data and may enhance our ability to prospectively screen and better treat various diseases associated with the female reproductive lifespan.

Authors: Schuh SM; Kadie J; Rosen MP; Sternfeld B; Reijo Pera RA; Cedars MI

Fertil Steril. 2019 04;111(4):629-640.

PubMed abstract

Shake Rattle & Roll – Design and rationale for a pragmatic trial to improve blood pressure control among blacks with persistent hypertension

In Kaiser Permanente Northern California (KPNC), members had similar access to care and a very high overall rate of hypertension control. However, blacks had poorer blood pressure (BP) control than whites. The Shake Rattle & Roll (SRR) trial aimed to improve BP control rates in blacks and to reduce disparities in hypertension control. SRR was a cluster randomized controlled trial conducted at an urban medical center. All 98 adult primary care physicians (PCP) and their panels of hypertensive black patients were randomized, stratified by panel size, to one of three arms: 1) Usual Care (n?=?33 PCPs, N?=?1129 patients); 2) Enhanced Monitoring arm with an emphasis on improving pharmacotherapy protocol adherence (n?=?34 PCPs, N?=?349 patients); or 3) Lifestyle arm with a culturally tailored diet and lifestyle coaching intervention focusing on the Dietary Approaches to Stop Hypertension eating plan (n?=?31 PCPs, N?=?286 patients). The intervention period was for 12-months post-enrollment. Follow-up was planned for one and three years post-intervention completion. Primary outcome measure was the proportion of participants with controlled BP, defined as <140/90?mmHg, at 12-months post-enrollment. Secondary outcome included adverse cardiovascular events. An intention-to-treat analysis was carried out as the primary analysis. SRR was a uniquely designed trial that included components from both pragmatic and explanatory methods. The pragmatic aspects allow for a more cost-effective way to conduct a clinical trial and easier implementation of successful interventions into clinical practice. However, there were also challenges of having mixed methodology with regards to trial conduction and analysis.

Authors: Nguyen-Huynh MN; Young JD; Alexeeff S; Hatfield MK; Sidney S

Contemp Clin Trials. 2019 01;76:85-92. Epub 2018-11-28.

PubMed abstract

Birth in High Infant Mortality States and Dementia Risk in a Cohort of Elderly African American and White Health Care Members

Birth in areas with high infant mortality rates (IMRs) has been linked to worse long-term health outcomes, yet it is completely unknown if it impacts dementia risk. In total 6268 health care members were followed for dementia diagnosis from 1996 to 2015. Birth state IMRs from 1928 were ranked into quartile (worst IMRs quartile range, whites: 69 to 129 deaths/1000 live births, Non-whites: 129 to 277 deaths/1000 live births). Cox proportional hazard models estimated the dementia risk associated with birth state IMR quartile adjusting for demographics and lifecourse health indicators. Compared with whites born outside of states in the worst IMR quartile, African Americans born in states in the worst IMR quartile had 92% increased dementia risk (HR=1.92; 95% CI: 1.42, 2.59), and African Americans born outside those states had 36% increased risk (HR=1.36; 95% CI: 1.20, 1.53). There was no association between birth state IMR and dementia risk among whites. Birth in states with the highest rates of infant mortality was associated with elevated dementia risk among African Americans but not whites. The large absolute difference in IMRs likely reflects harsher early childhood conditions experienced by African Americans. These findings suggest that childhood conditions may play a role in racial disparities in dementia rates.

Authors: Gilsanz P; Mayeda ER; Glymour MM; Quesenberry CP; Mungas D; DeCarli CS; Whitmer RA

Alzheimer Dis Assoc Disord. 2019 Jan-Mar;33(1):1-6.

PubMed abstract

Patterns of medication adherence in a multi-ethnic cohort of prevalent statin users diagnosed with breast, prostate, or colorectal cancer

To investigate the implications of a cancer diagnosis on medication adherence for pre-existing comorbid conditions, we explored statin adherence patterns prior to and following a new diagnosis of breast, colorectal, or prostate cancer among a multi-ethnic cohort. We identified adults enrolled at Kaiser Permanente Northern California who were prevalent statin medication users, newly diagnosed with breast, colorectal, or prostate cancer between 2000 and 2012. Statin adherence was measured using the proportion of days covered (PDC) during the 2-year pre-cancer diagnosis and the 2-year post-cancer diagnosis. Adherence patterns were assessed using generalized estimating equations, for all cancers combined and stratified by cancer type and race/ethnicity, adjusted for demographic, clinical, and tumor characteristics. Among 10,177 cancer patients, statin adherence decreased from pre- to post-cancer diagnosis (adjusted odds ratio (ORadj):0.91, 95% confidence interval (95% CI):0.88-0.94). Statin adherence decreased from pre- to post-cancer diagnosis among breast (ORadj:0.94, 95% CI:0.90-0.99) and colorectal (ORadj:0.79, 95% CI:0.74-0.85) cancer patients. No difference in adherence was observed among prostate cancer patients (ORadj:1.01, 95% CI:0.97-1.05). Prior to cancer diagnosis, adherence to statins was generally higher among non-Hispanic whites and multi-race patients than other groups. However, statin adherence after diagnosis decreased only among these two populations (ORadj:0.85, 95% CI:0.85-0.92 and ORadj:0.86, 95% CI:0.76-0.97), respectively. We found substantial variation in statin medication adherence following diagnosis by cancer type and race/ethnicity among a large cohort of prevalent statin users in an integrated health care setting. Improving our understanding of comorbidity management and polypharmacy across diverse cancer patient populations is warranted to develop tailored interventions that improve medication adherence and reduce disparities in health outcomes.

Authors: Banegas MP; Emerson MA; Adams AS; Achacoso NS; Chawla N; Alexeeff S; Habel LA

J Cancer Surviv. 2018 12;12(6):794-802. Epub 2018-10-18.

PubMed abstract

Disparities in the Receipt of Tobacco Treatment Counseling within the US Context of the Affordable Care Act and Meaningful Use Implementation

Disparities in receiving advice to quit smoking and other tobacco use from health professionals may contribute to the continuing gap in smoking prevalence among priority populations. Under the Affordable Care Act (ACA), beginning in 2010, tobacco cessation services are currently covered in private and public health insurance plans. Providers and hospitals are also incentivized through the Meaningful Use of Electronic Health Records (EHRs) to screen and document patients’ tobacco use and deliver brief cessation counseling. This study analyzes trends and correlates of receiving health professionals’ advice to quit and potential disparities among US adult smokers from 2010 to 2015. Data were from the National Health Interview Survey in 2010 and 2015. We analyzed the weighted prevalence of smokers’ receipt of advice to quit smoking and other tobacco use from a health professional in 2010 and 2015 and correlates of receiving advice to quit. Prevalence of receiving advice to quit from a health professional increased from 51.4% in 2010 to 60.6% in 2015. This positive trend was observed across tobacco disparity population groups. Survey year (2015), age (older), ethnicity (non-Hispanic), region (Northeast), poverty level (above 100% poverty level), past quit attempt, daily smoking, cigarettes per day (11+ per day), and psychological distress were associated with higher odds of receiving advice to quit. Based on national level data, receipt of advice to quit from health professionals increased between 2010 and 2015. However, disparities in receiving advice to quit from health professionals persist in certain populations. This study provides important data on the national trends in receipt of health professional advice to quit smoking and other tobacco use in the context of the ACA and Meaningful Use implementation and whether these policies helped to narrow the gaps in receipt of health professional advice among vulnerable populations.

Authors: Tan ASL; Young-Wolff KC; Carter-Harris L; Salloum RG; Banerjee SC

Nicotine Tob Res. 2018 11 15;20(12):1474-1480.

PubMed abstract

Examining the role of access to care: Racial/ethnic differences in receipt of resection for early-stage non-small cell lung cancer among integrated system members and non-members

To examine the role of uniform access to care in reducing racial/ethnic disparities in receipt of resection for early stage non-small cell lung cancer (NSCLC) by comparing integrated health system member patients to demographically similar non-member patients. Using data from the California Cancer Registry, we conducted a retrospective cohort study of patients from four racial/ethnic groups (White, Black, Hispanic, Asian/Pacific Islander), aged 21-80, with a first primary diagnosis of stage I or II NSCLC between 2004 and 2011, in counties served by Kaiser Permanente Northern California (KPNC) at diagnosis. Our cohort included 1565 KPNC member and 4221 non-member patients. To examine the relationship between race/ethnicity and receipt of surgery stratified by KPNC membership, we used modified Poisson regression to calculate risk ratios (RR) adjusted for patient demographic and tumor characteristics. Black patients were least likely to receive surgery regardless of access to integrated care (64-65% in both groups). The magnitude of the black-white difference in the likelihood of surgery receipt was similar for members (RR: 0.82, 95% CI: 0.73-0.93) and non-members (RR: 0.86, 95% CI: 0.80-0.94). Among members, roughly equal proportions of Hispanic and White patients received surgery; however, among non-members, Hispanic patients were less likely to receive surgery (non-members, RR: 0.93, 95% CI: 0.86-1.00; members, RR: 0.98, 95% CI: 0.89-1.08). Disparities in surgical treatment for NSCLC were not reduced through integrated health system membership, suggesting that factors other than access to care (e.g., patient-provider communication) may underlie disparities. Future research should focus on identifying such modifiable factors.

Authors: Check DK; Albers KB; Uppal KM; Suga JM; Adams AS; Habel LA; Quesenberry CP; Sakoda LC

Lung Cancer. 2018 Nov;125:51-56. Epub 2018-09-11.

PubMed abstract

Evaluating the Impact of Eliminating Copayments for Tobacco Cessation Pharmacotherapy

We examined the impact of the Affordable Care Act-mandated elimination of tobacco cessation pharmacotherapy (TCP) copayments on patient use of TCP, overall and by income. Electronic health record data captured any and combination (eg, nicotine gum plus patch) TCP use among adult smokers newly enrolled in Kaiser Permanente Northern California (KPNC). KPNC eliminated TCP copayments in 2015. We included current smokers newly enrolled in the first 6 months of 2014 (before copayment elimination, N=16,199) or 2015 (after elimination, N=16,469). Multivariable models estimated 1-year changes in rates of any TCP fill, and of combination TCP fill, and tested for differences by income (<$50k, $50?75k, ?$75k). Through telephone surveys in 2016 with a subset of smokers newly enrolled in 2014 (n=306), we assessed barriers to TCP use, with results stratified by income. Smokers enrolled in KPNC in 2015 versus 2014 were more likely to have a TCP fill (9.1% vs. 8.2%; relative risk, 1.19; 95% confidence interval, 1.11-1.27), and combination TCP fill, among those with any fill (42.3% vs. 37.9%; relative risk, 1.12; 95% confidence interval, 1.02-1.23); findings were stronger for low-income smokers. Low-income patients (<$50k) were less likely to report that clinicians discussed smoking treatments with them (58%) compared with higher income smokers ($50?75k, 67%; ?$75k, 83%), and were less aware that TCP was free (40% vs. 53% and 69%, respectively, P-values<0.05). The Affordable Care Act's copayment elimination was associated with a modest increase in TCP use and a greater effect among low-income smokers. Uptake may have been enhanced if promoted to patients directly and via providers.

Authors: Young-Wolff KC; Adams SR; Klebaner D; Adams AS; Campbell CI; Satre DD; Prochaska JJ

Med Care. 2018 11;56(11):912-918.

PubMed abstract

Mobile-accessible personal health records increase the frequency and timeliness of PHR use for patients with diabetes

Personal health records (PHRs) offer patients a portal to view lab results, communicate with their doctors, and refill medications. Expanding PHR access to mobile devices could increase patients’ engagement with their PHRs. We examined whether access to a mobile-optimized PHR changed the frequency and timeliness of PHR use among adult patients with diabetes in an integrated delivery system. Among patients originally using the PHR only by computer, PHR use frequency increased with mobile access. Non-White patients were more likely to view their lab results within 7 days if they had computer and mobile access compared with computer only; however, there were no statistically significant differences among White patients. More frequent and timely mobile access to PHR data and tools may lead to convenient and effective PHR engagement to support patient self-management. Future studies should evaluate whether PHR use with a mobile device is associated with changes in self-management and outcomes.

Authors: Graetz I; Huang J; Brand R; Hsu J; Reed ME

J Am Med Inform Assoc. 2018 Oct 24.

PubMed abstract

Depression Screening Rates and Symptom Severity by Alcohol Use Among Primary Care Adult Patients

Hazardous alcohol use with depression may exacerbate health conditions and complicate medical care. We examined the rate of depression screening by alcohol use severity among primary care patients screened for hazardous alcohol use and, among those screened, examined patterns of significant depressive symptoms. Using cross-sectional data from primary care patients (n = 2,894,906), we examined past-90-day alcohol use (number of typical drinking days/week and typical number of drinks consumed daily); depression screening rates (using the Patient Health Questionnaire 9 [PHQ-9]); and symptom severity, demographics, and prevalence of selected psychiatric diagnoses. Within 30 days of routine, in-clinic alcohol use screening by medical assistants, 2.4% (n = 68,686) of patients also completed a PHQ-9; these patients were more likely to be female, younger, white, Medicaid insured, and to have a nondepressive psychiatric diagnosis and a lower Charlson comorbidity score. Abstainers and moderate drinkers (1 to 7 drinks/week or 1 to 4 drinks/week for women and individuals >65 years or for men ≤65 years, respectively) were less likely than hazardous drinkers (exceeding weekly limits) to complete the PHQ-9 or to have significant depressive symptoms (PHQ-9 score ≥10). Nonwhite patients with higher Charlson comorbidity scores were more likely to endorse significant depressive symptoms. Only a small fraction of patients in this cohort were screened for depression. Nonwhite patients and those with higher comorbidity burden were more likely to report depression but less likely to be screened. These discrepancies between depression-screening rates and significant depressive symptoms suggest that screening for depression should be enhanced in these at-risk groups.

Authors: Hirschtritt ME; Kline-Simon AH; Kroenke K; Sterling SA

J Am Board Fam Med. 2018 Sep-Oct;31(5):724-732.

PubMed abstract

Language barriers and LDL-C/SBP control among Latinos with diabetes

Language barriers in healthcare are associated with worse glycemic control among Latino patients with limited English proficiency and diabetes. We examined the association of patient-physician language concordance with lipid (low-density lipoprotein cholesterol [LDL-C]) and systolic blood pressure (SBP) control. Retrospective cohort study. Data were obtained from a survey and the electronic health records of Latino and white patients with diabetes receiving care within 1 integrated health plan with interpreter services available. Limited English proficiency and patient-physician language concordance were defined by patient report. Outcomes were poor lipid control (LDL-C >100 mg/dL) and poor SBP control (SBP >140 mm Hg). In total, 3463 Latino (2921 who spoke English and 542 who were limited English proficient [LEP]) and 3896 English-speaking white patients participated. One-third of the patients had poor lipid control and one-fifth had poor SBP control. English-speaking white patients were slightly less likely to have poor lipid control than English-speaking Latino patients, but the difference did not persist after adjustment for age and sex. Among Latinos, LEP patients were less likely to have poor lipid control than English-speaking patients (odds ratio, 0.71; 95% CI, 0.54-0.93), with no difference by LEP patient-physician language concordance. Poor SBP control did not differ by ethnicity, primary language, or patient-physician language concordance. We found no evidence that ethnicity or language barriers in healthcare were associated with poorer lipid or blood pressure control among Latino and white patients with diabetes receiving care in settings with professional interpreters.

Authors: Fernandez A; Warton EM; Schillinger D; Moffet HH; Kruger J; Adler N; Karter AJ

Am J Manag Care. 2018 09;24(9):405-410.

PubMed abstract

Association of behavioral health factors and social determinants of health with high and persistently high healthcare costs

A high proportion of U.S. health care costs are attributable to a relatively small proportion of patients. Understanding behavioral and social factors that predict initial and persistent high costs for these “high utilizers” is critical for health policy-makers. This prospective observational study was conducted at Kaiser Permanente Northern California (KPNC), an integrated healthcare delivery system with 4.1 million members. A stratified random sample of high-cost vs. non-high-cost adult KPNC members matched by age, gender, race/ethnicity, type of health insurance, and medical severity (N = 378) was interviewed between 3/14/2013 and 3/20/2014. Data on health care costs and clinical diagnoses between 1/1/2008 and 12/31/2012 were derived from the electronic health record (EHR). Social-economic status, depression symptoms, adverse childhood experiences (ACEs), interpersonal violence, financial stressors, neighborhood environment, transportation access, and patient activation and engagement were obtained through telephone interviews. Initial and subsequent high-cost status were defined as being classified in top 20% cost levels over 1/1/2009-12/31/2011 and 1/1/2012-12/31/2012, respectively. Psychiatric diagnosis (OR 2.55, 95% CI 1.52-4.29, p < 0.001), financial stressors (OR 1.97, 95% CI 1.19-3.26, p = 0.009), and ACEs (OR 1.10, 95% CI 1.00-1.20, p = 0.051) predicted initial high-cost status. ACEs alone predicted persistent high-cost status in the subsequent year (OR 1.12, 95% CI 1.00-1.25, p = 0.050). Non-medical factors such as psychiatric problems, financial stressors and adverse childhood experiences contribute significantly to the likelihood of high medical utilization and cost. Efforts to predict and reduce high utilization must include measuring and potentially addressing these factors.

Authors: Sterling S; Chi F; Weisner C; Grant R; Pruzansky A; Bui S; Madvig P; Pearl R

Prev Med Rep. 2018 Sep;11:154-159. Epub 2018-06-27.

PubMed abstract

Cumulative Incidence of Hypertension by 55 Years of Age in Blacks and Whites: The CARDIA Study

Blacks have higher blood pressure levels compared with whites beginning in childhood. Few data are available on racial differences in the incidence of hypertension from young adulthood through middle age. We calculated the cumulative incidence of hypertension from age 18 to 55 years among participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study. Incident hypertension was defined by the first visit with mean systolic blood pressure ≥130 mm Hg, mean diastolic blood pressure ≥80 mm Hg, or self-reported use of antihypertensive medication. Among 3890 participants without hypertension at baseline (aged 18-30 years), cumulative incidence of hypertension by age 55 years was 75.5%, 75.7%, 54.5%, and 40.0% in black men, black women, white men, and white women, respectively. Among participants with systolic blood pressure/diastolic blood pressure

Authors: Thomas SJ; Li X; Sidney S; Muntner P; et al.

J Am Heart Assoc. 2018 Jul 11;7(14). Epub 2018-07-11.

PubMed abstract

Common mitochondrial haplogroups and cutaneous squamous cell carcinoma risk

Background: Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer in United States, and its incidence is substantially higher in men than women, but the reasons for the difference are unknown. We explored whether common mitochondrial DNA (mtDNA) haplogroups, which have been associated with cancer risk, and in particular squamous cell carcinoma risk arising in other organs, could explain this biological sex difference in cSCC susceptibility.Methods: We performed a retrospective cohort study using data from the Genetic Epidemiology Research in Adult Health and Aging cohort composed of 67,868 non-Hispanic white subjects (7,701 cSCC cases and 60,167 controls). Genotype information on >665,000 SNPs was generated using Affymetrix Axiom arrays designed to maximize genome-wide coverage, and 102 high-quality mtDNA SNPs were used to determine mtDNA haplogroups. Associations between each mtDNA haplogroup and cSCC risk were evaluated by logistic regression analysis adjusting for age, sex, and population stratification using ancestry principal components.Results: cSCC was more common in men (15.4% vs. 8.4% for women). Nine common mtDNA haplogroups (frequency ≥1%) were identified in addition to the most common haplogroup, H, used as the reference group. No association with cSCC risk was detected for any of the mtDNA haplogroups or overall or sex-stratified analyses.Conclusions: Common mitochondrial variation is not associated with cSCC risk.Impact: This well-powered study refutes the hypothesis that common mitochondrial haplogroups play a role in the differential sex predilection of cSCCs. Cancer Epidemiol Biomarkers Prev; 27(7); 838-41. ©2018 AACR.

Authors: Jorgenson E; Choquet H; Yin J; Asgari MM

Cancer Epidemiol Biomarkers Prev. 2018 07;27(7):838-841. Epub 2018-04-25.

PubMed abstract

Diabetes and Prediabetes Prevalence by Race and Ethnicity Among People With Severe Mental Illness

Authors: Mangurian CV; Schillinger D; Newcomer JW; Vittinghoff E; Essock SM; Zhu Z; Dyer WT; Schmittdiel JA

Diabetes Care. 2018 07;41(7):e119-e120. Epub 2018-06-13.

PubMed abstract

Disparities in Initiation of Direct-Acting Antiviral Agents for Hepatitis C Virus Infection in an Insured Population

The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on factors associated with DAA initiation. We conducted a retrospective cohort study of HCV-infected Kaiser Permanente Northern California members aged ≥18 during October 2014 to December 2016, using Poisson regression models to evaluate demographic, behavioral, and clinical factors associated with DAA initiation. Of 14 790 HCV-infected patients aged ≥18 (median age, 60; interquartile range, 53-64), 6148 (42%) initiated DAAs. DAA initiation was less likely among patients who were non-Hispanic black (adjusted rate ratio [aRR] = 0.7; 95% confidence interval [CI], 0.7-0.8), Hispanic (aRR = 0.8; 95% CI, 0.7-0.9), and of other minority races/ethnicities (aRR = 0.9; 95% CI, 0.8-1.0) than among non-Hispanic white people and among those with lowest compared with highest neighborhood deprivation index (ie, a marker of socioeconomic status) (aRR = 0.8; 95% CI, 0.7-0.8). Having maximum annual out-of-pocket health care costs >$3000 compared with ≤$3000 (aRR = 0.9; 95% CI, 0.8-0.9) and having Medicare (aRR = 0.8; 95% CI, 0.8-0.9) or Medicaid (aRR = 0.7; 95% CI, 0.6-0.8) compared with private health insurance were associated with a lower likelihood of DAA initiation. Behavioral factors (eg, drug abuse diagnoses, alcohol use, and smoking) were also significantly associated with a lower likelihood of DAA initiation (all P < .001). Clinical factors associated with a higher likelihood of DAA initiation were advanced liver fibrosis, HCV genotype 1, previous HCV treatment (all P < .001), and HIV infection ( P = .007). Racial/ethnic and socioeconomic disparities exist in DAA initiation. Substance use may also influence patient or provider decision making about DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations.

Authors: Marcus JL; Lam JO; Quesenberry CP; Silverberg MJ; et al.

Public Health Rep. 2018 Jul/Aug;133(4):452-460. Epub 2018-05-11.

PubMed abstract

Manuscript title: Can survival bias explain the age attenuation of racial inequalities in stroke incidence? A simulation study

In middle age, stroke incidence is higher among black than white Americans. For unknown reasons, this inequality decreases and reverses with age. We conducted simulations to evaluate whether selective survival could account for observed age patterning of black-white stroke inequalities. We simulated birth cohorts of 20,000 blacks and 20,000 whites with survival distributions based on US life tables for the 1919-1921 birth cohort. We generated stroke incidence rates for ages 45-94 years using Reasons for Geographic and Racial Disparities in Stroke (REGARDS) study rates for whites and setting the effect of black race on stroke to incidence rate difference (IRD) = 20/10,000 person-years at all ages, the inequality observed at younger ages in REGARDS. We compared observed age-specific stroke incidence across scenarios, varying effects of U, representing unobserved factors influencing mortality and stroke risk. Despite a constant adverse effect of black race on stroke risk, the observed black-white inequality in stroke incidence attenuated at older age. When the hazard ratio for U on stroke was 1.5 for both blacks and whites, but U only directly influenced mortality for blacks (hazard ratio for U on mortality =1.5 for blacks; 1.0 for whites), stroke incidence rates in late life were lower among blacks (average observed IRD = -43/10,000 person-years at ages 85-94 years versus causal IRD = 20/10,000 person-years) and mirrored patterns observed in REGARDS. A relatively moderate unmeasured common cause of stroke and survival could fully account for observed age attenuation of racial inequalities in stroke.

Authors: Mayeda ER; Banack HR; Bibbins-Domingo K; Zeki Al Hazzouri A; Marden JR; Whitmer RA; Glymour MM

Epidemiology. 2018 07;29(4):525-532.

PubMed abstract

Patient and System Characteristics Associated with Performance on the HEDIS Measures of Alcohol and Other Drug Treatment Initiation and Engagement

Understand patient and system characteristics associated with performance on the Healthcare Effectiveness Data and Information Set (HEDIS) Alcohol and Other Drug (AOD) Initiation and Engagement of Treatment (IET) measures. This mixed-methods study linked patient and health system data from four Kaiser Permanente regions to HEDIS performance measure data for 44,320 commercially or Medicare-insured adults with HEDIS-eligible AOD diagnoses in 2012. Characteristics associated with IET were examined using multilevel logistic regression models. Key informant interviews (n = 18) focused on opportunities to improve initiation and engagement. Non-white race/ethnicity, alcohol abuse, or nonopioid drug abuse diagnoses were associated with lower odds of treatment initiation among commercially insured. For both insurance groups, those diagnosed in healthcare departments other than specialty AOD treatment were less likely to initiate or engage in treatment. Being diagnosed in facilities with co-located AOD/primary care clinics, and those with medications for addiction treatment available, was each associated with higher odds of initiation and engagement for both commercially and Medicare-insured. Having behavioral medicine specialists or clinical health educators in primary care increased initiation and engagement odds among commercially insured. Key informants recommended were as follows: patient-centered care; increased treatment choices; cross-departmental patient identification, engagement, and coordination; provider education; and use of informatics/technology. Tailoring treatment, enhancing treatment motivation among individuals with lower severity diagnoses, offering medication treatment of addiction, clinician education, care coordination, co-located AOD and primary care departments, and behavioral medicine specialists in primary care may improve rates of initiation and engagement in AOD treatment.

Authors: Yarborough BJH; Chi FW; Green CA; Hinman A; Mertens J; Beck A; Horberg M; Weisner C; Campbell CI

J Addict Med. 2018 Jul/Aug;12(4):278-286.

PubMed abstract

Mapping hot spots of breast cancer mortality in the United States: place matters for Blacks and Hispanics.

PURPOSE: The goals of this study were to identify geographic and racial/ethnic variation in breast cancer mortality, and evaluate whether observed geographic differences are explained by county-level characteristics.METHODS: We analyzed data on breast cancer deaths among women in 3,108 contiguous United States (US) counties from years 2000 through 2015. We applied novel geospatial methods and identified hot spot counties based on breast cancer mortality rates. We assessed differences in county-level characteristics between hot spot and other counties using Wilcoxon rank-sum test and Spearman correlation, and stratified all analysis by race/ethnicity.RESULTS: Among all women, 80 of 3,108 (2.57%) contiguous US counties were deemed hot spots for breast cancer mortality with the majority located in the southern region of the US (72.50%, p value CONCLUSIONS: We observed geographic and racial/ethnic disparities in breast cancer mortality: NH-Black and Hispanic breast cancer deaths were more concentrated in southern, lower SES counties.

Authors: Moore, Justin Xavier JX; Royston, Kendra J KJ; Langston, Marvin E ME; Griffin, Russell R; Hidalgo, Bertha B; Wang, Henry E HE; Colditz, Graham G; Akinyemiju, Tomi T

Cancer causes & control : CCC. 2018 Aug ;29(8):737-750. Epub 2018-06-19.

PubMed abstract

10-year changes in accelerometer-based physical activity and sedentary time during midlife: CARDIA Study

To describe 10-year changes in accelerometer-determined physical activity (PA) and sedentary time in a midlife cohort, within and by race/sex groups. Coronary Artery Risk Development in Young Adults participants (n = 962) who wore the accelerometer with valid wear (≥4 of 7 days, ≥10 hours per day) at baseline (2005-06; ages 38-50; ActiGraph 7164) and 10-year follow-up (2015-16; ages 48-60; ActiGraph wGT3X-BT). Data were calibrated to account for accelerometer model differences. Participants (aged 45.0 ± 3.5 years at baseline) experienced reductions in accelerometer counts overall [-65.5 (10.2) ct·min·d-1], and within race/sex groups (all p

Authors: Gabriel KP; Sidney S; Sternfeld B; et al.

Am J Epidemiol. 2018 Jun 11.

PubMed abstract

Implementation Research to Address the United States Health Disadvantage: Report of a National Heart, Lung, and Blood Institute Workshop

Four decades ago, U.S. life expectancy was within the same range as other high-income peer countries. However, during the past decades, the United States has fared worse in many key health domains resulting in shorter life expectancy and poorer health-a health disadvantage. The National Heart, Lung, and Blood Institute convened a panel of national and international health experts and stakeholders for a Think Tank meeting to explore the U.S. health disadvantage and to seek specific recommendations for implementation research opportunities for heart, lung, blood, and sleep disorders. Recommendations for National Heart, Lung, and Blood Institute consideration were made in several areas including understanding the drivers of the disadvantage, identifying potential solutions, creating strategic partnerships with common goals, and finally enhancing and fostering a research workforce for implementation research. Key recommendations included exploring why the United States is doing better for health indicators in a few areas compared with peer countries; targeting populations across the entire socioeconomic spectrum with interventions at all levels in order to prevent missing a substantial proportion of the disadvantage; assuring partnership have high-level goals that can create systemic change through collective impact; and finally, increasing opportunities for implementation research training to meet the current needs. Connecting with the research community at large and building on ongoing research efforts will be an important strategy. Broad partnerships and collaboration across the social, political, economic, and private sectors and all civil society will be critical-not only for implementation research but also for implementing the findings to have the desired population impact. Developing the relevant knowledge to tackle the U.S. health disadvantage is the necessary first step to improve U.S. health outcomes.

Authors: Engelgau MM; Siega-Riz AM; Mensah GA; et al.

Glob Heart. 2018 06;13(2):65-72. Epub 2018-04-30.

PubMed abstract

Cardiovascular disease incidence in adolescent and young adult cancer survivors: a retrospective cohort study

Few population-based studies have focused on cardiovascular disease (CVD) risk in adolescent and young adult (AYA; 15-39 years) cancer survivors and none have considered whether CVD risk differs by sociodemographic factors. Analyses focused on 79,176 AYA patients diagnosed with 14 first primary cancers in 1996-2012 and surviving > 2 years after diagnosis with follow-up through 2014. Data were obtained from the California Cancer Registry and State hospital discharge data. CVD included coronary artery disease, heart failure, and stroke. The cumulative incidence of developing CVD accounted for the competing risk of death. Multivariable Cox proportional hazards regression evaluated factors associated with CVD and the impact of CVD on mortality. Overall, 2249 (2.8%) patients developed CVD. Survivors of central nervous system cancer (7.3%), acute lymphoid leukemia (6.9%), acute myeloid leukemia (6.8%), and non-Hodgkin lymphoma (4.1%) had the highest 10-year CVD incidence. In multivariable models, African-Americans (hazard ratio (HR) = 1.55, 95% confidence interval (CI) = 1.33-1.81; versus non-Hispanic Whites), those with public/no health insurance (HR = 1.78, 95% CI = 1.61-1.96; versus private) and those who resided in lower socioeconomic status neighborhoods had a higher CVD risk. These sociodemographic differences in CVD incidence were apparent across most cancer sites. The risk of death was increased by eightfold or higher among AYAs who developed CVD. While cancer therapies are known to increase the risk of CVD, this study additionally shows that CVD risk varies by sociodemographic factors. The identification and mitigation of CVD risk factors in these subgroups may improve long-term patient outcomes.

Authors: Keegan THM; Kushi LH; Li Q; Brunson A; Chawla X; Chew HK; Malogolowkin M; Wun T

J Cancer Surviv. 2018 06;12(3):388-397. Epub 2018-02-09.

PubMed abstract

Identifying Geographic Disparities in Diabetes Prevalence Among Adults and Children Using Emergency Claims Data

Geographic surveillance can identify hotspots of disease and reveal associations between health and the environment. Our study used emergency department surveillance to investigate geographic disparities in type 1 and type 2 diabetes prevalence among adults and children. Using all-payer emergency claims data from 2009 to 2013, we identified unique New York City residents with diabetes and geocoded their location using home addresses. Geospatial analysis was performed to estimate diabetes prevalence by New York City Census tract. We also used multivariable regression to identify neighborhood-level factors associated with higher diabetes prevalence. We estimated type 1 and type 2 diabetes prevalence at 0.23% and 10.5%, respectively, among adults and 0.20% and 0.11%, respectively, among children in New York City. Pediatric type 1 diabetes was associated with higher income (P = 0.001), whereas adult type 2 diabetes was associated with lower income (P < 0.001). Areas with a higher proportion of nearby restaurants categorized as fast food had a higher prevalence of all types of diabetes (P < 0.001) except for pediatric type 2 diabetes. Type 2 diabetes among children was only higher in neighborhoods with higher proportions of African American residents (P < 0.001). Our findings identify geographic disparities in diabetes prevalence that may require special attention to address the specific needs of adults and children living in these areas. Our results suggest that the food environment may be associated with higher type 1 diabetes prevalence. However, our analysis did not find a robust association with the food environment and pediatric type 2 diabetes, which was predominantly focused in African American neighborhoods.

Authors: Lee DC; Gallagher MP; Gopalan A; Osorio M; Vinson AJ; Wall SP; Ravenell JE; Sevick MA; Elbel B

J Endocr Soc. 2018 May 01;2(5):460-470. Epub 2018-04-17.

PubMed abstract

An Empirical Dietary Inflammatory Pattern Score Is Associated with Circulating Inflammatory Biomarkers in a Multi-Ethnic Population of Postmenopausal Women in the United States

The empirical dietary inflammatory pattern (EDIP) score has been associated with concentrations of circulating inflammatory biomarkers in European Americans. We used the EDIP score, a weighted sum of 18 food groups that characterizes dietary inflammatory potential based on circulating concentrations of inflammatory biomarkers, to test the hypothesis that a pro-inflammatory dietary pattern is associated with inflammatory biomarker concentrations in a US multi-ethnic population. In this cross-sectional study, we calculated EDIP scores using baseline food frequency questionnaire data from 31,472 women, aged 50-79 y, in the Women’s Health Initiative observational study and clinical trials. Circulating biomarkers outcomes at baseline were: C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor (TNF)-α, TNF receptor (TNFR) 1 and 2, and adiponectin. We used multivariable-adjusted linear regression analyses to estimate absolute concentrations and relative differences in biomarker concentrations, overall and in subgroups of race/ethnicity and BMI (body mass index) categories. Independent of energy intake, BMI, physical activity, and other potential confounding variables, higher EDIP scores were significantly associated with higher (lower for adiponectin) absolute concentrations of all 6 biomarkers. On the relative scale, the percentage of difference in the concentration of biomarkers, among women in the highest compared to the lowest EDIP quintile, was: CRP, +13% (P-trend

Authors: Tabung FK; Cespedes Feliciano EM; Rexrode KM; et al.

J Nutr. 2018 Apr 20.

PubMed abstract

A recursive partitioning approach to investigating correlates of self-rated health: The CARDIA Study

Self-rated health (SRH) is an independent predictor of mortality; studies have investigated correlates of SRH to explain this predictive capability. However, the interplay of a broad array of factors that influence health status may not be adequately captured with parametric multivariate regression. This study investigated associations between several health determinants and SRH using recursive partitioning methods. This non-parametric analytic approach aimed to reflect the social-ecological model of health, emphasizing relationships between multiple health determinants, including biological, behavioral, and from social/physical environments. The study sample of 3648 men and women was drawn from the year 15 (2000-2001) data collection of the CARDIA Study, USA, in order to study a young adult sample. Classification tree analysis identified 15 distinct, mutually exclusive, subgroups (eight with a larger proportion of individuals with higher SRH, and seven with a larger proportion of lower SRH), and multi-domain risk and protective factors associated with subgroup membership. Health determinant profiles were not uniform between subgroups, even for those with similar health status. The subgroup with the largest proportion of higher SRH was characterized by several protective factors, whilst that with the largest proportion of lower SRH, with several negative risk factors; certain factors were associated with both higher and lower SRH subgroups. In the full sample, physical activity, education and income were highest ranked by variable importance (random forests analysis) in association with SRH. This exploratory study demonstrates the utility of recursive partitioning methods in studying the joint impact of multiple health determinants. The findings indicate that factors do not affect SRH in the same way across the whole sample. Multiple factors from different domains, and with varying relative importance, are associated with SRH in different subgroups. This has implications for developing and prioritizing appropriate interventions to target conditions and factors that improve self-rated health status.

Authors: Nayak S; Hubbard A; Sidney S; Syme SL

SSM Popul Health. 2018 Apr;4:178-188. Epub 2017-12-15.

PubMed abstract

Girls’ Sleep Trajectories Across the Pubertal Transition: Emerging Racial/Ethnic Differences

This study aims to examine the longitudinal association between puberty and sleep in a diverse sample of girls and explore racial/ethnic differences in this association. Using latent growth curve modeling, the present study measured pubertal development (timing and rate) and sleep (wake time and bedtime) in 1,239 socioeconomically and ethnically diverse girls starting when they were 6-8 years old and followed longitudinally for up to 8 years. Pubertal assessment was conducted annually in clinic by physical examination, classified by sexual maturation stage for breast and pubic hair development by trained raters. In line with previous research, black girls had the earliest pubertal development, followed by Hispanic, white, and Asian girls. Black girls, on average, reported significantly shorter sleep duration than Hispanic (β = -.20, p < .001), Asian (β = -.29, p = .002), and white (β = -.35, p < .001) girls. In a series of dual-process models, we found that early pubertal timing predicted shorter sleep duration for early-maturing black girls (breast development: β = .13, p = .005; pubic hair development: β = .14, p = .012). There was no evidence of any association between pubertal rate and sleep. All models controlled for family socioeconomic status and body mass index. Sleep is essential for many aspects of youth development, including emotional, cognitive, and physical functioning. Developmental changes associated with puberty may put some early maturing girls at risk of shorter sleep duration in adolescence and exacerbate racial/ethnic disparities in health and well-being.

Authors: Hoyt LT; Kushi LH; Hiatt RA; et al.

J Adolesc Health. 2018 04;62(4):496-503.

PubMed abstract

Racial disparities in family-provider interactions for pediatric asthma care

Black and Latino children experience significantly worse asthma morbidity than their white peers for multifactorial reasons. This study investigated differences in family-provider interactions for pediatric asthma, based on race/ethnicity. This was a cross-sectional study of parent surveys of asthmatic children within the Population-Based Effectiveness in Asthma and Lung Diseases Network. Our study population comprised 647 parents with survey response data. Data on self-reported race/ethnicity of the child were collected from parents of the children with asthma. Outcomes studied were responses to the questions about family-provider interactions in the previous 12 months: (1) number of visits with asthma provider; (2) number of times provider reviewed asthma medications with patient/family; (3) review of a written asthma treatment plan with provider; and (4) preferences about making asthma decisions. In multivariate adjusted analyses controlling for asthma control and other co-morbidities, black children had fewer visits in the previous 12 months for asthma than white children: OR 0.63 (95% CI 0.40, 0.99). Additionally, black children were less likely to have a written asthma treatment plan given/reviewed by a provider than their white peers, OR 0.44 (95% CI 0.26, 0.75). There were no significant differences by race in preferences about asthma decision-making nor in the frequency of asthma medication review. Black children with asthma have fewer visits with their providers and are less likely to have a written asthma treatment plan than white children. Asthma providers could focus on improving these specific family-provider interactions in minority children.

Authors: Trivedi M; Fung V; Kharbanda EO; Larkin EK; Butler MG; Horan K; Lieu TA; Wu AC

J Asthma. 2018 04;55(4):424-429. Epub 2017-07-14.

PubMed abstract

Older adults’ readiness to engage with eHealth patient education and self-care resources: a cross-sectional survey

This study examined access to digital technologies, skills and experience, and preferences for using web-based and other digital technologies to obtain health information and advice among older adults in a large health plan. A primary aim was to assess the extent to which digital divides by race/ethnicity and age group might affect the ability of a large percentage of seniors, and especially those in vulnerable groups, to engage with online health information and advice modalities (eHIA) and mobile health (mHealth) monitoring tools. A mailed survey was conducted with age-sex stratified random samples of English-speaking non-Hispanic white, African-American/black (black), Hispanic/Latino (Latino), Filipino-American (Filipino), and Chinese-American (Chinese) Kaiser Permanente Northern California members who were aged 65-79 years. Respondent data were weighted to the study population for the cross-sectional analyses. Older seniors and black, Latino, and Filipino seniors have less access to digital tools, less experience performing a variety of online tasks, and are less likely to believe that they would be capable of going online for health information and advice compared to younger and white Non-Hispanic seniors. Consequently, they are also less likely to be interested in using eHIA modalities. The same subgroups of seniors that have previously been shown to have higher prevalence of chronic conditions and greater difficulties with healthcare access are also less likely to adopt use of eHIA and mHealth monitoring technologies. At the patient population level, this digital divide is important to take into account when planning health information and chronic disease management programs. At the individual patient level, to provide good patient-centered care, it is important for providers to assess rather than assume digital access, eHealth skills, and preferences prior to recommending use of web-based resources and mHealth tools.

Authors: Gordon NP; Hornbrook MC

BMC Health Serv Res. 2018 03 27;18(1):220. Epub 2018-03-27.

PubMed abstract

Low Cancer Risk of South Asians: A Brief Report

South Asians (ancestry in India, Pakistan, Bangladesh, or Sri Lanka) may have lower cancer risk than other racial-ethnic groups. To supplement published cohort data suggesting low cancer risk in South Asians. Logistic regression models with 7 covariates to study cancer mortality through 2012 in 273,843 persons (1117 South Asians) with baseline examination data from 1964 to 1985. Cancer mortality. Through 2012, death was attributed to cancer in 28,031 persons, of which 1555 were Asians, including 32 South Asians. The all-Asian vs white adjusted odds ratio was 1.0, and the South Asian vs white odds ratio was 0.5 (p < 0.001). In separate regressions, South Asians were at lower risk than blacks, Chinese, Filipinos, Japanese, or other Asians. The South Asian-white disparity was concentrated in men but was generally similar when strata of smoking, body mass index, baseline age, and date of death were compared. These data support the observation that compared with whites and other Asian groups, South Asians, especially men, have a lower risk of cancer.

Authors: Tran HN; Udaltsova N; Li Y; Klatsky AL

Perm J. 2018 Mar 02;22.

PubMed abstract

Associations of overweight/obesity and socioeconomic status with hypertension prevalence across racial and ethnic groups

Racial/ethnic disparities in the prevalence of diagnosed hypertension are persistent but may be partially explained by racial/ethnic differences in weight category and neighborhood socioeconomic status. The authors compared hypertension prevalence rates among 4 060 585 adults with overweight or obesity across 10 healthcare systems by weight category and neighborhood education level in geographically and racially diverse individuals. Data were obtained from electronic health records. Hypertension was defined as at least two outpatient visits or one inpatient hospitalization with a coded diagnosis. Logistic regression, adjusted for age, sex, and site, with two-way interactions between race/ethnicity and weight category or neighborhood education, was used to examine the association between hypertension and race/ethnicity, with whites as the reference. Results documented that odds ratios for hypertension prevalence were greater for blacks, American Indians/Alaskan Natives, Asians, and Native Hawaiians/other Pacific Islanders compared with whites and lower for Hispanics in similar weight categories and neighborhood education levels. Although two-way interactions were statistically significant, the magnitude of the odds of hypertension compared with whites did not substantially vary across weight or neighborhood education. Hypertension odds were almost double relative to whites for blacks and Native Hawaiians/other Pacific Islanders across most weight categories and all neighborhood education levels. Odds of hypertension were about 50% greater for Asians relative to whites across weight categories. Results suggest that other factors might be associated with racial/ethnic disparities in hypertension. More research is needed to understand the many factors that may contribute to variation in diagnosed hypertension across racial/ethnic groups with overweight or obesity.

Authors: Young DR; Ferrara A; Yamamoto A; et al.

J Clin Hypertens (Greenwich). 2018 03;20(3):532-540. Epub 2018-02-12.

PubMed abstract

Research Strategies for Nutritional and Physical Activity Epidemiology and Cancer Prevention

Very large international and ethnic differences in cancer rates exist, are minimally explained by genetic factors, and show the huge potential for cancer prevention. A substantial portion of the differences in cancer rates can be explained by modifiable factors, and many important relationships have been documented between diet, physical activity, and obesity, and incidence of important cancers. Other related factors, such as the microbiome and the metabolome, are emerging as important intermediary components in cancer prevention. It is possible with the incorporation of newer technologies and studies including long follow-up and evaluation of effects across the life cycle, additional convincing results will be produced. However, several challenges exist for cancer researchers; for example, measurement of diet and physical activity, and lack of standardization of samples for microbiome collection, and validation of metabolomic studies. The United States National Cancer Institute convened the Research Strategies for Nutritional and Physical Activity Epidemiology and Cancer Prevention Workshop on June 28-29, 2016, in Rockville, Maryland, during which the experts addressed the state of the science and areas of emphasis. This current paper reflects the state of the science and priorities for future research. Cancer Epidemiol Biomarkers Prev; 27(3); 233-44. ©2017 AACR.

Authors: Mahabir S; Kushi LH; Prentice RL; et al.

Cancer Epidemiol Biomarkers Prev. 2018 03;27(3):233-244. Epub 2017-12-18.

PubMed abstract

Feasibility and Acceptability of Screening for Adverse Childhood Experiences in Prenatal Care

Adverse childhood experiences (ACEs) are common among pregnant women and contribute to increased risk for negative perinatal outcomes, yet few clinicians screen prenatal patients for ACEs. The purpose of this study was to evaluate the feasibility and acceptability of screening for ACEs in standard prenatal care. We evaluated a 4-month pilot (March 2016-June 2016) to screen pregnant women (at ∼14-23 weeks of gestation) for ACEs and resiliency in two Kaiser Permanente Northern California medical centers (N = 480). We examined the acceptability of the screening to patients through telephone surveys (N = 210) and to clinicians through surveys and focus groups (N = 26). Most eligible patients (78%) were screened. Patients who received the screening were significantly more likely to be non-Hispanic White, Asian, or of "Other" or "Unknown" race/ethnicity than African American or Hispanic race/ethnicity (p = 0.02). Among those screened, 88% completed the questionnaires; 54% reported 0 ACEs, 28% reported 1-2 ACEs, and 18% reported ≥3 ACEs. Most patients were somewhat or very comfortable completing the questionnaires (91%) and discussing ACEs with their clinician (93%), and strongly or somewhat strongly agreed that clinicians should ask their prenatal patients about ACEs (85%). Clinicians reported significant pre- to postpilot increases in comfort discussing ACEs, providing education, and offering resources (ps 

Authors: Flanagan T; Alabaster A; McCaw B; Stoller N; Watson C; Young-Wolff KC

J Womens Health (Larchmt). 2018 Jan 19.

PubMed abstract

Using Neighborhood-Level Census Data to Predict Diabetes Progression in Patients with Laboratory-Defined Prediabetes

Research on predictors of clinical outcomes usually focuses on the impact of individual patient factors, despite known relationships between neighborhood environment and health. To determine whether US census information on where a patient resides is associated with diabetes development among patients with prediabetes. Retrospective cohort study of all 157,752 patients aged 18 years or older from Kaiser Permanente Northern California with laboratory-defined prediabetes (fasting plasma glucose, 100 mg/dL-125 mg/dL, and/or glycated hemoglobin, 5.7%-6.4%). We assessed whether census data on education, income, and percentage of households receiving benefits through the US Department of Agriculture’s Supplemental Nutrition Assistance Program (SNAP) was associated with diabetes development using logistic regression controlling for age, sex, race/ethnicity, blood glucose levels, and body mass index. Progression to diabetes within 36 months. Patients were more likely to progress to diabetes if they lived in an area where less than 16% of adults had obtained a bachelor’s degree or higher (odds ratio [OR] =1.22, 95% confidence interval [CI] = 1.09-1.36), where median annual income was below $79,999 (OR = 1.16 95% CI = 1.03-1.31), or where SNAP benefits were received by 10% or more of households (OR = 1.24, 95% CI = 1.1-1.4). Area-level socioeconomic and food assistance data predict the development of diabetes, even after adjusting for traditional individual demographic and clinical factors. Clinical interventions should take these factors into account, and health care systems should consider addressing social needs and community resources as a path to improving health outcomes.

Authors: Schmittdiel JA; Dyer WT; Marshall CJ; Bivins R

Perm J. 2018;22:18-096.

PubMed abstract

Diabetes Screening among Antipsychotic-Treated Adults with Severe Mental Illness in an Integrated Delivery System: A Retrospective Cohort Study

Severe mental illness (SMI) is associated with increased risk for type 2 diabetes, partly due to adverse metabolic effects of antipsychotic medications. In public health care settings, annual screening rates are 30%. We measured adherence to national diabetes screening guidelines for patients taking antipsychotic medications. To estimate diabetes screening prevalence among patients with SMI within an integrated health care system, and to assess characteristics associated with lack of screening. Retrospective cohort study. Antipsychotic-treated adults with SMI. We excluded participants with known diabetes. Primary outcome was screening via fasting glucose test or hemoglobin A1c during a 1-year period. In 2014, 16,754 patients with SMI diagnoses were receiving antipsychotics. Seventy-four percent of these patients’ providers ordered diabetes screening tests that year, but only 55% (9247/16,754) received screening. When the observation time frame was extended to 2 years, 73% (12,250/16,754) were screened. Adjusting for sex and race/ethnicity, young adults (aged 18-29 years) were less likely to receive screening than older age groups [adjusted RR (aRR) 1.23-1.57, p < 0.0001]. Compared to whites, screening was more common for Asians (aRR 1.141, 95% CI 1.089-1.195, p < 0.0001), less common for blacks (aRR 0.946, 95% CI 0.898-0.997, p < 0.0375), and no different for Hispanics (aRR 1.030, 95% CI 0.988-1.074, p = 0.165). Smokers were less likely to be screened than non-smokers (aRR 0.93, 95% CI 0.89-0.97, p < 0.0008). Utilization of either mental health or primary care services increased the likelihood of screening. While almost three-fourths of adults with SMI taking antipsychotic medications received a lab order for diabetes screening, only 55% received screening within a 12-month period. Young adults and smokers were less likely to be screened, despite their disproportionate metabolic risk. Future studies should assess the barriers and facilitators with regard to diabetes screening in this vulnerable population at the patient, provider, and system levels.

Authors: Mangurian C; Schillinger D; Newcomer JW; Vittinghoff E; Essock S; Zhu Z; Dyer W; Schmittdiel J

J Gen Intern Med. 2018 01;33(1):79-86. Epub 2017-10-31.

PubMed abstract

Association Between Gestational Diabetes and Incident Maternal CKD: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Gestational diabetes mellitus (GDM) is associated with increased risk for diabetes mellitus, metabolic syndrome, and cardiovascular disease. We evaluated whether GDM is associated with incident chronic kidney disease (CKD), controlling for prepregnancy risk factors for both conditions. Prospective cohort. Of 2,747 women (aged 18-30 years) enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study in 1985 to 86, we studied 820 who were nulliparous at enrollment, delivered at least 1 pregnancy longer than 20 weeks’ gestation, and had kidney function measurements during 25 years of follow-up. GDM was self-reported by women for each pregnancy. CKD was defined as the development of estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2 or urine albumin-creatinine ratio ≥ 25mg/g at any one CARDIA examination in years 10, 15, 20, or 25. HRs for developing CKD were estimated for women who developed GDM versus women without GDM using complementary log-log models, adjusting for prepregnancy age, systolic blood pressure, dyslipidemia, body mass index, smoking, education, eGFR, fasting glucose concentration, physical activity level (all measured at the CARDIA examination before the first pregnancy), race, and family history of diabetes. We explored for an interaction between race and GDM. During a mean follow-up of 20.8 years, 105 of 820 (12.8%) women developed CKD, predominantly increased urine albumin excretion (98 albuminuria only, 4 decreased eGFR only, and 3 both). There was evidence of a GDM-race interaction on CKD risk (P=0.06). Among black women, the adjusted HR for CKD was 1.96 (95% CI, 1.04-3.67) in GDM compared with those without GDM. Among white women, the HR was 0.65 (95% CI, 0.23-1.83). Albuminuria was assessed by single untimed measurements of urine albumin and creatinine. GDM is associated with the subsequent development of albuminuria among black women in CARDIA.

Authors: Dehmer EW; Phadnis MA; Gunderson EP; Lewis CE; Bibbins-Domingo K; Engel SM; Jonsson Funk M; Kramer H; Kshirsagar AV; Heiss G

Am J Kidney Dis. 2018 01;71(1):112-122. Epub 2017-11-08.

PubMed abstract

Detecting Risk of Low Health Literacy in Disadvantaged Populations Using Area-based Measures.

Introduction: Socio-economic status (SES) and low health literacy (LHL) are closely correlated. Both are directly associated with clinical and behavioral risk factors and healthcare outcomes. Learning healthcare systems are introducing small-area measures to address the challenges associated with maintaining patient-reported measures of SES and LHL. This study’s purpose was to measure the association between two available census block measures associated with SES and LHL. Understanding the relationship can guide the identification of a multi-purpose area based measure for delivery system use.Methods: A retrospective observational design was deployed using all US Census block groups in Utah. The principal dependent variable was a nationally-standardized health literacy score (HLS). The primary explanatory variable was a state-standardized area deprivation index (ADI). Statistical methods included linear regression and tests of association. Receiver operating characteristic (ROC) analysis was used to develop LHL criteria using ADI.Results: A significant negative association between the HLS and the ADI score remained after adjusting for area-level risk factors (β: -0.21 (95% CI: -0.22, -0.19) p < .001). Eighteen block groups (Conclusions: HLS and ADI use differing measurement criteria but are closely correlated. A state-based ADI detected additional neighborhoods with risk of LHL compared to use of a national HLS. An ADI represents a multi-purpose area measure of social determinants useful for learning health systems tailoring care.

Authors: Knighton, Andrew J; Brunisholz, Kimberly D; Savitz, Samuel T

EGEMS (Washington, DC). 2017 Dec 15;5(3):7. Epub 2017-12-15.

PubMed abstract

Disparities in Prostate, Lung, Breast, and Colorectal Cancer Survival and Comorbidity Status among Urban American Indians and Alaskan Natives

Cancer is the second leading cause of death among American Indians and Alaskan Natives (AIAN), although cancer survival information in this population is limited, particularly among urban AIAN. In this retrospective cohort study, we compared all-cause and prostate, breast, lung, and colorectal cancer-specific mortality among AIAN (n = 582) and non-Hispanic white (NHW; n = 82,696) enrollees of Kaiser Permanente Northern California (KPNC) diagnosed with primary invasive breast, prostate, lung, or colorectal cancer from 1997 to 2015. Tumor registry and other electronic health records provided information on sociodemographic, comorbidity, tumor, clinical, and treatment characteristics. Cox regression models were used to estimate adjusted survival curves and hazard ratios (HR) with 95% confidence intervals (CI). AIAN had a significantly higher comorbidity burden compared with NHW (P < 0.05). When adjusting for patient, disease characteristics, and Charlson comorbidity scores, all-cause mortality and cancer-specific mortality were significantly higher for AIAN than NHW patients with breast cancer (HR, 1.47; 95% CI, 1.13-1.92) or with prostate cancer (HR, 1.87; 95% CI, 1.14-3.06) but not for AIAN patients with lung and colorectal cancer. Despite approximately equal access to preventive services and cancer care in this setting, we found higher mortality for AIAN than NHW with some cancers, and a greater proportion of AIAN cancer patients with multiple comorbid conditions. This study provides severely needed information on the cancer experience of the 71% of AIANs who live in urban areas and access cancer care outside of the Indian Health Services, from which the vast majority of AIAN cancer information comes. Cancer Res; 77(23); 6770-6. ©2017 AACR.

Authors: Emerson MA; Banegas MP; Chawla N; Achacoso N; Alexeeff SE; Adams AS; Habel LA

Cancer Res. 2017 12 01;77(23):6770-6776. Epub 2017-11-29.

PubMed abstract

Effects of Transitioning to Medicare Part D on Access to Drugs for Medical Conditions among Dual Enrollees with Cancer

To evaluate the impact of transitioning from Medicaid to Medicare Part D drug coverage on the use of noncancer treatments among dual enrollees with cancer. We leveraged a representative 5% national sample of all fee-for-service dual enrollees in the United States (2004-2007) to evaluate the impact of the removal of caps on the number of reimbursable prescriptions per month (drug caps) under Part D on 1) prevalence and 2) average days’ supply dispensed for antidepressants, antihypertensives, and lipid-lowering agents overall and by race (white and black). The removal of drug caps was associated with increased use of lipid-lowering medications (days’ supply 3.63; 95% confidence interval [CI] 1.57-5.70). Among blacks in capped states, we observed increased use of lipid-lowering therapy (any use 0.08 percentage points; 95% CI 0.05-0.10; and days’ supply 4.01; 95% CI 2.92-5.09) and antidepressants (days’ supply 2.20; 95% CI 0.61-3.78) and increasing trends in antihypertensive use (any use 0.01 percentage points; 95% CI 0.004-0.01; and days’ supply 1.83; 95% CI 1.25-2.41). The white-black gap in the use of lipid-lowering medications was immediately reduced (-0.09 percentage points; 95% CI -0.15 to -0.04). We also observed a reversal in trends toward widening white-black differences in antihypertensive use (level -0.08 percentage points; 95% CI -0.12 to -0.05; and trend -0.01 percentage points; 95% CI -0.02 to -0.01) and antidepressant use (-0.004 percentage points; 95% CI -0.01 to -0.0004). Our findings suggest that the removal of drug caps under Part D had a modest impact on the treatment of hypercholesterolemia overall and may have reduced white-black gaps in the use of lipid-lowering and antidepressant therapies.

Authors: Adams AS; Madden JM; Zhang F; Lu CY; Ross-Degnan D; Lee A; Soumerai SB; Gilden D; Chawla N; Griggs JJ

Value Health. 2017 Dec;20(10):1345-1354. Epub 2017-07-06.

PubMed abstract

Contemporary rates and correlates of statin use and adherence in nondiabetic adults with cardiovascular risk factors: The KP CHAMP study

Statin therapy is highly efficacious in the prevention of fatal and nonfatal atherosclerotic events in persons at increased cardiovascular risk. However, its long-term effectiveness in practice depends on a high level of medication adherence by patients. We identified nondiabetic adults with cardiovascular risk factors between 2008 and 2010 within a large integrated health care delivery system in Northern California. Through 2013, we examined the use and adherence of newly initiated statin therapy based on data from dispensed prescriptions from outpatient pharmacy databases. Among 209,704 eligible adults, 68,085 (32.5%) initiated statin therapy during the follow-up period, with 90.4% receiving low-potency statins. At 12 and 24 months after initiating statins, 84.3% and 80.2%, respectively, were actively receiving statin therapy, but only 42% and 30%, respectively, had no gaps in treatment during those time periods. There was also minimal switching between statins or use of other lipid-lowering therapies for augmentation during follow-up. Age≥50 years, Asian/Pacific Islander race, Hispanic ethnicity, prior myocardial infarction, prior ischemic stroke, hypertension, and baseline low-density lipoprotein cholesterol>100 mg/dL were associated with higher adjusted odds, whereas female gender, black race, current smoking, dementia were associated with lower adjusted odds, of active statin treatment at 12 months after initiation. There remain opportunities for improving prevention in patients at risk for cardiovascular events. Our study identified certain patient subgroups that may benefit from interventions to enhance medication adherence, particularly by minimizing treatment gaps and discontinuation of statin therapy within the first year of treatment.

Authors: Go AS; Fan D; Sung SH; Inveiss AI; Romo-LeTourneau V; Mallya UG; Boklage S; Lo JC

Am Heart J. 2017 Dec;194:25-38. Epub 2017-08-24.

PubMed abstract

Associations of Race and Ethnicity with Patient-Reported Outcomes and Health Care Utilization among Older Adults Initiating a New Episode of Care for Back Pain

Secondary analysis of the Back Pain Outcomes using Longitudinal Data (BOLD) cohort study. To characterize associations of self-reported race/ethnicity with back pain (BP) patient-reported outcomes (PROs) and health care utilization among older adults with a new episode of care for BP. No prior longitudinal studies have characterized associations between multiple race/ethnicity groups, and BP-related PROs and health care utilization in the United States. This study included 5117 participants ≥65 years from three US health care systems. The primary BP-related PROs were BP intensity and back-related functional limitations over 24 months. Health care utilization measures included common diagnostic tests and treatments related to BP (spine imaging, spine-related relative value units [RVUs], and total RVUs) over 24 months. Analyses were adjusted for multiple potential confounders including sociodemographics, clinical characteristics, and study site. Baseline BP ratings were significantly higher for blacks vs. whites (5.8 vs. 5.0; P < 0.001). Participants in all race/ethnicity groups showed statistically significant, but modest improvements in BP over 24 months. Blacks and Hispanics did not have statistically significant improvement in BP-related functional limitations over time, unlike whites, Asians, and non-Hispanics; however, the magnitude of differences in improvement between groups was small. Blacks had less spine-related health care utilization over 24 months than whites (spine-related RVU ratio of means 0.66, 95% confidence interval [CI] 0.51-0.86). Hispanics had less spine-related health care utilization than non-Hispanics (spine-related RVU ratio of means 0.60; 95% CI 0.40-0.90). Blacks and Hispanics had slightly less improvement in BP-related functional limitations over time, and less spine-related health care utilization, as compared to whites and non-Hispanics, respectively. Residual confounding may explain some of the association between race/ethnicity and health outcomes. Further studies are needed to understand the factors underlying these differences and which differences reflect disparities. 3.

Authors: Milani CJ; Avins A; Suri P; et al.

Spine. 2017 Nov 20.

PubMed abstract

Cohort Study of ECG Left Ventricular Hypertrophy Trajectories: Ethnic Disparities, Associations With Cardiovascular Outcomes, and Clinical Utility

ECG left ventricular hypertrophy (LVH) is a well-known predictor of cardiovascular disease. However, no prior study has characterized patterns of presence/absence of ECG LVH (“ECG LVH trajectories”) across the adult lifespan in both sexes and across ethnicities. We examined: (1) correlates of ECG LVH trajectories; (2) the association of ECG LVH trajectories with incident coronary heart disease, transient ischemic attack, ischemic stroke, hemorrhagic stroke, and heart failure; and (3) reclassification of cardiovascular disease risk using ECG LVH trajectories. We performed a cohort study among 75 412 men and 107 954 women in the Northern California Kaiser Permanente Medical Care Program who had available longitudinal exposures of ECG LVH and covariates, followed for a median of 4.8 (range <1-9.3) years. ECG LVH was measured by Cornell voltage-duration product. Adverse trajectories of ECG LVH (persistent, new development, or variable pattern) were more common among blacks and Native American men and were independently related to incident cardiovascular disease with hazard ratios ranging from 1.2 for ECG LVH variable pattern and transient ischemic attack in women to 2.8 for persistent ECG LVH and heart failure in men. ECG LVH trajectories reclassified 4% and 7% of men and women with intermediate coronary heart disease risk, respectively. ECG LVH trajectories were significant indicators of coronary heart disease, stroke, and heart failure risk, independently of level and change in cardiovascular disease risk factors, and may have clinical utility.

Authors: Iribarren C; Round AD; Lu M; Okin PM; McNulty EJ

J Am Heart Assoc. 2017 Oct 05;6(10). Epub 2017-10-05.

PubMed abstract

The Incidence and Prevalence of Systemic Lupus Erythematosus in San Francisco County, California: The California Lupus Surveillance Project

Estimates of the incidence and prevalence of systemic lupus erythematosus (SLE) in the US have varied widely. The purpose of this study was to conduct the California Lupus Surveillance Project (CLSP) to determine credible estimates of SLE incidence and prevalence, with a special focus on Hispanics and Asians. The CLSP, which is funded by the Centers for Disease Control and Prevention, is a population-based registry of individuals with SLE residing in San Francisco County, CA, from January 1, 2007 through December 31, 2009. Data sources included hospitals, rheumatologists, nephrologists, commercial laboratories, and a state hospital discharge database. We abstracted medical records to ascertain SLE cases, which we defined as patients who met ≥4 of the 11 American College of Rheumatology classification criteria for SLE. We estimated crude and age-standardized incidence and prevalence, which were stratified by sex and race/ethnicity. The overall age-standardized annual incidence rate was 4.6 per 100,000 person-years. The average annual period prevalence was 84.8 per 100,000 persons. The age-standardized incidence rate in women and men was 8.6 and 0.7 per 100,000 person-years, respectively. This rate was highest among black women (30.5), followed by Hispanic women (8.9), Asian women (7.2), and white women (5.3). The age-standardized prevalence in women per 100,000 persons was 458.1 in blacks, 177.9 in Hispanics, 149.7 in Asians, and 109.8 in whites. Capture-recapture modeling estimated 33 additional incident cases and 147 additional prevalent cases. Comprehensive methods that include intensive case-finding provide more credible estimates of SLE in Hispanics and Asians, and confirm racial and ethnic disparities in SLE. The disease burden of SLE is highest in black women, followed by Hispanic women, Asian women, and white women.

Authors: Dall'Era M; Cisternas MG; Snipes K; Herrinton LJ; Gordon C; Helmick CG

2017 Oct;69(10):1996-2005. Epub 2017-09-10.

PubMed abstract

Ethnic disparities in renal cell carcinoma: An analysis of Hispanic patients in a single-payer healthcare system

To investigate differences between Hispanics and non-Hispanic whites diagnosed with and treated for renal cell carcinoma in an equal access healthcare system. We carried out a retrospective cohort study within the Kaiser Permanente healthcare system using records from renal cell carcinoma cases. Ethnicity was identified as Hispanic or non-Hispanic whites. Patient characteristics, comorbidities, tumor characteristics and treatment were compared. Overall and disease-specific survival was calculated, and a Cox proportion hazard model estimated the association of ethnicity and survival. A total of 2577 patients (2152 non-Hispanic whites, 425 Hispanic) were evaluated. Hispanics were diagnosed at a younger age (59.6 years vs 65.3 years). Clear cell renal cell carcinoma was more prevalent, whereas papillary renal cell carcinoma was less common among Hispanics. Hispanics had a lower American Joint Committee on Cancer stage (I/II vs III/IV) than non-Hispanic whites (67.4% vs 62.2%). Hispanics were found to have a greater frequency of comorbidities, such as chronic kidney disease and diabetes, but were more likely to receive surgery. The presence of metastases, nodal involvement, increased tumor size, non-surgical management, increasing age and Hispanic ethnicity were independent predictors of worse cancer-specific outcome. Within an equal access healthcare system, Hispanics seem to be diagnosed at younger ages, to have greater comorbidities and to present more frequently with clear cell renal cell carcinoma compared with non-Hispanic white patients. Despite lower stage and greater receipt of surgery, Hispanic ethnicity seems to be an independent predictor of mortality. Further work is necessary to confirm these findings.

Authors: Suarez-Sarmiento A; Yao X; Hofmann JN; Syed JS; Zhao WK; Purdue MP; Chow WH; Corley D; Shuch B

Int J Urol. 2017 10;24(10):765-770. Epub 2017-09-15.

PubMed abstract

Urine leakage during sexual activity among ethnically diverse, community-dwelling middle-aged and older women

Urinary incontinence is associated with decreased female sexual function, but little is known about the prevalence, predictors, and impact of urine leakage during sexual activity among women in the community. The purpose of this study was to evaluate the prevalence and impact of urine leakage during sex in ethnically diverse, community-dwelling midlife and older women. Urinary incontinence and sexual function were assessed by structured questionnaire in a multiethnic, community-based cohort of women enrolled in Kaiser Permanente Northern California, an integrated healthcare delivery system in California. All women were aged 40-80 years and sampled from 1 of 4 racial/ethnic groups (20% black, 20% Latina, 20% Asian, and 40% non-Latina white). Differences in frequency, bother, and fear of urine leakage during sexual activity were examined among women with monthly, weekly, and daily urinary incontinence and across different types of urinary incontinence (stress, urgency, mixed, and other type urinary incontinence), with the use of chi-square tests. Independent risk factors for urine leakage during sexual activity were identified through multivariable logistic regression. Of the 509 women who reported being sexually active and having at least monthly urinary incontinence, 127 of them (25%) reported experiencing any urine leakage during sex during the past 3 months. Nineteen percent of the women reported being subjectively bothered by leakage during sex, and 16% of them reported restricting sexual activity because of fear of leakage. Women with more frequent underlying urinary incontinence were more likely to report experiencing or being bothered by leakage during sex and restricting sexual activity because of fear of leakage (P<.001 for all). Participants with predominantly stress or mixed type urinary incontinence were more likely to report experiencing leakage during sex and being subjectively bothered by this leakage (P<.002 for all). Factors independently associated with leakage during sex were depression (odds ratio,1.96; 95% confidence interval, 1.20-3.20), symptomatic pelvic organ prolapse (odds ratio, 2.10; 95% confidence interval, 1.11-3.98), mixed vs urgency type urinary incontinence (odds ratio, 3.16; 95% confidence interval, 1.70-5.88), stress vs urgency type urinary incontinence (odds ratio, 1.94; 95% confidence interval, 1.01-3.70), and frequency of sexual activity (odds ratio, 1.6395% confidence interval, 1.05-2.55), but not age or race/ethnicity. Up to a quarter of women with at least monthly urinary incontinence in the community may experience urine leakage during sexual activity. Many incontinent women who leak urine during sex remain sexually active, which indicates that the preservation of sexual function should still be a priority in this population. Among incontinent women, depression, pelvic organ prolapse, and stress mixed-type urinary incontinence may be associated with urine leakage during sexual activity.

Authors: Munaganuru N; Van Den Eeden SK; Creasman J; Subak LL; Strano-Paul L; Huang AJ

Am J Obstet Gynecol. 2017 10;217(4):439.e1-439.e8. Epub 2017-06-08.

PubMed abstract


Background: Higher socioeconomic position (SEP) has been associated with increased risk of breast cancer. Its relationship with earlier age of pubertal onset, a risk factor for breast cancer, is less clear.Methods: We studied the relationship of SEP to pubertal onset in a multiethnic cohort of 1,237 girls ages 6 to 8 years at baseline. Girls in three U.S. cities were followed for 5 to 8 years with annual clinical examinations from 2004 to 2012. SEP measures were examined for associations with pubertal onset, assessed by breast budding (thelarche) and pubic hair development (adrenarche). Analyses were conducted with accelerated failure time models using a Weibull distribution, with left, right, and interval censoring.Results: Higher body mass index percentage at entry to the study and black or Hispanic race/ethnicity were the strongest predictors of age at pubertal onset. An SEP index comprising household family income, mother’s education, and home ownership was an independent predictor of thelarche in adjusted models for all girls together and for white and Latina, separately, but not black girls, and the relationship varied by study site. The SEP index was not related to adrenarche in adjusted models. Overall, girls from the lowest quintile of SEP entered puberty on average 6% earlier than girls from the highest quintile (time ratio = 0.94; 95% confidence interval 0.91-0.97) in adjusted models.Conclusions: Our results suggest that early-life SEP may influence the timing of pubertal development.Impact: Factors related to lower SEP in childhood can adversely affect early development in ways that may increase the risk of breast cancer. Cancer Epidemiol Biomarkers Prev; 26(12); 1714-21. ©2017 AACR.

Authors: Hiatt RA; Stewart SL; Hoeft KS; Kushi LH; Windham GC; Biro FM; Pinney SM; Wolff MS; Teitelbaum SL; Braithwaite D

Cancer Epidemiol Biomarkers Prev. 2017 Sep 22.

PubMed abstract

Genetic contributors to variation in alcohol consumption vary by race/ethnicity in a large multi-ethnic genome-wide association study

Alcohol consumption is a complex trait determined by both genetic and environmental factors, and is correlated with the risk of alcohol use disorders. Although a small number of genetic loci have been reported to be associated with variation in alcohol consumption, genetic factors are estimated to explain about half of the variance in alcohol consumption, suggesting that additional loci remain to be discovered. We conducted a genome-wide association study (GWAS) of alcohol consumption in the large Genetic Epidemiology Research in Adult Health and Aging (GERA) cohort, in four race/ethnicity groups: non-Hispanic whites, Hispanic/Latinos, East Asians and African Americans. We examined two statistically independent phenotypes reflecting subjects’ alcohol consumption during the past year, based on self-reported information: any alcohol intake (drinker/non-drinker status) and the regular quantity of drinks consumed per week (drinks/week) among drinkers. We assessed these two alcohol consumption phenotypes in each race/ethnicity group, and in a combined trans-ethnic meta-analysis comprising a total of 86 627 individuals. We observed the strongest association between the previously reported single nucleotide polymorphism (SNP) rs671 in ALDH2 and alcohol drinker status (odd ratio (OR)=0.40, P=2.28 × 10-72) in East Asians, and also an effect on drinks/week (beta=-0.17, P=5.42 × 10-4) in the same group. We also observed a genome-wide significant association in non-Hispanic whites between the previously reported SNP rs1229984 in ADH1B and both alcohol consumption phenotypes (OR=0.79, P=2.47 × 10-20for drinker status and beta=-0.19, P=1.91 × 10-35for drinks/week), which replicated in Hispanic/Latinos (OR=0.72, P=4.35 × 10-7and beta=-0.21, P=2.58 × 10-6, respectively). Although prior studies reported effects of ADH1B and ALDH2 on lifetime measures, such as risk of alcohol dependence, our study adds further evidence of the effect of the same genes on a cross-sectional measure of average drinking. Our trans-ethnic meta-analysis confirmed recent findings implicating the KLB and GCKR loci in alcohol consumption, with strongest associations observed for rs7686419 (beta=-0.04, P=3.41 × 10-10for drinks/week and OR=0.96, P=4.08 × 10-5for drinker status), and rs4665985 (beta=0.04, P=2.26 × 10-8for drinks/week and OR=1.04, P=5 × 10-4for drinker status), respectively. Finally, we also obtained confirmatory results extending previous findings implicating AUTS2, SGOL1 and SERPINC1 genes in alcohol consumption traits in non-Hispanic whites.

Authors: Jorgenson E; Thai KK; Hoffmann TJ; Sakoda LC; Kvale MN; Banda Y; Schaefer C; Risch N; Mertens J; Weisner C; Choquet H

Mol Psychiatry. 2017 Sep;22(9):1359-1367. Epub 2017-05-09.

PubMed abstract

Racial and ethnic differences in hip fracture outcomes in men

To examine temporal trends and racial/ethnic differences in hip fracture incidence and mortality outcome in older men. Retrospective cohort study. We ascertained men 50 years or older with a hip fracture during 2000 to 2010 in a diverse northern California healthcare population. Age, comorbidity index, hip fracture incidence, and all-cause mortality up to 12 months post fracture were examined and compared by race/ethnicity. A total of 6247 men (aged 79.3 ± 9.8 years) experienced a hip fracture during 2000 to 2010: 81.4% were white, 7.5% Hispanic, 3.8% black, and 3.9% Asian. The age-adjusted annual incidence of hip fracture averaged 127 per 100,000, ranging from 116 to 139 per 100,000 during this period. In 2010, the age-adjusted incidence of hip fracture was highest among white men (137), followed by Hispanic (98) and black (80), and was lowest among Asian men (45 per 100,000). Mortality following hip fracture was 11.1%, 19.8%, 25.4%, and 32.9%, within 1, 3, 6, and 12 months, respectively, and increased with age. One-year mortality was similar for whites (33.7%), blacks (32.4%), and Hispanics (31.1%), but lower for Asians (23.1%; P <.05). Adjusting for age, comorbidity index, and calendar year, Asians remained at lower mortality risk compared with whites (adjusted odds ratio, 0.62; 95% confidence interval, 0.45-0.86). Although hip fracture rates were largely stable among older men, contemporary rates of hip fracture were highest for white and lowest for Asian men. One-year mortality was similar for white, black, and Hispanic men, but significantly lower for Asians. Future studies should investigate factors underlying observed ethnic differences in fracture outcome among US men.

Authors: Liu LH; Chandra M; Gonzalez JR; Lo JC

Am J Manag Care. 2017 Sep;23(9):560-564.

PubMed abstract

Association Between Birth in a High Stroke Mortality State, Race, and Risk of Dementia

Birth in a group of predominantly southern US states is robustly linked to increased stroke risk. Given the role of cerebrovascular disease in dementia risk, geographic patterning may also occur for dementia incidence. To determine whether birth in 9 high stroke mortality states (HSMSs) is associated with dementia in a diverse cohort of individuals living in Northern California. An observational cohort study included 7423 members of Kaiser Permanente Northern California (KPNC), an integrated health care delivery system, with health survey and clinical examination data available. Data were collected between 1964 and 1973 when the individuals were middle-aged and 1996 and 2015 when participants were in later life. Self-reported state of birth in an HSMS (top quintile of states for stroke mortality). Dementia diagnoses obtained from electronic health records from January 1, 1996, to October 15, 2015. Place of birth, race, educational level, and midlife vascular risk factors data were collected between 1964 and 1973. Of the 7423 persons included in the analysis, 4049 (54.5%) were women; 1354 (18.2%) were black. The mean (SD) age of study participants at their first visit between 1963 and 1974 was 42.94 (1.73) years and mean (SD) age at the beginning of follow-up for dementia in 1996 was 71.14 (2.72) years. Dementia was diagnosed in 2254 (30.4%) of the participants and was more common among those born in an HSMS than those born outside of one (455 [39.0%] vs 1799 [28.8%]). Birth in an HSMS was 9.6 times more common for black participants (795 [58.7%]) than nonblack participants (371 [6.1%]). Overall, birth in an HSMS was associated with a 28% higher risk of dementia (adjusted hazard ratio [aHR], 1.28; 95% CI, 1.13-1.46) adjusted for age, sex, and race. Compared with nonblack persons born outside of an HSMS, black individuals born in an HSMS had the highest dementia risk (aHR, 1.67; 95% CI, 1.48-1.88), followed by black individuals not born in an HSMS (aHR, 1.48; 95% CI, 1.28-1.72), and nonblack persons born in an HSMS had a 46% increased risk (aHR, 1.46; 95% CI, 1.23-1.74). Cumulative 20-year dementia risks at age 65 years were 30.13% (95% CI, 26.87%-32.93%) and 21.80% (95% CI, 20.51%-22.91%) for individuals born in and outside an HSMS, respectively. To our knowledge, this is the first study to date of place of birth and incident dementia and shows increased risk for individuals born in an HSMS, even though all participants subsequently resided in California. Birth in an HSMS was common among black participants. Place of birth has enduring consequences for dementia risk and may be a major contributor to racial disparities in dementia.

Authors: Gilsanz P; Mayeda ER; Glymour MM; Quesenberry CP; Whitmer RA

JAMA Neurol. 2017 Sep 01;74(9):1056-1062.

PubMed abstract

Cohort study of cancer risk among insured transgender people

Authors: Silverberg MJ; Hunkeler E; Goodman M; et al.

Ann Epidemiol. 2017 08;27(8):499-501. Epub 2017-07-22.

PubMed abstract

Heterogeneity in national U.S. mortality trends within heart disease subgroups, 2000-2015

The long-term downward national U.S. trend in heart disease-related mortality slowed substantially during 2011-2014 before turning upward in 2015. Examining mortality trends in the major subgroups of heart disease may provide insight into potentially more targeted and effective prevention and treatment approaches to promote favorable trajectories. We examined national trends between 2000 and 2015 in mortality attributed to major heart disease subgroups including ischemic heart disease, heart failure, and all other types of heart disease. Using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER) data system, we determined national trends in age-standardized mortality rates attributed to ischemic heart disease, heart failure, and other heart diseases from January 1, 2000, to December 31, 2011, and from January 1, 2011, to December 31, 2015. Annual rate of changes in mortality attributed to ischemic heart disease, heart failure, and other heart diseases for 2000-2011 and 2011-2015 were compared. Death attributed to ischemic heart disease declined from 2000 to 2015, but the rate of decline slowed from 4.96% (95% confidence interval 4.77%-5.15%) for 2000-2011 to 2.66% (2.00%-3.31%) for 2011-2015. In contrast, death attributed to heart failure and all other causes of heart disease declined from 2000 to 2011 at annual rates of 1.94% (1.77%-2.11%) and 0.64% (0.44%-0.82%) respectively, but increased from 2011 to 2015 at annual rates of 3.73% (3.21% 4.26%) and 1.89% (1.33-2.46%). Differences in 2000-2011 and 2011-2015 decline rates were statistically significant for all 3 endpoints overall, by sex, and all race/ethnicity groups except Asian/Pacific Islanders (heart failure only significant) and American Indian/Alaskan Natives. While the long-term decline in death attributed to heart disease slowed between 2011 and 2014 nationally before turning upward in 2015, heterogeneity existed in the trajectories attributed to heart disease subgroups, with ischemic heart disease mortality continuing to decline while death attributed to heart failure and other heart diseases switched from a downward to upward trend. While systematic efforts to prevent and treat ischemic heart disease continue to be effective, urgent attention is needed to address the challenge of heart failure.

Authors: Sidney S; Quesenberry CP; Jaffe MG; Sorel M; Go AS; Rana JS

BMC Cardiovasc Disord. 2017 07 18;17(1):192. Epub 2017-07-18.

PubMed abstract

Association of Changes in Neighborhood-Level Racial Residential Segregation With Changes in Blood Pressure Among Black Adults: The CARDIA Study

Despite cross-sectional evidence linking racial residential segregation to hypertension prevalence among non-Hispanic blacks, it remains unclear how changes in exposure to neighborhood segregation may be associated with changes in blood pressure. To examine the association of changes in neighborhood-level racial residential segregation with changes in systolic and diastolic blood pressure over a 25-year period. This observational study examined longitudinal data of 2280 black participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective investigation of adults aged 18 to 30 years who underwent baseline examinations in field centers in 4 US locations from March 25, 1985, to June 7, 1986, and then were re-examined for the next 25 years. Racial residential segregation was assessed using the Getis-Ord Gi* statistic, a measure of SD between the neighborhood’s racial composition (ie, percentage of black residents) and the surrounding area’s racial composition. Segregation was categorized as high (Gi* >1.96), medium (Gi* 0-1.96), and low (Gi* <0). Fixed-effects linear regression modeling was used to estimate the associations of within-person change in exposure to segregation and within-person change in blood pressure while tightly controlling for time-invariant confounders. Data analyses were performed between August 4, 2016, and February 9, 2017. Within-person changes in systolic and diastolic blood pressure across 6 examinations over 25 years. Of the 2280 participants at baseline, 974 (42.7%) were men and 1306 (57.3%) were women. Of these, 1861 (81.6%) were living in a high-segregation neighborhood; 278 (12.2%), a medium-segregation neighborhood; and 141 (6.2%), a low-segregation neighborhood. Systolic blood pressure increased by a mean of 0.16 (95% CI, 0.06-0.26) mm Hg with each 1-SD increase in segregation score after adjusting for interactions of time with age, sex, and field center. Of the 1861 participants (81.6%) who lived in high-segregation neighborhoods at baseline, reductions in exposure to segregation were associated with reductions in systolic blood pressure. Mean differences in systolic blood pressure were -1.33 (95% CI, -2.26 to -0.40) mm Hg when comparing high-segregation with medium-segregation neighborhoods and -1.19 (95% CI, -2.08 to -0.31) mm Hg when comparing high-segregation with low-segregation neighborhoods after adjustment for time and interactions of time with baseline age, sex, and field center. Changes in segregation were not associated with changes in diastolic blood pressure. Decreases in exposure to racial residential segregation are associated with reductions in systolic blood pressure. This study adds to the small but growing body of evidence that policies that reduce segregation may have meaningful health benefits.

Authors: Kershaw KN; Robinson WR; Gordon-Larsen P; Hicken MT; Goff DC; Carnethon MR; Kiefe CI; Sidney S; Diez Roux AV

JAMA Intern Med. 2017 Jul 01;177(7):996-1002.

PubMed abstract

Heterogeneity in 14-year Dementia Incidence Between Asian American Subgroups

Asian Americans are a rapidly growing and diverse population. Prior research on dementia among Asian Americans focused on Japanese Americans or Asian Americans overall, although marked differences in cardiometabolic conditions between subgroups have been documented. We compared dementia incidence among 4 Asian American subgroups (n=8384 Chinese; n=4478 Japanese; n=6210 Filipino; n=197 South Asian) and whites (n=206,490) who were Kaiser Permanente Northern California members aged 64 years and above with no dementia diagnoses as of January 1, 2000. Dementia diagnoses were collected from medical records January 1, 2000 to December 31, 2013. Baseline medical utilization and comorbidities (diabetes, depression, hypertension, stroke, cardiovascular disease) were abstracted from medical records January 1, 1996 to December 31, 1999. We calculated age-standardized dementia incidence rates and Cox models adjusted for age, sex, medical utilization, and comorbidities. Mean baseline age was 71.7 years; mean follow-up was 9.6 years. Age-standardized dementia incidence rates were higher among whites than “All Asian-Americans” or any subgroup. Compared with Chinese (13.7/1000 person-years), dementia incidence was slightly higher among Japanese [14.8/1000 person-years; covariate-adjusted hazard ratio (adjusted-HR)=1.08; 95% confidence interval (CI), 0.99-1.18] and Filipinos (17.3/1000 person-years; adjusted-HR=1.20; 95% CI, 1.11-1.31), and lower among South Asians (12.1/1000 person-years; adjusted-HR=0.81; 95% CI, 0.53-1.25). Future studies are needed to understand how immigration history, social, environmental, and genetic factors contribute to dementia risk in the growing and diverse Asian American population.

Authors: Mayeda ER; Glymour MM; Quesenberry CP; Whitmer RA

Alzheimer Dis Assoc Disord. 2017 Jul-Sep;31(3):181-186.

PubMed abstract

Association Between Neighborhood Supermarket Presence and Glycated Hemoglobin Levels Among Patients With Type 2 Diabetes Mellitus

We estimated associations between neighborhood supermarket gain or loss and glycemic control (assessed by glycated hemoglobin (HbA1c) values) in patients from the Kaiser Permanente Northern California Diabetes Registry (n = 434,806 person-years; 2007-2010). Annual clinical measures were linked to metrics from a geographic information system for each patient’s address of longest residence. We estimated the association between change in supermarket presence (gain, loss, or no change) and change in HbA1c value, adjusting for individual- and area-level attributes and according to baseline glycemic control (near normal, <6.5%; good, 6.5%-7.9%; moderate, 8.0%-8.9%; and poor, ≥9.0%). Supermarket loss was associated with worse HbA1c trajectories for those with good, moderate, and poor glycemic control at baseline, while supermarket gain was associated with marginally better HbA1c outcomes only among patients with near normal HbA1c values at baseline. Patients with the poorest baseline HbA1c values (≥9.0%) had the worst associated changes in glycemic control following either supermarket loss or gain. Differences were not clinically meaningful relative to no change in supermarket presence. For patients with type 2 diabetes mellitus, gaining neighborhood supermarket presence did not benefit glycemic control in a substantive way. The significance of supermarket changes on health depends on a complex interaction of resident, neighborhood, and store characteristics.

Authors: Zhang YT; Mujahid MS; Laraia BA; Warton EM; Blanchard SD; Moffet HH; Downing J; Karter AJ

Am J Epidemiol. 2017 Jun 15;185(12):1297-1303.

PubMed abstract

Comparison of recruitment and retention among demographic subgroups in a large diverse population study of diet

We examined the feasibility of conducting a longitudinal study of diet among diverse populations by comparing rates of response throughout recruitment and retention phases by demographic and other characteristics. Using quota sampling, participants were recruited from 3 geographically and demographically diverse integrated health systems in the United States. Overall, 12,860 adults, ages 20-70, were invited to participate via mail. Participation first required accessing the study’s website and later meeting eligibility criteria via telephone interview. Enrollees were asked to provide two 24-hour dietary recalls, either interviewer-administered or self-administered on the web, over 6 weeks. Stepped monetary incentives were provided. Rates for accessing the study website ranged from 6% to 23% (9% overall) across sites. Site differences may reflect differences in recruitment strategy or target samples. Of those accessing the website, enrollment was high (≥ 87%). Of the 1185 enrollees, 42% were non-Hispanic white, 34% were non-Hispanic black, and 24% were Hispanic. Men and minorities had lower enrollment rates than women and non-Hispanic whites, partially due to less successful telephone contact for eligibility screening. Once enrolled, 90% provided 1 recall and 80% provided both. Women had higher retention rates than men, as did older compared to younger participants. Retention rates were similar across race/ethnicity groups. While study recruitment remains challenging, once recruited most participants, regardless of race/ethnicity, completed two 24-hour dietary recalls, both interviewer-administered and self-administered on the web. This study demonstrates the feasibility of collecting multiple 24-hour recalls including less expensive automated self-administered recalls among diverse populations.

Authors: Alexander GL; Kushi LH; Thompson FE; et al.

Contemp Clin Trials Commun. 2017 Jun;6:140-146. Epub 2017-04-10.

PubMed abstract

Making a difference in medical trainees’ attitudes toward Latino patients: A pilot study of an intervention to modify implicit and explicit attitudes.

Negative attitudes and discrimination against Latinos exist in the dominant U.S. culture and in healthcare systems, contributing to ongoing health disparities. This article provides findings of a pilot test of Yo Veo Salud (I See Health), an intervention designed to positively modify attitudes toward Latinos among medical trainees. The research question was: Compared to the comparison group, did the intervention group show lower levels of implicit bias against Latinos versus Whites, and higher levels of ethnocultural empathy, healthcare empathy, and patient-centeredness? We used a sequential cohort, post-test design to evaluate Yo Veo Salud with a sample of 69 medical trainees. The intervention setting was an academic medical institution in a Southeastern U.S. state with a fast-growing Latino population. The intervention was delivered, and data were collected online, between July and December of 2014. Participants in the intervention group showed greater ethnocultural empathy, healthcare empathy, and patient-centeredness, compared to the comparison group. The implicit measure assessed four attitudinal dimensions (pleasantness, responsibility, compliance, and safety). Comparisons between our intervention and comparison groups did not find any average differences in implicit anti-Latino bias between the groups. However, in a subset analysis of White participants, White participants in the intervention group demonstrated a significantly decreased level of implicit bias in terms of pleasantness. A dose response was also founded indicating that participants involved in more parts of the intervention showed more change on all measures. Our findings, while modest in size, provide proof of concept for Yo Veo Salud as a means for increasing ethno-cultural and physician empathy, and patient-centeredness among medical residents and decreasing implicit provider bias toward Latinos.

Authors: Chapman, Mimi V MV; Hall, William J WJ; Lee, Kent K; Colby, Robert R; Coyne-Beasley, Tamera T; Day, Steve S; Eng, Eugenia E; Lightfoot, Alexandra F AF; Merino, Yesenia Y; Simán, Florence M FM; Thomas, Tainayah T; Thatcher, Kari K; Payne, Keith K

Social science & medicine (1982). 2018 02 09;199(1):202-208. Epub 2017-05-05.

PubMed abstract

Food Environment and Weight Change: Does Residential Mobility Matter?: The Diabetes Study of Northern California (DISTANCE)

Associations between neighborhood food environment and adult body mass index (BMI; weight (kg)/height (m)2) derived using cross-sectional or longitudinal random-effects models may be biased due to unmeasured confounding and measurement and methodological limitations. In this study, we assessed the within-individual association between change in food environment from 2006 to 2011 and change in BMI among adults with type 2 diabetes using clinical data from the Kaiser Permanente Diabetes Registry collected from 2007 to 2011. Healthy food environment was measured using the kernel density of healthful food venues. Fixed-effects models with a 1-year-lagged BMI were estimated. Separate models were fitted for persons who moved and those who did not. Sensitivity analysis using different lag times and kernel density bandwidths were tested to establish the consistency of findings. On average, patients lost 1 pound (0.45 kg) for each standard-deviation improvement in their food environment. This relationship held for persons who remained in the same location throughout the 5-year study period but not among persons who moved. Proximity to food venues that promote nutritious foods alone may not translate into clinically meaningful diet-related health changes. Community-level policies for improving the food environment need multifaceted strategies to invoke clinically meaningful change in BMI among adult patients with diabetes.

Authors: Laraia BA; Downing JM; Zhang YT; Dow WH; Kelly M; Blanchard SD; Adler N; Schillinger D; Moffet H; Warton EM; Karter AJ

Am J Epidemiol. 2017 May 01;185(9):743-750.

PubMed abstract

Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities

Population care approaches for diabetes have the potential to improve the quality of care and decrease diabetes-related mortality and morbidity. Population care strategies are particularly relevant as accountable care organizations (ACOs), patient-centered medical homes (PCMH), and integrated delivery systems are increasingly focused on managing chronic disease care at the health system level. This review outlines the key elements of population care approaches for diabetes in the current health care environment. Population care approaches proactively identify diabetes patients through disease registries and electronic health record data and utilize multidisciplinary care teams, personalized provider feedback, and decision support tools to target and care for patients at risk for poor outcomes. Existing evidence suggests that these strategies can improve care outcomes and potentially ameliorate existing race/ethnic disparities in health care. However, such strategies may be less effective for patients who are disengaged from the health care system. As population care for diabetes continues to evolve, future initiatives should consider ways to tailor population care to meet individual patient needs, while leveraging improvements in clinical information systems and care integration to optimally manage and prevent diabetes in the future.

Authors: Schmittdiel JA; Gopalan A; Lin MW; Banerjee S; Chau CV; Adams AS

Curr Diab Rep. 2017 May;17(5):31.

PubMed abstract

High rates of severe hypoglycemia among African American patients with diabetes: the surveillance, prevention, and Management of Diabetes Mellitus (SUPREME-DM) network

Seven-year surveillance study (2005-2011) to evaluate race/ethnic differences in the trends in rates of severe hypoglycemia (SH) in a population of insured, at-risk adults with diabetes. SH events were identified via any primary or principal diagnosis from emergency department or inpatient encounters among African American, Asian, Latino and White adult diabetes patients treated with insulin or secretagogues (Sulfonylureas or Meglitinides), receiving care from integrated healthcare delivery systems across the United States. We calculated age- and sex-standardized annual SH rates and average annual percent change (AAPC) in SH rates. Annual SH rates ranged from 1.8% to 2.1% during this 7-year observation period (2,200,471 person-years). African Americans had consistently higher SH rates compared with Whites, while Latinos and Asians had consistently lower rates compared with Whites in each of the 7 years (all p < 0.01). The trend increased significantly only among African Americans (AAPC = +4.3%; 95% CI: +2.1, +6.5%); in the other groups, the AAPC was not significantly different from zero. Surveillance efforts should monitor the racial/ethnic-specific rates. The factors underlying substantially higher rates of hypoglycemia in African Americans should be evaluated. Clinically and culturally-appropriate strategies to reduce the risk of SH need to be developed and tested.

Authors: Karter AJ; SUPREME-DM Study Group; et al.

J Diabetes Complicat. 2017 May;31(5):869-873. Epub 2017-02-21.

PubMed abstract

Socioeconomic differences in adolescent substance abuse treatment participation and long-term outcomes

Socioeconomic status (SES) has been consistently linked to poorer access, utilization and outcomes of health care services, but this relationship has been understudied in adolescent substance abuse treatment research. This study examined SES differences in adolescent’s treatment participation and long-term outcomes of abstinence and 12-step attendance over five years after treatment. Data are from 358 adolescents (ages 13-18) who were recruited at intake to substance abuse treatment between 2000 and 2002 at four Kaiser Permanente Northern California outpatient treatment programs. Follow-up interviews of adolescents and their parents were conducted at 1, 3, and 5years, with over 80% response rates across time points. Using parent SES as a proxy for adolescent SES, no socioeconomic differences were found in treatment initiation, treatment retention, or long-term abstinence from alcohol or drugs. Parent education, but not parent income, was significantly associated with 12-step attendance post-treatment such that adolescents with higher parent education were more likely to attend than those with lower parent education. Findings suggest a lack of socioeconomic disparities in substance abuse treatment participation in adolescence, but potential disparities in post-treatment 12-step attendance during the transition from adolescence to young adulthood.

Authors: Lui CK; Sterling SA; Chi FW; Lu Y; Campbell CI

Addict Behav. 2017 May;68:45-51. Epub 2017-01-06.

PubMed abstract

Racial Differences in Associations of Blood Pressure Components in Young Adulthood With Incident Cardiovascular Disease by Middle Age: Coronary Artery Risk Development in Young Adults (CARDIA) Study

Data are sparse regarding which blood pressure (BP) components in young adulthood optimally determine cardiovascular disease (CVD) by middle age. To assess which BP components best determine incident CVD events in young adults and determine whether these associations vary by race and age at BP measurement. Using data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, this study assessed the longitudinal race-stratified associations between BP and cardiovascular outcomes. CARDIA is a community-based cohort that recruited black and white individuals (age range, 18-30 years) from March 26, 1985, through June 7, 1986. CARDIA followed up participants for up to 28 years, and 94% of the surviving cohort completed at least 1 telephone interview or examination from August 2009 through August 2014. Blood pressures measubred at baseline (Y0) and 15 years later (Y15). Composite CVD events, including coronary heart disease, stroke, heart failure, and other vascular diseases. A total of 4880 participants participated in the study (mean [SD] age, 24.9 [3.6] years at Y0 and 25.0 [3.6] years at Y15; 2223 male [45.6%] at Y0 and 1800 [44.2%] at Y15; 2657 female [54.4%] at Y0 and 2277 [55.8%] at Y0; 2473 black individuals [50.7%] at Y0 and 1994 [48.9%] at Y15; and 2407 white individuals [49.3%] at Y0 and 2083 [51.1%] at Y15). The mean SBP/DBP was 112/69 mm Hg in blacks and 109/68 mm Hg in whites at Y0 and 117/77 mm Hg in blacks and 110/72 mm Hg in whites at Y15. During a 25-year follow-up from Y0, 210 CVD events occurred (twice as many events in blacks [n = 140] compared with whites), of which 131 (87 in blacks) occurred after Y15. With adjustments for covariates, results from Cox proportional hazards models, including SBP and DBP, jointly suggested that, at Y0, SBP (hazard ratio [HR] per 1-SD increase, 1.32; 95% CI, 1.09-1.61) but not DBP (HR, 1.05; 95% CI, 0.88-1.26) was associated with CVD risk in blacks, whereas DBP (HR, 1.74; 95% CI, 1.21-2.50) but not SBP (HR, 0.82; 95% CI, 0.57-1.18) was associated with CVD risk in whites. At Y15, SBP was the strongest indicator of CVD in blacks (HR, 1.64; 95% CI, 1.25-2.16) and whites (HR, 1.67; 95% CI, 1.02-2.69). This study questions the classic view that DBP is more able to identify future CVD events than SBP in all individuals younger than 50 years. In young adulthood, SBP in black individuals and DBP in white individuals were the most robust indicators of future CVD. In middle-age, SBP in both races identified risk of incident CVD.

Authors: Yano Y; Reis JP; Tedla YG; Goff DC; Jacobs DR; Sidney S; Ning H; Liu K; Greenland P; Lloyd-Jones DM

JAMA Cardiol. 2017 04 01;2(4):381-389.

PubMed abstract

Beyond the Great Recession: Was the Foreclosure Crisis Harmful to the Health of Individuals With Diabetes?

The housing foreclosure crisis was harmful to the financial well-being of many households. In the present study, we investigated the health effects of the housing foreclosure crisis on glycemic control within a population of patients with diabetes. We hypothesized that an increase in the neighborhood foreclosure rate could worsen glycemic control by activating stressors such as higher neighborhood crime, lower housing prices, and erosion of neighborhood social cohesion. To test this, we linked public foreclosure records at the census-block level with clinical records from 2006 to 2009 of patients with diabetes. We specified individual fixed-effects models and controlled for individual time-invariant confounders and area-level time-varying confounders, including housing prices and unemployment rate, to estimate the effect of the foreclosure rate per census-block group on glycated hemoglobin. We found no statistically significant relationship between changes in the neighborhood foreclosure rate per block group in the prior year and changes in glycated hemoglobin. There is no evidence that increased foreclosure rates worsened glycemic control in this continuously insured population with diabetes. More research is needed to inform our knowledge of the role of insurance and health-care delivery systems in protecting the health of diabetic patients during times of economic stress.

Authors: Downing J; Laraia B; Rodriguez H; Dow WH; Adler N; Schillinger D; Warton EM; Karter AJ

Am J Epidemiol. 2017 Mar 15;185(6):429-435.

PubMed abstract

Racial-Ethnic Differences in Fall Prevalence among Older Women: A Cross-Sectional Survey Study

Falls are the leading cause of hip fracture in older women, with important public health implications. Fall risk increases with age and other clinical factors, and varies by race/ethnicity. International studies suggest that fall risk is lower in Asians, although data are limited in U.S. This study examines racial/ethnic differences in fall prevalence among older U.S. women within a large integrated healthcare delivery system. This cross-sectional study used data from 6277 women ages 65-90 who responded to the 2008 or 2011 Kaiser Permanente Northern California Member Health Survey (KPNC-MHS). The KPNC-MHS is a mailed questionnaire sent to a random sample of adult members stratified by age, gender, and geographic location, representing a population estimate of >200,000 women age ≥65 years. Age, race/ethnicity, self-reported health status, presence of diabetes, arthritis or prior stroke, mobility limitations and number of falls in the past year were obtained from the KPNC-MHS. The independent association of race/ethnicity and recent falls was examined, adjusting for known risk factors. The weighted sample was 76.7% non-Hispanic white, 6.2% Hispanic, 6.8% black and 10.3% Asian. Over 20% reported having fallen during the past year (28.5% non-Hispanic white, 27.8% Hispanic, 23.4% black and 20.1% Asian). Older age was associated with greater fall risk, as was having diabetes (OR 1.24, CI 1.03-1.48), prior stroke (OR 1.51, CI 1.09-2.07), arthritis (OR 1.61, CI 1.39-1.85) and mobility limitations (OR 2.82, CI 2.34-3.39), adjusted for age. Compared to whites, Asian (OR 0.64, CI 0.50-0.81) and black (OR 0.73, CI 0.55-0.95) women were much less likely to have ≥1 fall in the past year, adjusting for age, comorbidities, mobility limitation and poor health status. Asians were also less likely to have ≥2 falls (OR 0.62, CI 0.43-0.88). Among older women, the risk of having a recent fall was substantially lower for black and Asian women when compared to white women. This may contribute to their lower rates of hip fracture. Future studies should examine cultural and behavioral factors that contribute to these observed racial/ethnic differences in fall risk among U.S. women.

Authors: Geng Y; Lo JC; Brickner L; Gordon NP

BMC Geriatr. 2017 Mar 11;17(1):65. Epub 2017-03-11.

PubMed abstract

Cumulative receipt of an anti-poverty tax credit for families did not impact tobacco smoking among parents

The effect of anti-poverty tax credit interventions on tobacco consumption is unclear. Previous studies have estimated short-term effects, did not isolate the effects of cumulative dose of tax credits, produced conflicting results, and used methods with limited control for some time-varying confounders (e.g., those affected by prior treatment) and treatment regimen (i.e., study participants’ tax credit receipt pattern over time). We estimated the longer-term, cumulative effect of New Zealand’s Family Tax Credit (FTC) on tobacco consumption, using a natural experiment (administrative errors leading to exogenous variation in FTC receipt) and methods specifically for controlling confounding, reverse causation, and treatment regimen. We extracted seven waves (2002-2009) of the nationally representative Survey of Family, Income and Employment including 4404 working-age (18-65 years) parents in families. The exposure was the total numbers of years of receiving FTC. The outcomes were regular smoking and the average daily number of cigarettes usually smoked at wave 7. We estimated average treatment effects using inverse probability of treatment weighting and marginal structural modelling. Each additional year of receiving FTC affected neither the odds of regular tobacco smoking among all parents (odds ratio 1.02, 95% confidence interval 0.94-1.11), nor the number of cigarettes smoked among parents who smoked regularly (rate ratio 1.01, 95% confidence interval 0.99-1.03). We found no evidence for an association between the cumulative number of years of receiving an anti-poverty tax credit and tobacco smoking or consumption among parents. The assumptions of marginal structural modelling are quite demanding, and we therefore cannot rule out residual confounding. Nonetheless, our results suggest that tax credit programme participation will not increase tobacco consumption among poor parents, at least in this high-income country.

Authors: Pega, Frank F; Gilsanz, Paola P; Kawachi, Ichiro I; Wilson, Nick N; Blakely, Tony T

Social science & medicine (1982). 2017 04 ;179(5):160-165. Epub 2017-03-02.

PubMed abstract

Racial/ethnic differences in preterm perinatal outcomes.

​BACKGROUND: Racial disparities in preterm birth and infant death have been well documented. Less is known about racial disparities in neonatal morbidities among infants who are born at <37 weeks of gestation.OBJECTIVE: The purpose of this study was to determine whether the risk for morbidity and death among infants who are born preterm differs by maternal race.STUDY DESIGN: A retrospective cohort design included medical records from preterm deliveries of 19,325 black, Hispanic, and white women in the Consortium on Safe Labor. Sequentially adjusted Poisson models with generalized estimating equations estimated racial differences in the risk for neonatal morbidities and death, controlling for maternal demographics, health behaviors, and medical history. Sex differences between and within race were examined.RESULTS: Black preterm infants had an elevated risk for perinatal death, but there was no difference in risk for neonatal death across racial groups. Relative to white infants, black infants were significantly more likely to experience sepsis (9.1% vs 13.6%), peri- or intraventricular hemorrhage (2.6% vs 3.3%), intracranial hemorrhage (0.6% vs 1.8%), and retinopathy of prematurity (1.0% vs 2.6%). Hispanic and white preterm neonates had similar risk profiles. In general, female infants had lower risk relative to male infants, with white female infants having the lowest prevalence of a composite indicator of perinatal death or any morbidity across all races (30.9%). Differences in maternal demographics, health behaviors, and medical history did little to influence these associations, which were robust to sensitivity analyses of pregnancy complications as potential underlying mechanisms.CONCLUSION: Preterm infants were at similar risk for neonatal death, regardless of race; however, there were notable racial disparities and sex differences in rare, but serious, adverse neonatal morbidities.

Authors: Wallace ME; Mendola P; Kim SS; Epps N; Chen Z; Smarr M; Hinkle SN; Zhu Y; Grantz KL;

​Am J Obstet Gynecol. 2017 Mar;216(3):306.e1-306.e12. doi: 10.1016/j.ajog.2016.11.1026. Epub 2016 Nov 16.

PubMed abstract

Racial/ethnic differences in obesity and comorbidities between safety-net- and non safety-net integrated health systems

Previous research shows that patients in integrated health systems experience fewer racial disparities compared with more traditional healthcare systems. Little is known about patterns of racial/ethnic disparities between safety-net and non safety-net integrated health systems.We evaluated racial/ethnic differences in body mass index (BMI) and the Charlson comorbidity index from 3 non safety-net- and 1 safety-net integrated health systems in a cross-sectional study. Multinomial logistic regression modeled comorbidity and BMI on race/ethnicity and health care system type adjusting for age, sex, insurance, and zip-code-level incomeThe study included 1.38 million patients. Higher proportions of safety-net versus non safety-net patients had comorbidity score of 3+ (11.1% vs. 5.0%) and BMI ?35 (27.7% vs. 15.8%). In both types of systems, blacks and Hispanics were more likely than whites to have higher BMIs. Whites were more likely than blacks or Hispanics to have higher comorbidity scores in a safety net system, but less likely to have higher scores in the non safety-nets. The odds of comorbidity score 3+ and BMI 35+ in blacks relative to whites were significantly lower in safety-net than in non safety-net settings.Racial/ethnic differences were present within both safety-net and non safety-net integrated health systems, but patterns differed. Understanding patterns of racial/ethnic differences in health outcomes in safety-net and non safety-net integrated health systems is important to tailor interventions to eliminate racial/ethnic disparities in health and health care.

Authors: Balasubramanian BA; Garcia MP; Corley DA; Doubeni CA; Haas JS; Kamineni A; Quinn VP; Wernli K; Zheng Y; Skinner CS

Medicine (Baltimore). 2017 Mar;96(11):e6326.

PubMed abstract

Association of Patient-Physician Language Concordance and Glycemic Control for Limited-English Proficiency Latinos With Type 2 Diabetes

Providing culturally competent care to the growing number of limited-English proficiency (LEP) Latinos with diabetes in the United States is challenging. To evaluate changes in risk factor control among LEP Latinos with diabetes who switched from language-discordant (English-only) primary care physicians (PCPs) to language-concordant (Spanish-speaking) PCPs or vice versa. This pre-post, difference-in-differences study selected 1605 adult patients with diabetes who self-identified as Latino, whose preferred language was Spanish, and who switched PCPs between January 1, 2007, and December 31, 2013. Study participants were members of the Kaiser Permanente Northern California health care system (an integrated health care delivery system with access to bilingual PCPs and/or professional interpreter services). Spanish-speaking and English-only PCPs were identified by self-report or utilization data. Change in patient-PCP language concordance after switching PCPs. Glycemic control (glycated hemoglobin [HbA1c] < 8%), poor glycemic control (HbA1c > 9%), low-density-lipoprotein (LDL) control (LDL < 100 mg/dL), and systolic blood pressure (SBP) control (SBP < 140 mm Hg). Overall, 1605 LEP Latino adults with diabetes (mean [SD] age, 60.5 [13.1] years) were included in this study, and there was a significant net improvement in glycemic and LDL control among patients who switched from language-discordant PCPs to concordant PCPs relative to those who switched from one discordant PCP to another discordant PCP. After adjustment and accounting for secular trends, the prevalence of glycemic control increased by 10% (95% CI, 2% to 17%; P = .01), poor glycemic control decreased by 4% (95% CI, -10% to 2%; P = .16) and LDL control increased by 9% (95% CI, 1% to 17%; P = .03). No significant changes were observed in SBP control. Prevalence of LDL control increased 15% (95% CI, 7% to 24%; P < .001) among LEP Latinos who switched from concordant to discordant PCPs. Risk factor control did not worsen following a PCP switch in any group. We observed significant improvements in glycemic control among LEP Latino patients with diabetes who switched from language-discordant to concordant PCPs. Facilitating language-concordant care may be a strategy for diabetes management among LEP Latinos.

Authors: Parker MM; Fernández A; Moffet HH; Grant RW; Torreblanca A; Karter AJ

JAMA Intern Med. 2017 Mar 01;177(3):380-387.

PubMed abstract

Effect of Race and Ethnicity on Antihypertensive Medication Utilization Among Women in the United States: Study of Women’s Health Across the Nation (SWAN)

Antihypertensive medication use may vary by race and ethnicity. Longitudinal antihypertensive medication use patterns are not well described in women. Participants from the Study of Women’s Health Across the Nation (SWAN), a prospective cohort of women (n=3302, aged 42-52), who reported a diagnosis of hypertension or antihypertensive medication use at any annual visit were included. Antihypertensive medications were grouped by class and examined by race/ethnicity adjusting for potential confounders in logistic regression models. A total of 1707 (51.7%) women, mean age 50.6 years, reported hypertension or used antihypertensive medications at baseline or during follow-up (mean 9.1 years). Compared with whites, blacks were almost 3 times as likely to receive a calcium channel blocker (odds ratio, 2.92; 95% CI, 2.24-3.82) and twice as likely to receive a thiazide diuretic (odds ratio, 2.38; 95% CI, 1.93-2.94). Blacks also had a higher probability of reporting use of ≥2 antihypertensive medications (odds ratio, 1.95; 95% CI, 1.55-2.45) compared with whites. Use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and thiazide diuretics increased over time for all racial/ethnic groups. Contrary to our hypothesis, rates of β-blocker usage did not decrease over time. Among this large cohort of multiethnic midlife women, use of antihypertensive medications increased over time, with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers becoming the most commonly used antihypertensive medication, even for blacks. Thiazide diuretic utilization increased over time for all race/ethnic groups as did use of calcium channel blockers among blacks; both patterns are in line with guideline recommendations for the management of hypertension.

Authors: Jackson EA; Ruppert K; Derby CA; Lian Y; Neal-Perry G; Habel LA; Tepper PG; Harlow SD; Solomon DH

J Am Heart Assoc. 2017 Feb 23;6(3). Epub 2017-02-23.

PubMed abstract

Neighborhood Differences in Post-Stroke Mortality

BACKGROUND: Post-stroke mortality is higher among residents of disadvantaged neighborhoods, but it is not known whether neighborhood inequalities are specific to stroke survival or similar to mortality patterns in the general population. We hypothesized that neighborhood disadvantage would predict higher poststroke mortality, and neighborhood effects would be relatively larger for stroke patients than for individuals with no history of stroke.METHODS AND RESULTS: Health and Retirement Study participants aged ≥50 years without stroke at baseline (n=15 560) were followed ≤12 years for incident stroke (1715 events over 159 286 person-years) and mortality (5325 deaths). Baseline neighborhood characteristics included objective measures based on census tracts (family income, poverty, deprivation, residential stability, and percent white, black, or foreign-born) and self-reported neighborhood social ties. Using Cox proportional hazard models, we compared neighborhood mortality effects for people with versus people without a history of stroke. Most neighborhood variables predicted mortality for both stroke patients and the general population in demographic-adjusted models. Neighborhood percent white predicted lower mortality for stroke survivors (hazard ratio, 0.75 for neighborhoods in highest 25th percentile versus below, 95% confidence interval, 0.62-0.91) more strongly than for stroke-free adults (hazard ratio, 0.92; 95% confidence interval, 0.83-1.02;P=0.04 for stroke-by-neighborhood interaction). No other neighborhood characteristic had different effects for people with versus without stroke. Neighborhood-mortality associations emerged within 3 months after stroke, when associations were often stronger than among stroke-free individuals.CONCLUSIONS: Neighborhood characteristics predict mortality, but most effects are similar for individuals without stroke. Eliminating disparities in stroke survival may require addressing pathways that are not specific to traditional poststroke care.

Authors: Osypuk, Theresa L TL; Ehntholt, Amy A; Moon, J Robin JR; Gilsanz, Paola P; Glymour, M Maria MM

Circulation. Cardiovascular quality and outcomes. 2017 Feb ;10(2):120-128. Epub 2017-02-22.

PubMed abstract

Actigraphic Sleep Patterns of U.S. Hispanics: The Hispanic Community Health Study/Study of Latinos

To assess the extent to which objective sleep patterns vary among U.S. Hispanics/Latinos. We assessed objective sleep patterns in 2087 participants of the Hispanic Community Health Study/Study of Latinos from 6 Hispanic/Latino subgroups aged 18-64 years who underwent 7 days of wrist actigraphy. The age- and sex-standardized mean (SE) sleep duration was 6.82 (0.05), 6.72 (0.07), 6.61 (0.07), 6.59 (0.06), 6.57 (0.10), and 6.44 (0.09) hr among individuals of Mexican, Cuban, Dominican, Central American, Puerto Rican, and South American heritage, respectively. Sleep maintenance efficiency ranged from 89.2 (0.2)% in Mexicans to 86.5 (0.4)% in Puerto Ricans, while the sleep fragmentation index ranged from 19.7 (0.3)% in Mexicans to 24.2 (0.7)% in Puerto Ricans. In multivariable models adjusted for age, sex, season, socioeconomic status, lifestyle habits, and comorbidities, these differences persisted. There are important differences in actigraphically measured sleep across U.S. Hispanic/Latino heritages. Individuals of Mexican heritage have longer and more consolidated sleep, while those of Puerto Rican heritage have shorter and more fragmented sleep. These differences may have clinically important effects on health outcomes.

Authors: Dudley KA; Weng J; Sotres-Alvarez D; Simonelli G; Cespedes Feliciano E; Ramirez M; Ramos AR; Loredo JS; Reid KJ; Mossavar-Rahmani Y; Zee PC; Chirinos DA; Gallo LC; Wang R; Patel SR

Sleep. 2017 Feb 01;40(2).

PubMed abstract

Measurement equivalence of the Consumer Assessment of Healthcare Providers and Systems (CAHPS(�)) Medicare survey items between Whites and Asians

Asians report worse experiences with care than Whites. This could be due to true differences in care received, expectations about care, or survey response styles. We examined responses to the Consumer Assessment of Healthcare Providers and Systems (CAHPS(®)) Medicare survey items by Whites and Asians, controlling for underlying level on the CAHPS constructs. We conducted multiple group analyses to evaluate measurement equivalence of CAHPS Medicare survey data between White and Asian Medicare beneficiaries for CAHPS reporting composites (communication with personal doctor, access to care, plan customer service) and global ratings of care using pooled data from 2007 to 2011. Responses were obtained from 1,326,410 non-Hispanic Whites and 40,672 non-Hispanic Asians (hereafter referred to as Whites and Asians). The median age for Whites was 70, with 24 % 80 or older, and 70 for Asians, with 23 % 80 or older. Fifty-eight percent of Whites and 56 % of Asians were female. A model without group-specific estimates fit the data as well as a model that included 12 group-specific estimates (7 factor loadings, 3 measured variable errors, and 2 item intercepts): Comparative Fit Index = 0.947 and 0.948; root-mean-square error of approximation = 0.052 and 0.052, respectively). Differences in latent CAHPS score means between Whites and Hispanics estimated from the two models were similar, differing by 0.053 SD or less. This study provides support for measurement equivalence of the CAHPS Medicare survey composites (communication, access, customer service) and global ratings between White and Asian respondents, supporting comparisons of care experiences between the two groups.

Authors: Hays RD; Chawla N; Kent EE; Arora NK

Qual Life Res. 2017 Feb;26(2):311-318. Epub 2016-08-05.

PubMed abstract

Global Variations in Patient Populations and Outcomes in Heart Failure Clinical Trials.

PURPOSE OF REVIEW: Heart failure is a global pandemic and there has been a growing effort to enroll patients from different geographical regions in randomized controlled trials. In this review, we examined regional variation in both patient characteristics and outcomes among several of the most recent global heart failure trials RECENT FINDINGS: Retrospective analyses of global heart failure trials have identified marked variations in both baseline characteristics and management of heart failure by region of enrollment. In some trials, this variation has been significant enough to cause differential treatment effects. We summarized key heterogeneity observed in global heart failure clinical trials. Differences in both patient population and organization of these trials abroad pose an important challenge in making interpretations and country-level decisions. As such, we encourage a concerted effort to account for these differences in future research.

Authors: Egwim, Chidiebube C; Dixon, Brittany B; Ambrosy, Andrew P AP; Mentz, Robert J RJ

Current heart failure reports. 2017 02 01;14(1):30-39. Epub 2017-01-19.

PubMed abstract

The Next Frontier in Communication and the ECLIPPSE Study: Bridging the Linguistic Divide in Secure Messaging

Health systems are heavily promoting patient portals. However, limited health literacy (HL) can restrict online communication via secure messaging (SM) because patients’ literacy skills must be sufficient to convey and comprehend content while clinicians must encourage and elicit communication from patients and match patients’ literacy level. This paper describes the Employing Computational Linguistics to Improve Patient-Provider Secure Email (ECLIPPSE) study, an interdisciplinary effort bringing together scientists in communication, computational linguistics, and health services to employ computational linguistic methods to (1) create a novel Linguistic Complexity Profile (LCP) to characterize communications of patients and clinicians and demonstrate its validity and (2) examine whether providers accommodate communication needs of patients with limited HL by tailoring their SM responses. We will study >5 million SMs generated by >150,000 ethnically diverse type 2 diabetes patients and >9000 clinicians from two settings: an integrated delivery system and a public (safety net) system. Finally, we will then create an LCP-based automated aid that delivers real-time feedback to clinicians to reduce the linguistic complexity of their SMs. This research will support health systems’ journeys to become health literate healthcare organizations and reduce HL-related disparities in diabetes care.

Authors: Schillinger D; Karter AJ; et al.

J Diabetes Res. 2017;2017:1348242. Epub 2017-02-07.

PubMed abstract

Racial Differences in HIV and HCV Risk Behaviors, Transmission, and Prevention Knowledge among Non-Treatment-Seeking Individuals with Opioid Use Disorder.

In light of New York’s recently reinforced strategy to end the AIDS epidemic by expanding testing, treatment, and access to pre-exposure prophylaxis (PrEP), we assessed drug use and sexual risk behaviors, along with HIV/Hepatitis C virus (HCV) transmission and prevention knowledge among non-treatment-seeking adults with opioid use disorder (OUD) in New York City. Over the course of 18 months, volunteers screening for research studies in the Opioid Laboratory at the New York State Psychiatric Institute completed a locally developed self-assessment questionnaire. A total of 138 adults with OUD (24 female, 114 male) with a mean age of 46.5 years (SD = 9.5 yrs) were assessed. Significant differences among the four racial/ethnic subgroups (n = 65 African-Americans, n = 34 Hispanics, n = 31 Caucasians or Whites, n = 8 Multiracial) were found. Whites were the youngest (p = 0.001), most frequently injecting drugs (p

Authors: Metz, Verena E VE; Sullivan, Maria A MA; Jones, Jermaine D JD; Evans, Elizabeth E; Luba, Rachel R; Vogelman, Jonathan J; Comer, Sandra D SD

Journal of psychoactive drugs. 2017 08 01;49(1):59-68. Epub 2016-12-05.

PubMed abstract

Characteristics associated with self-rated health in the CARDIA study: Contextualising health determinants by income group

An understanding of factors influencing health in socioeconomic groups is required to reduce health inequalities. This study investigated combinations of health determinants associated with self-rated health (SRH), and their relative importance, in income-based groups. Cross-sectional data from year 15 (2000 – 2001) of the CARDIA study (Coronary Artery Risk Development in Young Adults, USA) – 3648 men and women (mean 40 years) – were split into 5 income-based groups. SRH responses were categorized as ‘higher’/’lower’. Health determinants (medical, lifestyle, and social factors, living conditions) associated with SRH in each group were analyzed using classification tree analysis (CTA). Income and SRH were positively associated (p < 0.05). Data suggested an income-based gradient for lifestyle/medical/social factors/living conditions. Profiles, and relative importance ranking, of multi-domain health determinants, in relation to SRH, differed by income group. The highest ranking variable for each income group was chronic burden-personal health problem (<$25,000); physical activity ($25-50,000; $50-75,000; $100,000 +); and cigarettes/day ($75-100,000). In lower income groups, more risk factors and chronic burden indicators were associated with SRH. Social support, control over life, optimism, and resources for paying for basics/medical care/health insurance were greater (%) with higher income. SRH is a multidimensional measure; CTA is useful for contextualizing risk factors in relation to health status. Findings suggest that for lower income groups, addressing contributors to chronic burden is important alongside lifestyle/medical factors. In a proportionate universalism context, in addition to differences in intensity of public health action across the socioeconomic gradient, differences in the type of interventions to improve SRH may also be important.

Authors: Nayak S; Hubbard A; Sidney S; Syme SL

Prev Med Rep. 2016 Dec;4:199-208. Epub 2016-06-08.

PubMed abstract

Applying ethnic-specific bone mineral density T-scores to Chinese women in the USA

Caucasian reference data are used to classify bone mineral density in US women of all races. However, use of Chinese American reference data yields lower osteoporosis prevalence in Chinese women. The reduction in osteoporosis labeling may be relevant for younger Chinese women at low fracture risk. Caucasian reference data are used for osteoporosis classification in US postmenopausal women regardless of race, including Asians who tend to have lower bone mineral density (BMD) than women of white race. This study examines BMD classification by ethnic T-scores for Chinese women. Using BMD data in a Northern California healthcare population, Chinese women aged 50-79 years were compared to age-matched white women (1:5 ratio), with femoral neck (FN), total hip (TH), and lumbar spine (LS) T-scores calculated using Caucasian versus Chinese American reference data. Comparing 4039 Chinese and 20,195 white women (44.8 % age 50-59 years, 37.5 % age 60-69 years, 17.7 % age 70-79 years), Chinese women had lower BMD T-scores at the FN, TH, and LS (median T-score 0.29-0.72 units lower across age groups, p < 0.001) using Caucasian reference data. Using Chinese American BMD reference data resulted in an average +0.47, +0.36, and +0.48 units higher FN, TH, and LS T-scores, respectively, reducing the prevalence of osteoporosis (T-score ≤ -2.5) in Chinese women at the FN (16.7 to 6.6 %), TH (9.8 to 3.2 %), and LS (23.2 to 8.9 %); osteoporosis prevalence at any one of three sites fell from 29.6 to 12.6 % (22.4 to 8.1 % for age 50-64 years and 43.2 to 21.0 % for age 65-79 years). Use of Chinese American BMD reference data yields higher (ethnic) T-scores by 0.4-0.5 units, with a large proportion of Chinese women reclassified from osteoporosis to osteopenia. The reduction in osteoporosis labeling with ethnic T-scores may be relevant for younger Chinese women at low fracture risk.

Authors: Lo JC; Kim S; Chandra M; Ettinger B

Osteoporos Int. 2016 12;27(12):3477-3484. Epub 2016-07-28.

PubMed abstract

Examining racial variation in antiemetic use and post-chemotherapy health care utilization for nausea and vomiting among breast cancer patients

Racial minority cancer patients may experience underuse of antiemetic medications to prevent chemotherapy-induced nausea and vomiting (CINV). In addition to its adverse implications for quality of life, antiemetic underuse may contribute to observed disparities in acute illness during chemotherapy. To understand the potential contribution of CINV prophylaxis to breast cancer disparities, we assessed racial variation in potent antiemetic use and post-chemotherapy utilization related to CINV and the relationship between the two. We used SEER-Medicare data to evaluate the health care utilization in the 14 days following chemotherapy initiation among black and white women receiving highly emetogenic chemotherapy for breast cancer. We used modified Poisson regression to assess the relationship between (1) race and CINV-related utilization and (2) NK1 use and CINV-related utilization, overall and stratified by race. We report adjusted risk ratios (aRR) and 95 % confidence intervals (CI). The study included 1130 women. Black women were 11 % less likely than white women to use neurokinin-1 receptor antagonists (NK1s) for CINV prophylaxis (p = 0.02); however, they experienced fewer CINV-related encounters following chemotherapy (unadjusted RR = 0.63, 95 %CI = 0.40-0.99; p = 0.05). After adjustment for clinical covariates, estimates were similar but no longer statistically significant (p = 0.07). Among white women, NK1 use was associated with increased CINV-related utilization (aRR NK1 users vs. non-users: 1.35, 95 % CI = 1.07-1.69, p = 0.01), likely resulting from unmeasured confounders. Black women were less likely to use NK1s- and CINV-related services. Racial variation in CINV-related services use may be partly explained by differential symptom reporting or access to care.

Authors: Check DK; Reeder-Hayes KE; Zullig LL; Weinberger M; Basch EM; Dusetzina SB

Support Care Cancer. 2016 Dec;24(12):4839-4847. Epub 2016-07-27.

PubMed abstract

Trends in cancer survivors’ experience of patient-centered communication: results from the Health Information National Trends Survey (HINTS)

Two Institute of Medicine reports almost a decade apart suggest that cancer survivors often feel “lost in transition” and experience suboptimal quality of care. The six core functions of patient-centered communication: managing uncertainty, responding to emotions, making decisions, fostering healing relationships, enabling self-management, and exchanging information, represent a central aspect of survivors’ care experience that has not been systematically investigated. Nationally representative data from four administrations of the Health Information National Trends Survey (HINTS) was merged with combined replicate weights using the jackknife replication method. Linear and logistic regression models were used to assess (1) characteristics of cancer survivors (N = 1794) who report suboptimal patient-centered communication and (2) whether survivors’ patient-centered communication experience changed from 2007 to 2013. One third to one half of survivors report suboptimal patient-centered communication, particularly on core functions of providers helping manage uncertainty (48 %) and responding to emotions (49 %). In a fully adjusted linear regression model, survivors with more education (Wald F = 2.84, p = .04), without a usual source of care (Wald F = 11.59, p < .001), and in poorer health (Wald F = 9.08, p < .001) were more likely to report less patient-centered communication. Although ratings of patient-centered communication improved over time (p trend = .04), this trend did not remain significant in fully adjusted models. Despite increased attention to survivorship, many survivors continue to report suboptimal communication with their health care providers. Survivorship communication should include managing uncertainty about future risk and address survivors' emotional needs. Efforts to improve patient-centered communication should focus on survivors without a usual source of care and in poorer health.

Authors: Blanch-Hartigan D; Chawla N; Moser RP; Finney Rutten LJ; Hesse BW; Arora NK

J Cancer Surviv. 2016 Dec;10(6):1067-1077. Epub 2016-05-19.

PubMed abstract

Association of Acculturation and Health Literacy with Prevalent Dysglycemia and Diabetes Control Among Latinos in the Boston Area Community Health (BACH) Survey

This study assessed the effect of acculturation on type 2 diabetes and whether health literacy may mediate this association. The Boston Area Community Health cohort is a multi-stage stratified random sample of adults from Boston including 744 Latinos. We defined dysglycemia as a HbA1c ≥5.7 %. Multivariable analyses examined the associations between acculturation and health literacy adjusting for demographic and clinical variables. Similar analyses were performed among participants with HbA1c ≥7.0 % to assess the association between acculturation and diabetes control. Among an insured primarily foreign born Spanish speaking Latino population, with a long residence period in the US and good healthcare utilization, higher levels of acculturation were not associated with dysglycemia. Lower levels of acculturation were associated with worse diabetes control. Health literacy level did not modify these associations. Elucidating the components of heterogeneity among Latinos will be essential for understanding the influence of acculturation on diabetes.

Authors: López L; Grant RW; Marceau L; Piccolo R; McKinlay JB; Meigs JB

J Immigr Minor Health. 2016 Dec;18(6):1266-1273.

PubMed abstract

Research Needs to Improve Hypertension Treatment and Control in African Americans

Authors: Whelton PK; Hyman DJ; National Heart, Lung, and Blood Institute Working Group on Research Needs to Improve Hypertension Treatment and Control in African Americans; et al.

Hypertension. 2016 11;68(5):1066-1072. Epub 2016-09-12.

PubMed abstract

Race/Ethnicity and Adoption of a Population Health Management Approach to Colorectal Cancer Screening in a Community-Based Healthcare System

Screening outreach programs using population health management principles offer services uniformly to all eligible persons, but racial/ethnic colorectal cancer (CRC) screening patterns in such programs are not well known. To examine the association between race/ethnicity and the receipt of CRC screening and timely follow-up of positive results before and after implementation of a screening program. Retrospective cohort study of screen-eligible individuals at the Kaiser Permanente Northern California community-based integrated healthcare delivery system (2004-2013). A total of 868,934 screen-eligible individuals 51-74 years of age at cohort entry, which included 662,872 persons in the period before program implementation (2004-2006), 654,633 during the first 3 years after implementation (2007-2009), and 665,268 in the period from 4 to 7 years (2010-2013) after program implementation. A comprehensive system-wide long-term effort to increase CRC that included leadership alignment, goal-setting, and quality assurance through a PHM approach, using mailed fecal immunochemical testing (FIT) along with offering screening at office visits. Differences over time and by race/ethnicity in up-to-date CRC screening (overall and by test type) and timely follow-up of a positive screen. Race/ethnicity categories included non-Hispanic white, non-Hispanic black, Hispanic/Latino, Asian/Pacific Islander, Native American, and multiple races. From 2004 to 2013, age/sex-adjusted CRC screening rates increased in all groups, including 35.2 to 81.1 % among whites and 35.6 to 78.0 % among blacks. Screening rates among Hispanics (33.1 to 78.3 %) and Native Americans (29.4 to 74.5 %) remained lower than those for whites both before and after program implementation. Blacks, who had slightly higher rates before program implementation (adjusted rate ratio [RR] = 1.04, 99 % CI: 1.02-1.05), had lower rates after program implementation (RR for period from 4 to 7 years = 0.97, 99 % CI: 0.96-0.97). There were also substantial improvements in timely follow-up of positive screening results. In this screening program using core PHM principles, CRC screening increased markedly in all racial/ethnic groups, but disparities persisted for some groups and developed in others, which correlated with levels of adoption of mailed FIT.

Authors: Mehta SJ; Levin TR; Corley DA; Doubeni CA; et al.

J Gen Intern Med. 2016 Nov;31(11):1323-1330. Epub 2016-07-13.

PubMed abstract

CKD Progression and Mortality among Hispanics and Non-Hispanics

Although recommended approaches to CKD management are achieved less often in Hispanics than in non-Hispanics, whether long-term outcomes differ between these groups is unclear. In a prospective longitudinal analysis of participants enrolled into the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC Studies, we used Cox proportional hazards models to determine the association between race/ethnicity, CKD progression (50% eGFR loss or incident ESRD), incident ESRD, and all-cause mortality, and linear mixed-effects models to assess differences in eGFR slope. Among 3785 participants, 13% were Hispanic, 43% were non-Hispanic white (NHW), and 44% were non-Hispanic black (NHB). Over a median follow-up of 5.1 years for Hispanics and 6.8 years for non-Hispanics, 27.6% of all participants had CKD progression, 21.3% reached incident ESRD, and 18.3% died. Hispanics had significantly higher rates of CKD progression, incident ESRD, and mean annual decline in eGFR than did NHW (P<0.05) but not NHB. Hispanics had a mortality rate similar to that of NHW but lower than that of NHB (P<0.05). In adjusted analyses, the risk of CKD progression did not differ between Hispanics and NHW or NHB. However, among nondiabetic participants, compared with NHB, Hispanics had a lower risk of CKD progression (hazard ratio, 0.61; 95% confidence interval, 0.39 to 0.95) and incident ESRD (hazard ratio, 0.50; 95% confidence interval, 0.30 to 0.84). At higher levels of urine protein, Hispanics had a significantly lower risk of mortality than did non-Hispanics (P<0.05). Thus, important differences in CKD progression and mortality exist between Hispanics and non-Hispanics and may be affected by proteinuria and diabetes.

Authors: Fischer MJ; Go AS; Chronic Renal Insufficiency Cohort (CRIC) Study Investigators; et al.

J Am Soc Nephrol. 2016 Nov;27(11):3488-3497. Epub 2016-05-05.

PubMed abstract

Heart Failure Clinical Trials in East and Southeast Asia: Understanding the Importance and Defining the Next Steps.

Heart failure (HF) is a major and increasing global public health problem. In Asia, aging populations and recent increases in cardiovascular risk factors have contributed to a particularly high burden of HF, with outcomes that are poorer than those in the rest of the world. Representation of Asians in landmark HF trials has been variable. In addition, HF patients from Asia demonstrate clinical differences from patients in other geographic regions. Thus, the generalizability of some clinical trial results to the Asian population remains uncertain. In this article, we review differences in HF phenotype, HF management, and outcomes in patients from East and Southeast Asia. We describe lessons learned in Asia from recent HF registries and clinical trial databases and outline strategies to improve the potential for success in future trials. This review is based on discussions among scientists, clinical trialists, industry representatives, and regulatory representatives at the CardioVascular Clinical Trialist Asia Forum in Singapore on July 4, 2014.

Authors: Mentz, Robert J RJ; Roessig, Lothar L; Greenberg, Barry H BH; Sato, Naoki N; Shinagawa, Kaori K; Yeo, Daniel D; Kwok, Bernard W K BW; Reyes, Eugenio B EB; Krum, Henry H; Pieske, Burkert B; Greene, Stephen J SJ; Ambrosy, Andrew P AP; Kelly, Jacob P JP; Zannad, Faiez F; Pitt, Bertram B; Lam, Carolyn S P CS

JACC. Heart failure. 2016 06 01;4(6):419-27. Epub 2016-10-17.

PubMed abstract

Disparities in Uptake of HIV Preexposure Prophylaxis in a Large Integrated Health Care System

Authors: Marcus JL; Hurley LB; Hare CB; Silverberg MJ; Volk JE

Am J Public Health. 2016 10;106(10):e2-3.

PubMed abstract

Risk of cancer in Asian Americans: a Kaiser Permanente cohort study

To supplement published cohort data about incident cancer in Asian Americans (Asians) including risk of specific Asian ethnic groups. A cohort study in 124,193 persons (13,344 Asians) with baseline examination data in 1978-1985 used Cox proportional hazards models with seven covariates to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs). Through 2012 cancer was diagnosed in 18,687 persons including 1,522 Asians. Compared to Whites, the HR (CIs) for any cancer in Asians was 0.8 (0.7-0.9, p < 0.001). Lower Asian risk was stronger for men (HR = 0.7, p < 0.001) than for women (HR = 0.9, p = 0.003). Lower Asian vs. White risks with p < 0.05 were found for cancers of the upper airway digestive area, hematologic malignancies, melanoma, and cancers of the prostate, bladder, and brain. Melanoma contributed substantially to lower Asian risk, especially in women. HRs for specific Asian groups versus Whites follow: Chinese = 0.9 (p < 0.001), Japanese = 0.9 (p = 0.01), Filipinos = 0.8 (p < 0.001), South Asians = 0.5 (p < 0.001), and Other Asians = 0.7 (p = 0.006). Both South Asian men and women had lower risk than Whites, and South Asians had lower risk than any other racial/ethnic group. Asians had lower cancer risk than Whites, due to lower risk of several cancer types. Each Asian ethnic group had lower risk than Whites with South Asians at the lowest risk.

Authors: Tran HN; Li Y; Udaltsova N; Armstrong MA; Friedman GD; Klatsky AL

Cancer Causes Control. 2016 Oct;27(10):1197-207. Epub 2016-08-25.

PubMed abstract

Race/Ethnicity and Cardiovascular Outcomes in Adults With CKD: Findings From the CRIC (Chronic Renal Insufficiency Cohort) and Hispanic CRIC Studies

Non-Hispanic blacks and Hispanics with end-stage renal disease have a lower risk for death than non-Hispanic whites, but data for racial/ethnic variation in cardiovascular outcomes for non-dialysis-dependent chronic kidney disease are limited. Prospective cohort. 3,785 adults with entry estimated glomerular filtration rates of 20 to 70mL/min/1.73m(2) enrolled in the CRIC (Chronic Renal Insufficiency Cohort) Study. Race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). Cardiovascular outcomes (atherosclerotic events [myocardial infarction, stroke, or peripheral arterial disease] and heart failure) and a composite of each cardiovascular outcome or all-cause death. Multivariable Cox proportional hazards. During a median follow-up of 6.6 years, we observed 506 atherosclerotic events, 551 heart failure events, and 692 deaths. In regression analyses, there were no significant differences in atherosclerotic events among the 3 racial/ethnic groups. In analyses stratified by clinical site, non-Hispanic blacks had a higher risk for heart failure events (HR, 1.59; 95% CI, 1.29-1.95), which became nonsignificant after adjustment for demographic factors and baseline kidney function. In contrast, Hispanics had similar risk for heart failure events as non-Hispanic whites. In analyses stratified by clinical site, compared with non-Hispanic whites, non-Hispanic blacks were at similar risk for atherosclerotic events or death. However, after further adjustment for cardiovascular risk factors, medications, and mineral metabolism markers, non-Hispanic blacks had 17% lower risk for the outcome (HR, 0.83; 95% CI, 0.69-0.99) than non-Hispanic whites, whereas there was no significant association with Hispanic ethnicity. Hispanics were largely recruited from a single center, and the study was underpowered to evaluate the association between Hispanic ethnicity and mortality. There were no significant racial/ethnic differences in adjusted risk for atherosclerotic or heart failure outcomes. Future research is needed to better explain the reduced risk for atherosclerotic events or death in non-Hispanic blacks compared with non-Hispanic whites.

Authors: Lash JP; CRIC Study Investigators; CRIC Study Investigators; et al.

Am J Kidney Dis. 2016 Oct;68(4):545-53. Epub 2016-05-19.

PubMed abstract

Relation of longitudinal changes in body mass index with atherosclerotic cardiovascular disease risk scores in middle-aged black and white adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study

We assessed whether longitudinal changes in body mass index (BMI) are positively associated with changes in 10-year American College of Cardiology/American Heart Association atherosclerotic cardiovascular disease (ASCVD) risk scores in middle-aged blacks compared to whites. Data were from 1691 participants enrolled in the Coronary Artery Risk Development in Young Adults Study aged 40 years or more in 2000-2001, who had follow-up examinations 5 and 10 years later. The prevalence of obesity increased from 32.3% in 2000-2001 (mean age: 42.8 years) to 41.7% in 2010-2011, higher in blacks than whites. The corresponding change in 10-year ASCVD risk was significantly higher for blacks (men: 4.5%-9.6%, women: 1.7%-5.0%) than whites (men: 2.4%-5.2%, women: 0.7%-1.6%). In 2010-2011, 57.5% of black men had ASCVD risk scores of 7.5% or more compared to white men (14.7%), black women (17.4%), and white women (1.6%). Although BMI trends were positively associated with 10-year change in ASCVD risk scores (0.07% per 1 kg/m(2) increase), it explained very little variance in risk score trends in all race-sex groups. In middle-aged adults, longitudinal changes in BMI had little independent influence on changes in 10-year ASCVD risk scores as its effect may be largely mediated through ASCVD risk factors already accounted for in the risk score.

Authors: Appiah D; Schreiner PJ; Durant RW; Kiefe CI; Loria C; Lewis CE; Williams OD; Person SD; Sidney S

Ann Epidemiol. 2016 Aug;26(8):521-526. Epub 2016-06-17.

PubMed abstract

The Digital Divide and Patient Portals: Internet Access Explained Differences in Patient Portal Use for Secure Messaging by Age, Race, and Income

Online access to health records and the ability to exchange secure messages with physicians can improve patient engagement and outcomes; however, the digital divide could limit access to web-based portals among disadvantaged groups. To understand whether sociodemographic differences in patient portal use for secure messaging can be explained by differences in internet access and care preferences. Cross-sectional survey to examine the association between patient sociodemographic characteristics and internet access and care preferences; then, the association between sociodemographic characteristics and secure message use with and without adjusting for internet access and care preference. One thousand forty-one patients with chronic conditions in a large integrated health care delivery system (76% response rate). Internet access, portal use for secure messaging, preference for in-person or online care, and sociodemographic and health characteristics. Internet access and preference mediated some of the differences in secure message use by age, race, and income. For example, using own computer to access the internet explained 52% of the association between race and secure message use and 60% of the association between income and use (Sobel-Goodman mediation test, P<0.001 for both). Education and sex-related differences in portal use remained statistically significant when controlling for internet access and preference. As the availability and use of patient portals increase, it is important to understand which patients have limited access and the barriers they may face. Improving internet access and making portals available across multiple platforms, including mobile, may reduce some disparities in secure message use.

Authors: Graetz I; Gordon N; Fung V; Hamity C; Reed ME

Med Care. 2016 Aug;54(8):772-9.

PubMed abstract

Racial disparities in renal cell carcinoma: a single-payer healthcare experience

Significant racial disparities in survival for renal cell carcinoma (RCC) exist between white and black patients. Differences in access to care and comorbidities are possible contributors. To investigate if racial disparities persist when controlling for access to care, we analyzed data from a single-payer healthcare system. As part of a case-control study within the Kaiser Permanente Northern California system, pathologic and clinical records were obtained for RCC cases (2152 white, 293 black) diagnosed from 1998 to 2008. Patient demographics, comorbidities, tumor characteristics, and treatment status were compared. Overall survival and disease-specific survival (DSS) were calculated by the Kaplan-Meier method. A Cox proportion hazards model estimated the independent associations of race, comorbidity, and clinicopathologic variables with DSS. We found that compared to white patients, black patients were diagnosed at a younger age (median 62 vs. 66 years, P < 0.001), were more likely to have papillary RCC (15% vs. 5.2%, P < 0.001), and had similar rates of surgical treatment (78.8% vs. 77.9%, P = 0.764). On multivariate analysis, advanced American Joint Committee on Cancer (AJCC) stage, lack of surgical treatment, larger tumor size, and higher grade were predictors of worse DSS. Race was not an independent predictor of survival. Therefore, we conclude that within a single healthcare system, differences in characteristics of black and white patients with RCC persist; black patients had different comorbidities, were younger, and had decreased tumor stage. However, unlike other series, race was not an independent predictor of DSS, suggesting that survival differences in large registries may result from barriers to healthcare access and/or comorbidity rather than disease biology.

Authors: Mafolasire A; Yao X; Nawaf C; Suarez-Sarmiento A; Chow WH; Zhao W; Corley D; Hofmann JN; Purdue M; Adeniran AJ; Shuch B

Cancer Med. 2016 Aug;5(8):2101-8. Epub 2016-05-26.

PubMed abstract

Investigation of Racial Disparities in Early Supportive Medication Use and End-of-Life Care Among Medicare Beneficiaries With Stage IV Breast Cancer

PURPOSE:Early supportive care may improve quality of life and end-of-life care among patients with cancer. We assessed racial disparities in early use of medications for common cancer symptoms (depression, anxiety, insomnia) and whether these potential disparities modify end-of-life care.METHODS:We used 2007 to 2012 SEER-Medicare data to evaluate use of supportive medications (opioid pain medications and nonopioid psychotropics, including antidepressants/anxiolytics and sleep aids) in the 90 days postdiagnosis among black and white women with stage IV breast cancer who died between 2007 and 2012. We used modified Poisson regression to assess the relationship between race and supportive treatment use and end-of-life care (hospice, intensive care unit, more than one emergency department visit or hospitalization 30 days before death, in-hospital death).RESULTS:The study included 752 white and 131 black women. We observed disparities in nonopioid psychotropic use between black and white women (adjusted risk ratio [aRR], 0.51; 95% CI, 0.35 to 0.74) but not in opioid pain medication use. There were also disparities in hospice use (aRR, 0.86; 95% CI, 0.74 to 0.99), intensive care unit admission or more than one emergency department visit or hospitalization 30 days before death (aRR, 1.28; 95% CI, 1.01 to 1.63), and risk of dying in the hospital (aRR, 1.59; 95% CI, 1.22 to 2.09). Supportive medication use did not attenuate end-of-life care disparities.CONCLUSION:We observed racial disparities in early supportive medication use among patients with stage IV breast cancer. Although they did not clearly attenuate end-of-life care disparities, medication use disparities may be of concern if they point to disparities in adequacy of symptom management given the potential implications for quality of life.

Authors: Check DK; Samuel CA; Rosenstein DL; Dusetzina SB

​J Clin Oncol. 2016 Jul 1;34(19):2265-70. doi: 10.1200/JCO.2015.64.8162. Epub 2016 May 9.

PubMed abstract

The effect of patient and contextual characteristics on racial/ethnic disparity in breast cancer mortality

Racial/ethnic disparity in breast cancer-specific mortality in the United States is well documented. We examined whether accounting for racial/ethnic differences in the prevalence of clinical, patient, and lifestyle and contextual factors that are associated with breast cancer-specific mortality can explain this disparity. The California Breast Cancer Survivorship Consortium combined interview data from six California-based breast cancer studies with cancer registry data to create a large, racially diverse cohort of women with primary invasive breast cancer. We examined the contribution of variables in a previously reported Cox regression baseline model plus additional contextual, physical activity, body size, and comorbidity variables to the racial/ethnic disparity in breast cancer-specific mortality. The cohort comprised 12,098 women. Fifty-four percent were non-Latina Whites, 17% African Americans, 17% Latinas, and 12% Asian Americans. In a model adjusting only for age and study, breast cancer-specific HRs relative to Whites were 1.69 (95% CI, 1.46-1.96), 1.00 (0.84-1.19), and 0.52 (0.33-0.85) for African Americans, Latinas, and Asian Americans, respectively. Adjusting for baseline-model variables decreased disparity primarily by reducing the HR for African Americans to 1.13 (0.96-1.33). The most influential variables were related to disease characteristics, neighborhood socioeconomic status, and smoking status at diagnosis. Other variables had negligible impact on disparity. Although contextual, physical activity, body size, and comorbidity variables may influence breast cancer-specific mortality, they do not explain racial/ethnic mortality disparity. Other factors besides those investigated here may explain the existing racial/ethnic disparity in mortality. Cancer Epidemiol Biomarkers Prev; 25(7); 1064-72. ©2016 AACR.

Authors: Sposto R; Bernstein L; Lu Y; Wu AH; et al.

Cancer Epidemiol Biomarkers Prev. 2016 07;25(7):1064-72. Epub 2016-04-26.

PubMed abstract

Is a reduction in distance to nearest supermarket associated with BMI change among type 2 diabetes patients?

We examined whether residing within 2 miles of a new supermarket opening was longitudinally associated with a change in body mass index (BMI). We identified 12 new supermarkets that opened between 2009 and 2010 in 8 neighborhoods. Using the Kaiser Permanente Northern California Diabetes Registry, we identified members with type 2 diabetes residing continuously in any of these neighborhoods 12 months prior to the first supermarket opening until 10 months following the opening of the last supermarket. Exposure was defined as a reduction (yes/no) in travel distance to the nearest supermarket as a result of a new supermarket opening. First difference regression models were used to estimate the impact of reduced supermarket distance on BMI, adjusting for longitudinal changes in patient and neighborhood characteristics. Among patients in the exposed group, new supermarket openings reduced travel distance to the nearest supermarket by 0.7 miles on average. However, reduced distance to nearest supermarket was not associated with BMI changes. Overall, we found no evidence that reduced supermarket distance was associated with reduced levels of obesity for residents with type 2 diabetes.

Authors: Zhang YT; Laraia BA; Mujahid MS; Blanchard SD; Warton EM; Moffet HH; Karter AJ

Health Place. 2016 07;40:15-20. Epub 2016-05-07.

PubMed abstract

Health-Specific Information and Communication Technology Use and Its Relationship to Obesity in High-Poverty, Urban Communities: Analysis of a Population-Based Biosocial Survey

More than 35% of American adults are obese. For African American and Hispanic adults, as well as individuals residing in poorer or more racially segregated urban neighborhoods, the likelihood of obesity is even higher. Information and communication technologies (ICTs) may substitute for or complement community-based resources for weight management. However, little is currently known about health-specific ICT use among urban-dwelling people with obesity. We describe health-specific ICT use and its relationship to measured obesity among adults in high-poverty urban communities. Using data collected between November 2012 and July 2013 from a population-based probability sample of urban-dwelling African American and Hispanic adults residing on the South Side of Chicago, we described patterns of ICT use in relation to measured obesity defined by a body mass index (BMI) of ≥30 kg/m(2). Among those with BMI≥30 kg/m(2), we also assessed the association between health-specific ICT use and diagnosed versus undiagnosed obesity as well as differences in health-specific ICT use by self-reported comorbidities, including diabetes and hypertension. The survey response rate was 44.6% (267 completed surveys/598.4 eligible or likely eligible individuals); 53.2% were African American and 34.6% were Hispanic. More than 35% of the population reported an annual income of less than US $25,000. The population prevalence of measured obesity was 50.2%. People with measured obesity (BMI≥30 kg/m(2)) were more likely to report both general (81.5% vs 67.0%, P=.04) and health-specific (61.1% vs 41.2%, P=.01) ICT use. In contrast, among those with measured obesity, being told of this diagnosis by a physician was not associated with increased health-specific ICT use. People with measured obesity alone had higher rates of health-specific use than those with comorbid hypertension and/or diabetes diagnoses (77.1% vs 60.7% vs 47.4%, P=.04). In conclusion, ICT-based health resources may be particularly useful for people in high-poverty urban communities with isolated measured obesity, a population that is at high risk for poor health outcomes.

Authors: Gopalan A; Makelarski JA; Garibay LB; Escamilla V; Merchant RM; Wolfe MB; Holbrook R; Lindau ST

J Med Internet Res. 2016 Jun 28;18(6):e182. Epub 2016-06-28.

PubMed abstract

Cancer-Related Information Seeking Among Cancer Survivors: Trends Over a Decade (2003-2013)

The demonstrated benefits of information seeking for cancer patients, coupled with increases in information availability, underscore the importance of monitoring patient information seeking experiences over time. We compared information seeking among cancer survivors to those with a family history of cancer and those with no history of cancer. We identified characteristics associated with greater information seeking among cancer survivors, key sources of cancer-related information, and changes in information source use over time. Data from five iterations of the Health Information National Trends Survey (HINTS) spanning 2003 to 2013 were merged and analyzed. Frequencies, cross-tabulations, multivariate logistic regression, and multinomial regression analyses were conducted. All data were weighted to provide representative estimates of the adult US population. Cancer information seeking was reported most frequently by cancer survivors (69.8 %). The percentage of cancer survivors who reported information seeking increased from 66.8 % in 2003 to 80.8 % in 2013. Cancer information seeking was independently associated with age, education, and income; seeking was less likely among older adults, those with less education, and those with lower incomes. Compared to respondents in 2003, those in 2005 (odds ratio (OR)?=?0.40, 95 % confidence interval (CI)?=?0.24-0.65) and 2008 (OR?=?.43, 95 % CI?=?0.26-0.70) were about half as likely to use the Internet as the first source of cancer information compared to a healthcare provider. Despite overall increases in cancer information seeking and access to health information from a variety of sources, healthcare providers remain a key source of health information for cancer survivors.

Authors: Finney Rutten LJ; Agunwamba AA; Wilson P; Chawla N; Vieux S; Blanch-Hartigan D; Arora NK; Blake K; Hesse BW

J Cancer Educ. 2016 Jun;31(2):348-57.

PubMed abstract

Communication Barriers and the Clinical Recognition of Diabetic Peripheral Neuropathy in a Diverse Cohort of Adults: The DISTANCE Study

The purpose of this study was to explore communication barriers as independent predictors and potential mediators of variation in clinical recognition of diabetic peripheral neuropathy (DPN). In this cross-sectional analysis, we estimated the likelihood of having a DPN diagnosis among 4,436 patients with DPN symptoms. We controlled for symptom frequency, demographic and clinical characteristics, and visit frequency using a modified Poisson regression model. We then evaluated 4 communication barriers as independent predictors of clinical documentation and as possible mediators of racial/ethnic differences: difficulty speaking English, not talking to one’s doctor about pain, limited health literacy, and reports of suboptimal patient-provider communication. Difficulty speaking English and not talking with one’s doctor about pain were independently associated with not having a diagnosis, though limited health literacy and suboptimal patient-provider communication were not. Limited English proficiency partially attenuated, but did not fully explain, racial/ethnic differences in clinical documentation among Chinese, Latino, and Filipino patients. Providers should be encouraged to talk with their patients about DPN symptoms, and health systems should consider enhancing strategies to improve timely clinical recognition of DPN among patients who have difficult speaking English. More work is needed to understand persistent racial/ethnic differences in diagnosis.

Authors: Adams AS; Parker MM; Moffet HH; Jaffe M; Schillinger D; Callaghan B; Piette J; Adler NE; Bauer A; Karter AJ

J Health Commun. 2016 May;21(5):544-53. Epub 2016-04-26.

PubMed abstract

Neighborhood deprivation, race/ethnicity, and urinary metal concentrations among young girls in California

Although metals can adversely impact children’s health, the distribution of exposures to many metals, particularly among vulnerable subpopulations, is not well characterized. We sought to determine whether neighborhood deprivation was associated with urinary concentrations of thirteen metals and whether observed relationships varied by race/ethnicity. We obtained neighborhood characteristics from the 2005-2009 American Community Survey. Demographic information and urine samples from 400 healthy young girls in Northern California were obtained during a clinical visit. Urine samples were analyzed for metals using inductively-coupled plasma-mass spectrometry and levels were corrected for creatinine. We ran analysis of variance and generalized linear regression models to estimate associations of urinary metal concentrations with neighborhood deprivation and race/ethnicity and stratified multivariable models to evaluate possible interactions among predictors on metals concentrations. Urinary concentrations of three metals (barium, lead, antimony) varied significantly across neighborhood deprivation quartiles, and four (barium, lead, antimony, tin) varied across race/ethnicity groups. In models adjusted for family income and cotinine, both race/ethnicity (F3,224=4.34, p=0.01) and neighborhood deprivation (F3,224=4.32, p=0.01) were associated with antimony concentrations, but neither were associated with lead, barium, or tin, concentrations. Examining neighborhood deprivation within race/ethnicity groups, barium levels (pinteraction<0.01) decreased with neighborhood deprivation among Hispanic girls (ptrend<0.001) and lead levels (pinteraction=0.06) increased with neighborhood deprivation among Asian girls (ptrend=0.04). Our results indicate that children's vulnerability to some metals varies by neighborhood deprivation quartile and race/ethnicity. These differential distributions of exposures may contribute to environmental health disparities later in life.

Authors: Gonzales FA; Jones RR; Deardorff J; Windham GC; Hiatt RA; Kushi LH

Environ Int. 2016 May;91:29-39. Epub 2016-02-22.

PubMed abstract

Ethnic Differences in Risk of Coronary Heart Disease in a Large Contemporary Population

Racial/ethnic differences in diabetes and cardiovascular disease are well documented, but disease estimates are often confounded by differences in access to quality health care. The objective of this study was to evaluate the ethnic differences in risk of future coronary heart disease in patient populations stratified by status of diabetes mellitus and prior coronary heart disease among those with uniform access to care in an integrated healthcare delivery system in Northern California. A cohort was constructed consisting of 1,344,899 members with self-reported race/ethnicity, aged 30-90 years, and followed from 2002 through 2012. Cox proportional hazard regression models were specified to estimate race/ethnicity-specific hazard ratios for coronary heart disease (with whites as the reference category) separately in four clinical risk categories: (1) no diabetes with no prior coronary heart disease; (2) no diabetes with prior coronary heart disease; (3) diabetes with no prior coronary heart disease; and (4) diabetes with prior coronary heart disease. Analyses were performed in 2015. The median follow-up was 10 years (10,980,800 person-years). Compared with whites, blacks, Latinos, and Asians generally had lower risk of coronary heart disease across all clinical risk categories, with the exception of blacks with prior coronary heart disease and no diabetes having higher risk than whites. Findings were not substantively altered after multivariate adjustments. Identification of health outcomes in a system with uniform access to care reveals residual racial/ethnic differences and point to opportunities to improve health in specific subgroups and to improve health equity.

Authors: Rana JS; Liu JY; Moffet HH; Jaffe MG; Sidney S; Karter AJ

Am J Prev Med. 2016 May;50(5):637-41. Epub 2016-01-28.

PubMed abstract

Investigating racial disparities in use of NK1 receptor antagonists to prevent chemotherapy-induced nausea and vomiting among women with breast cancer

​Chemotherapy-induced nausea and vomiting (CINV) is a major concern for cancer patients and, if uncontrolled, can seriously compromise quality of life (QOL) and other treatment outcomes. Because of the expense of antiemetic medications used to prevent CINV (particularly oral medications filled through Medicare Part D), disparities in their use may exist. We used 2006-2012 SEER-Medicare data to evaluate the use of neurokinin-1 receptor antagonists (NK1s), a potent class of antiemetics, among black and white women initiating highly emetogenic chemotherapy for the treatment of early-stage breast cancer. We used modified Poisson regression to assess the relationship between race and (1) any NK1 use, (2) oral NK1 (aprepitant) use, and (3) intravenous NK1 (fosaprepitant) use. We report adjusted risk ratios (aRR) and 95 % confidence intervals (CI). The study included 1130 women. We observed racial disparities in use of any NK1 (aRR: 0.68, 95 % CI 0.51-0.91) and in use of oral aprepitant specifically (aRR: 0.54, 95 % CI 0.35-0.83). We did not observe disparities in intravenous fosaprepitant use. After controlling for variables related to socioeconomic status, disparities in NK1 and aprepitant use were reduced but not eliminated. We found racial disparities in women’s use of oral NK1s for the prevention of CINV. These disparities may be partly explained by racial differences in socioeconomic status, which may translate into differential ability to afford the medication.

Authors: Check DK; Reeder-Hayes KE; Basch EM; Zullig LL; Weinberger M; Dusetzina SB

​Breast Cancer Res Treat. 2016 Apr;156(2):351-9. doi: 10.1007/s10549-016-3747-6. Epub 2016 Mar 11.

PubMed abstract

Financial Strain and Medication Adherence among Diabetes Patients in an Integrated Health Care Delivery System: The Diabetes Study of Northern California (DISTANCE)

To examine self-reported financial strain in relation to pharmacy utilization adherence data. Survey, administrative, and electronic medical data from Kaiser Permanente Northern California. Retrospective cohort design (2006, n = 7,773). We compared survey self-reports of general and medication-specific financial strain to three adherence outcomes from pharmacy records, specifying adjusted generalized linear regression models. Eight percent and 9 percent reported general and medication-specific financial strain. In adjusted models, general strain was significantly associated with primary nonadherence (RR = 1.37; 95 percent CI: 1.04-1.81) and refilling late (RR = 1.34; 95 percent CI: 1.07-1.66); and medication-specific strain was associated with primary nonadherence (RR = 1.42, 95 percent CI: 1.09-1.84). Simple, minimally intrusive questions could be used to identify patients at risk of poor adherence due to financial barriers.

Authors: Lyles CR; Seligman HK; Parker MM; Moffet HH; Adler N; Schillinger D; Piette JD; Karter AJ

Health Serv Res. 2016 Apr;51(2):610-24. Epub 2015-08-09.

PubMed abstract

Inequalities in dementia incidence between six racial and ethnic groups over 14years

Reducing racial/ethnic disparities is a primary objective of the National Alzheimer’s Plan (NAPA), yet direct comparisons within large samples representing diversity of the United States are lacking. Dementia incidence from January 1, 2000 to December 31, 2013 and a 25-year cumulative risk in 274,283 health care members aged 64+ (n = 18,778 African-American, n = 4543 American Indian/Alaska Native [AIAN], n = 21,000 Latino, n = 440 Pacific Islander, n = 206,490 white, n = 23,032 Asian-Americans). Cox proportional hazard models were adjusted for age, sex, medical utilization, and comorbidities. Dementia incidence (n = 59,555) was highest for African-Americans (26.6/1000 person-years) and AIANs (22.2/1000 person-years); intermediate for Latinos (19.6/1000 person-years), Pacific Islanders (19.6/1000 person-years), and whites (19.3/1000 person-years) and lowest among Asian-Americans (15.2/1000 person-years). Risk was 65% greater for African-Americans (hazard ratio = 1.65; 95% confidence interval = 1.58-1.72) versus Asian-Americans. Cumulative 25-year risk at age 65 was as follows: 38% African-Americans, 35% AIANs, 32% Latino, 25% Pacific Islanders, 30% white, and 28% Asian-Americans. Dementia rates varied over 60% between groups, providing a comprehensive benchmark for the NAPA goal of reducing disparities.

Authors: Mayeda ER; Glymour MM; Quesenberry CP; Whitmer RA

Alzheimers Dement. 2016 Mar;12(3):216-24. Epub 2016-02-11.

PubMed abstract

​Predictive Models for Characterizing Disparities in Exclusive Breastfeeding Performance in a Multi-ethnic Population in the US.

Maternal lactation performance varies across populations, yet the relative impact of maternal sociodemographics, perinatal factors, and birth outcomes on disparities in exclusive breastfeeding (XBR) outcomes is not well known. We aimed to develop predictive models and compare the relative contribution of predictors for XBR initiation and XBR ≥ 6 months. METHODS:
Infant feeding data were obtained from women with children aged 0-6 years (n = 1471) in a multi-ethnic cross-sectional study in the US (2011-2012). We compared discriminant ability of predictors for ever XBR and XBR ≥ 6 months using discriminant function analysis, respectively. We also calculated adjusted ORs for factors associated with XBR outcomes and breast-bottle feeding (BrBot) subgroups. RESULTS:
Maternal sociodemographics (education level, marital status, nativity, and age at childbirth) had greater discriminating abilities in predicting ever XBR and XBR ≥ 6 months than birth outcomes and perinatal factors. Foreign-born women were two-fold more likely to initiate XBR but not necessarily continue to 6 months compared to their US-born counterparts. Factors associated with BrBot subgroups differed from those associated with XBR outcomes, whereas maternal age was the only predictor consistently associated with ever XBR, XBR ≥ 6 months, and BrBot subgroups. The areas under the receiver operating characteristic curves for models predicting ever XBR and XBR ≥ 6 months were 0.88 (95 % CI 0.85, 0.91) and 0.90 (95 % CI 0.88, 0.93), respectively. CONCLUSIONS:
Findings underscore the importance of educational, clinical, and social support to promote XBR in mothers with sociodemographic factors predictive of none or poor XBR outcomes.

Authors: Zhu Y; Hernandez LM; Mueller P; Dong Y; Hirschfeld S; Forman MR;

Matern Child Health J. 2016 Feb;20(2):398-407. doi: 10.1007/s10995-015-1838-3.

PubMed abstract

Medication Adherence Does Not Explain Black-White Differences in Cardiometabolic Risk Factor Control among Insured Patients with Diabetes

Among patients with diabetes, racial differences in cardiometabolic risk factor control are common. The extent to which differences in medication adherence contribute to such disparities is not known. We examined whether medication adherence, controlling for treatment intensification, could explain differences in risk factor control between black and white patients with diabetes. We identified three cohorts of black and white patients treated with oral medications and who had poor risk factor control at baseline (2009): those with glycated hemoglobin (HbA1c) >8 % (n?=?37,873), low-density lipoprotein cholesterol (LDL-C) >100 mg/dl (n?=?27,954), and systolic blood pressure (SBP) >130 mm Hg (n?=?63,641). Subjects included insured adults with diabetes who were receiving care in one of nine U.S. integrated health systems comprising the SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) consortium. Baseline and follow-up risk factor control, sociodemographic, and clinical characteristics were obtained from electronic health records. Pharmacy-dispensing data were used to estimate medication adherence (i.e., medication refill adherence [MRA]) and treatment intensification (i.e., dose increase or addition of new medication class) between baseline and follow-up. County-level income and educational attainment were estimated via geocoding. Logistic regression models were used to test the association between race and follow-up risk factor control. Models were specified with and without medication adherence to evaluate its role as a mediator. We observed poorer medication adherence among black patients than white patients (p?

Authors: Lafata JE; Karter AJ; Schmittdiel JA; Steiner JF; et al.

J Gen Intern Med. 2016 Feb;31(2):188-95.

PubMed abstract

Bridging the Gap: Determinants of Undiagnosed or Untreated Urinary Incontinence in Women

More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated. We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women. We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment. Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ? $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ? $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician. Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

Authors: Duralde ER; Walter LC; Van Den Eeden SK; Nakagawa S; Subak LL; Brown JS; Thom DH; Huang AJ

Am J Obstet Gynecol. 2016 Feb;214(2):266.e1-9. Epub 2015-09-05.

PubMed abstract

Racial Differences in the Performance of Existing Risk Prediction Models for Incident Type 2 Diabetes: The CARDIA Study

In 2010, the American Diabetes Association (ADA) added hemoglobin A1c (A1C) to the guidelines for diagnosing type 2 diabetes. However, existing models for predicting diabetes risk were developed prior to the widespread adoption of A1C. Thus, it remains unknown how well existing diabetes risk prediction models predict incident diabetes defined according to the ADA 2010 guidelines. Accordingly, we examined the performance of an existing diabetes prediction model applied to a cohort of African American (AA) and white adults from the Coronary Artery Risk Development Study in Young Adults (CARDIA). We evaluated the performance of the Atherosclerosis Risk in Communities (ARIC) diabetes risk prediction model among 2,456 participants in CARDIA free of diabetes at the 2005-2006 exam and followed for 5 years. We evaluated model discrimination, calibration, and integrated discrimination improvement with incident diabetes defined by ADA 2010 guidelines before and after adding baseline A1C to the prediction model. In the overall cohort, re-estimating the ARIC model in the CARDIA cohort resulted in good discrimination for the prediction of 5-year diabetes risk (area under the curve [AUC] 0.841). Adding baseline A1C as a predictor improved discrimination (AUC 0.841 vs. 0.863, P = 0.03). In race-stratified analyses, model discrimination was significantly higher in whites than AA (AUC AA 0.816 vs. whites 0.902; P = 0.008). Addition of A1C to the ARIC diabetes risk prediction model improved performance overall and in racial subgroups. However, for all models examined, discrimination was better in whites than AA. Additional studies are needed to further improve diabetes risk prediction among AA.

Authors: Lacy ME; Wellenius GA; Carnethon MR; Loucks EB; Carson AP; Luo X; Kiefe CI; Gjelsvik A; Gunderson EP; Eaton CB; Wu WC

Diabetes Care. 2016 Feb;39(2):285-91. Epub 2015-12-01.

PubMed abstract

Neighborhood-level social processes and substantiated cases of child maltreatment

​Child maltreatment is a preventable public health problem. Research has demonstrated that neighborhood structural factors (e.g. poverty, crime) can influence the proportion of a neighborhood’s children who are victims of maltreatment. A newer strategy is the identification of potentially modifiable social processes at the neighborhood level that can also influence maltreatment. Toward this end, this study examines neighborhood-level data (maltreatment cases substantiated by Illinois’ child protection agency, 1995-2005, social processes measured by the Project on Human Development in Chicago Neighborhoods, U.S. Census data, proportions of neighborhoods on public assistance, and crime data) that were linked across clusters of contiguous, relatively homogenous Chicago, IL census tracts with respect to racial/ethnic and socioeconomic composition. Our analysis-an ecological-level, repeated cross-sectional design utilizing random-intercept logit models-with a sensitivity analysis using spatial models to control for spatial autocorrelation-revealed consistent associations between neighborhood social processes and maltreatment. Neighborhoods higher in collective efficacy, intergenerational closure, and social networks, and lower in disorder had lower proportions of neglect, physical abuse, and sexual abuse substantiated cases, controlling for differences in structural factors. Higher collective efficacy and social network size also predicted a lower proportion of substance-exposed infants. This research indicates that strategies to mobilize neighborhood-level protective factors may decrease child maltreatment more effectively than individual and family-focused efforts alone.

Authors: Molnar BE; Goerge RM; Gilsanz P; Hill A; Subramanian SV; Holton JK; Duncan DT; Beatriz ED; Beardslee WR

​Child Abuse Negl. 2016 Jan;51:41-53. doi: 10.1016/j.chiabu.2015.11.007. Epub 2015 Dec 9.

PubMed abstract

Psychosocial Clusters and their Associations with Well-Being and Health: An Empirical Strategy for Identifying Psychosocial Predictors Most Relevant to Racially/Ethnically Diverse Women’s Health

Strategies for identifying the most relevant psychosocial predictors in studies of racial/ethnic minority women’s health are limited because they largely exclude cultural influences and they assume that psychosocial predictors are independent. This paper proposes and tests an empirical solution. Hierarchical cluster analysis, conducted with data from 140,652 Women’s Health Initiative participants, identified clusters among individual psychosocial predictors. Multivariable analyses tested associations between clusters and health outcomes. A Social Cluster and a Stress Cluster were identified. The Social Cluster was positively associated with well-being and inversely associated with chronic disease index, and the Stress Cluster was inversely associated with well-being and positively associated with chronic disease index. As hypothesized, the magnitude of association between clusters and outcomes differed by race/ethnicity. By identifying psychosocial clusters and their associations with health, we have taken an important step toward understanding how individual psychosocial predictors interrelate and how empirically formed Stress and Social clusters relate to health outcomes. This study has also demonstrated important insight about differences in associations between these psychosocial clusters and health among racial/ethnic minorities. These differences could signal the best pathways for intervention modification and tailoring.

Authors: Jabson JM; Bowen D; Weinberg J; Kroenke C; Luo J; Messina C; Shumaker S; Tindle HA

Clin Med Insights Womens Health. 2016;9(Suppl 1):31-40. Epub 2016-06-06.

PubMed abstract

Obesity Severity, Dietary Behaviors, and Lifestyle Risks Vary by Race/Ethnicity and Age in a Northern California Cohort of Children with Obesity

Identification of modifiable behaviors is important for pediatric weight management and obesity prevention programs. This study examined obesogenic behaviors in children with obesity in a Northern California obesity intervention program using data from a parent/teen-completed intake questionnaire covering dietary and lifestyle behaviors (frequency of breakfast, family meals, unhealthy snacking and beverages, fruit/vegetable intake, sleep, screen time, and exercise). Among 7956 children with BMI ? 95th percentile, 45.5% were females and 14.2% were 3-5, 44.2% were 6-11, and 41.6% were 12-17 years old. One-quarter (24.9%) were non-Hispanic white, 11.3% were black, 43.5% were Hispanic, and 12.0% were Asian/Pacific Islander. Severe obesity was prevalent (37.4%), especially among blacks, Hispanics, and older children, and was associated with less frequent breakfast and exercise and excess screen time, and in young children it was associated with consumption of sweetened beverages or juice. Unhealthy dietary behaviors, screen time, limited exercise, and sleep were more prevalent in older children and in selected black, Hispanic, and Asian subgroups, where consumption of sweetened beverages or juice was especially high. Overall, obesity severity and obesogenic behaviors increased with age and varied by gender and race/ethnicity. We identified several key prevalent modifiable behaviors that can be targeted by healthcare professionals to reduce obesity when counseling children with obesity and their parents.

Authors: Ford MC; Gordon NP; Howell A; Green CE; Greenspan LC; Chandra M; Mellor RG; Lo JC

J Obes. 2016;2016:4287976. Epub 2016-01-14.

PubMed abstract

Intersection of Race/Ethnicity and Socioeconomic Status in Mortality After Breast Cancer

We investigated social disparities in breast cancer (BC) mortality, leveraging data from the California Breast Cancer Survivorship Consortium. The associations of race/ethnicity, education, and neighborhood SES (nSES) with all-cause and BC-specific mortality were assessed among 9372 women with BC (diagnosed 1993-2007 in California with follow-up through 2010) from four racial/ethnic groups [African American, Asian American, Latina, and non-Latina (NL) White] using Cox proportional hazards models. Compared to NL White women with high-education/high-nSES, higher all-cause mortality was observed among NL White women with high-education/low-nSES [hazard ratio (HR) (95 % confidence interval) 1.24 (1.08-1.43)], and African American women with low-nSES, regardless of education [high education HR 1.24 (1.03-1.49); low-education HR 1.19 (0.99-1.44)]. Latina women with low-education/high-nSES had lower all-cause mortality [HR 0.70 (0.54-0.90)] and non-significant lower mortality was observed for Asian American women, regardless of their education and nSES. Similar patterns were seen for BC-specific mortality. Individual- and neighborhood-level measures of SES interact with race/ethnicity to impact mortality after BC diagnosis. Considering the joint impacts of these social factors may offer insights to understanding inequalities by multiple social determinants of health.

Authors: Shariff-Marco S; Kwan ML; Gomez SL; et al.

J Community Health. 2015 Dec;40(6):1287-99.

PubMed abstract

Development and Use of a Traditional Mexican Diet Score in Relation to Systemic Inflammation and Insulin Resistance among Women of Mexican Descent

Women of Mexican descent are disproportionally affected by obesity, systemic inflammation, and insulin resistance (IR). Available approaches used to give scores to dietary patterns relative to dietary guidelines may not effectively capture traditional diets of Mexicans, who comprise the largest immigrant group in the United States. We characterized an a priori traditional Mexican diet (MexD) score high in corn tortillas, beans, soups, Mexican mixed dishes (e.g., tamales), fruits, vegetables, full-fat milk, and Mexican cheeses and low in refined grains and added sugars and evaluated the association of the MexD score with systemic inflammation and IR in 493 postmenopausal participants in the Women’s Health Initiative (WHI) who are of Mexican ethnic descent. The MexD score was developed from the baseline (1993-1998) WHI food frequency questionnaire, which included Hispanic foods and was available in Spanish. Body mass index (BMI) was computed from baseline measured weight and height, and ethnicity was self-reported. Outcome variables were high sensitivity C-reactive protein (hsCRP), glucose, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), and triglyceride concentrations measured at follow-up (2012-2013). Multivariable linear and logistic regression models were used to test the associations of the MexD score with systemic inflammation and IR. The mean ± SD MexD score was 5.8 ± 2.1 (12 maximum points) and was positively associated with intakes of carbohydrates, vegetable protein, and dietary fiber and inversely associated with intakes of added sugars and total fat (P < 0.01). Women with high compared with low MexD scores, consistent with a more-traditional Mexican diet, had 23% and 15% lower serum hsCRP (P < 0.05) and insulin concentrations, respectively (P < 0.05). Baseline BMI modified these associations such that lower MexD scores were associated with higher insulin and HOMA-IR in overweight/obese women (P-interaction <0.05). These findings suggest that greater adherence to a traditional Mexican diet could help reduce the future risk of systemic inflammation and IR in women of Mexican descent.

Authors: Santiago-Torres M; Tinker LF; Allison MA; Breymeyer KL; Garcia L; Kroenke CH; Lampe JW; Shikany JM; Van Horn L; Neuhouser ML

J Nutr. 2015 Dec;145(12):2732-40. Epub 2015-10-21.

PubMed abstract

The HIV Care Cascade Measured Over Time and by Age, Sex, and Race in a Large National Integrated Care System

HIV care cascades can evaluate programmatic success over time. However, methodologies for estimating cascade stages vary, and few have evaluated differences by demographic subgroups. We examined cascade performance over time and by age, sex, and race/ethnicity in , providing HIV care in eight US states and Washington, DC. We created cascades for HIV+ members’ age ?13 for 2010-2012. We measured “linkage” (a visit/CD4 within 90 days of being diagnosed for new patients; ?1 medical visit/year if established); “retention” (?2 medical visits ?60 days apart); filled ART (filled ?3 months of combination ART); and viral suppression (HIV RNA <200 copies/mL last measured in year). The cascades were stratified by calendar year, sex, age, and race/ethnicity. We found men had statistically (p?

Authors: Horberg MA; Silverberg MJ; et al.

AIDS Patient Care STDS. 2015 Nov;29(11):582-90.

PubMed abstract

Does well-child care have a future in pediatrics?

The most common adult chronic diseases affect 1 in 3 adults and account for more than three-quarters of US health care spending. The major childhood drivers of adult disease are distinctly nonmedical: poverty, poor educational outcomes, unhealthy social and physical environments, and unhealthy lifestyle choices. Ideally, well-child care (WCC) would address these drivers and help create healthier adults with more productive lives and lower health care costs. For children without serious acute and chronic medical problems, however, traditional pediatric preventive services may be largely ineffective in addressing the outcomes that really matter; that is, improving lifelong health and reducing the burden of adult chronic disease. In this article, we examine what role WCC has in addressing the major childhood drivers of adult disease and consider various models for the future of WCC within pediatrics.

Authors: Coker, Tumaini R TR; Thomas, Tainayah T; Chung, Paul J PJ

Pediatrics. 2013 Apr 29;131 Suppl 2(12):S149-59. Epub 2015-10-15.

PubMed abstract

Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.

BACKGROUND: In the United States, people of color face disparities in access to health care, the quality of care received, and health outcomes. The attitudes and behaviors of health care providers have been identified as one of many factors that contribute to health disparities. Implicit attitudes are thoughts and feelings that often exist outside of conscious awareness, and thus are difficult to consciously acknowledge and control. These attitudes are often automatically activated and can influence human behavior without conscious volition.OBJECTIVES: We investigated the extent to which implicit racial/ethnic bias exists among health care professionals and examined the relationships between health care professionals’ implicit attitudes about racial/ethnic groups and health care outcomes.SEARCH METHODS: To identify relevant studies, we searched 10 computerized bibliographic databases and used a reference harvesting technique.SELECTION CRITERIA: We assessed eligibility using double independent screening based on a priori inclusion criteria. We included studies if they sampled existing health care providers or those in training to become health care providers, measured and reported results on implicit racial/ethnic bias, and were written in English.DATA COLLECTION AND ANALYSIS: We included a total of 15 studies for review and then subjected them to double independent data extraction. Information extracted included the citation, purpose of the study, use of theory, study design, study site and location, sampling strategy, response rate, sample size and characteristics, measurement of relevant variables, analyses performed, and results and findings. We summarized study design characteristics, and categorized and then synthesized substantive findings.MAIN RESULTS: Almost all studies used cross-sectional designs, convenience sampling, US participants, and the Implicit Association Test to assess implicit bias. Low to moderate levels of implicit racial/ethnic bias were found among health care professionals in all but 1 study. These implicit bias scores are similar to those in the general population. Levels of implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned people were relatively similar across these groups. Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Implicit attitudes were more often significantly related to patient-provider interactions and health outcomes than treatment processes.CONCLUSIONS: Most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color. Future studies need to employ more rigorous methods to examine the relationships between implicit bias and health care outcomes. Interventions targeting implicit attitudes among health care professionals are needed because implicit bias may contribute to health disparities for people of color.

Authors: Hall, William J WJ; Chapman, Mimi V MV; Lee, Kent M KM; Merino, Yesenia M YM; Thomas, Tainayah W TW; Payne, B Keith BK; Eng, Eugenia E; Day, Steven H SH; Coyne-Beasley, Tamera T

American journal of public health. 2015 Dec 29;105(12):e60-76. Epub 2015-10-15.

PubMed abstract

Cancer survivors’ receipt of treatment summaries and implications for patient-centered communication and quality of care

The Institute of Medicine recommends cancer survivors completing treatment be provided with a treatment summary to facilitate delivery of patient-centered survivorship care. However, the relationship between treatment summary receipt and patient-centered communication (PCC) and overall quality of care (QOC) are not well understood. Cancer survivors responding to the Health Information National Trends Survey reported treatment summary receipt, QOC, and experiences of six core functions of PCC. Multivariable logistic regression assessed the relationship between treatment summary receipt and PCC. The prevalence of survivors’ treatment summary receipt and demographic/clinical characteristics predictive of treatment summary receipt were also assessed. Of 359 respondents with a cancer history, 34.5% reported receiving a treatment summary. Greater treatment burden was associated with increased treatment summary receipt. Treatment summary receipt was associated with higher QOC and more PCC, both overall and for five of the six PCC functions. The receipt of cancer treatment summaries may improve PCC and QOC for survivors. The positive relationship between treatment summary receipt and survivors’ PCC experience substantiates continued efforts to provide treatment summaries to survivors transitioning from active treatment to survivorship care. Future research should characterize mechanisms by which treatment summary provision may enhance PCC.

Authors: Blanch-Hartigan D; Chawla N; Beckjord EI; Forsythe LP; de Moor JS; Hesse BW; Arora NK

Patient Educ Couns. 2015 Oct;98(10):1274-9. Epub 2015-06-17.

PubMed abstract

Leukocyte Telomere Length and Risks of Incident Coronary Heart Disease and Mortality in a Racially Diverse Population of Postmenopausal Women

Telomeres are regions at the ends of chromosomes that maintain chromosomal structural integrity and genomic stability. In studies of mainly older, white populations, shorter leukocyte telomere length (LTL) is associated with cardiometabolic risk factors and increased risks of mortality and coronary heart disease (CHD). On average, African Americans (AfAm) have longer LTL than whites, but the LTL-CHD relationship in AfAm is unknown. We investigated the relationship of LTL with CHD and mortality among AfAm. Using a case-cohort design, 1525 postmenopausal women (667 AfAm and 858 whites) from the Women’s Health Initiative had LTL measured in baseline blood samples by Southern blotting. CHD or mortality hazards ratios were estimated using race-stratified and risk factor-adjusted Cox proportional hazards models. There were 367 incident CHD (226 mortality) events in whites, whereas AfAm experienced 269 incident CHD (216 mortality) events during median follow-up of 13 years. Shorter LTL was associated with older age, current smoking, and white race/ethnicity. In whites, each 1 kilobase decrease in LTL was associated with 50% increased hazard of CHD, hazard ratio=1.50 (95% confidence interval, 1.08-2.10), P=0.017. There was no association between CHD and LTL in AfAm. White women with shorter LTL had higher risks of mortality. In contrast, shorter LTL was weakly associated with decreased mortality hazard in AfAm. As one of the largest prospective studies of LTL associations with incident CHD and mortality in a racially diverse sample, our study suggests differences in LTL associations with CHD and mortality between white and AfAm postmenopausal women.

Authors: Carty CL; Kooperberg C; Liu J; Herndon M; Assimes T; Hou L; Kroenke CH; LaCroix AZ; Kimura M; Aviv A; Reiner AP

Arterioscler Thromb Vasc Biol. 2015 Oct;35(10):2225-31. Epub 2015-08-06.

PubMed abstract

A large multi-ethnic genome-wide association study of prostate cancer identifies novel risk variants and substantial ethnic differences

A genome-wide association study (GWAS) of prostate cancer in Kaiser Permanente health plan members (7,783 cases, 38,595 controls; 80.3% non-Hispanic white, 4.9% African-American, 7.0% East Asian, and 7.8% Latino) revealed a new independent risk indel rs4646284 at the previously identified locus 6q25.3 that replicated in PEGASUS (N = 7,539) and the Multiethnic Cohort (N = 4,679) with an overall P = 1.0 × 10(-19) (OR, 1.18). Across the 6q25.3 locus, rs4646284 exhibited the strongest association with expression of SLC22A1 (P = 1.3 × 10(-23)) and SLC22A3 (P = 3.2 × 10(-52)). At the known 19q13.33 locus, rs2659124 (P = 1.3 × 10(-13); OR, 1.18) nominally replicated in PEGASUS. A risk score of 105 known risk SNPs was strongly associated with prostate cancer (P < 1.0 × 10(-8)). Comparing the highest to lowest risk score deciles, the OR was 6.22 for non-Hispanic whites, 5.82 for Latinos, 3.77 for African-Americans, and 3.38 for East Asians. In non-Hispanic whites, the 105 risk SNPs explained approximately 7.6% of disease heritability. The entire GWAS array explained approximately 33.4% of heritability, with a 4.3-fold enrichment within DNaseI hypersensitivity sites (P = 0.004). Taken together, our findings of independent risk variants, ethnic variation in existing SNP replication, and remaining unexplained heritability have important implications for further clarifying the genetic risk of prostate cancer. Our findings also suggest that there may be much promise in evaluating understudied variation, such as indels and ethnically diverse populations.

Authors: Hoffmann TJ; Van Den Eeden SK; Sakoda LC; Habel LA; Quesenberry CP; Schaefer C; Witte JS; et al.

Cancer Discov. 2015 Aug;5(8):878-91. Epub 2015-06-01.

PubMed abstract

Sex and Age Differences in Global Pain Status Among Patients Using Opioids Long Term for Chronic Noncancer Pain

The use of chronic opioid therapy (COT) has risen dramatically in recent years, especially among women. However, little is known about factors influencing overall pain and function (global pain status) among COT users. Characterizing the typical experiences of COT patients by age-sex group could help clinicians and patients better weigh the risks and benefits of COT. Thus, we sought to characterize global pain status among COT users in community practice by age and sex. Telephone survey of 2,163 health plan members aged 21-80 years using COT. We assessed average/usual pain (0-10 scale); pain-related interference (0-10); activity limitation days, last 3 months; and pain impact, last 2 weeks (0-11). Status on each indicator was classified as low (better pain/function), moderate, or high (worse pain/function). Global pain status was categorized as favorable if 2-4 indicators were low and 0-1 was high and unfavorable if 2-4 indicators were high and 0-1 was low. Among female COT patients, 15% (vs. 26% of males) had favorable global pain status and 59% (vs. 42% of males) had unfavorable status. Under age 65 years, women fared more poorly than men on every indicator. Among 65- to 80-year-olds, women and men had similar global pain status. Although pain and function among COT users vary considerably, only one in five reported low pain levels and high levels of function. Young and middle-aged women seem to be at particularly high risk for unfavorable global pain status. More research is needed about how to best manage pain in this group.

Authors: LeResche L; Saunders K; Dublin S; Thielke S; Merrill JO; Shortreed SM; Campbell C; Von Korff MR

J Womens Health (Larchmt). 2015 Aug;24(8):629-35. Epub 2015-07-08.

PubMed abstract

Ethnic Differences in Geriatric Conditions and Diabetes Complications Among Older, Insured Adults With Diabetes: The Diabetes and Aging Study

The aim of this study was to evaluate ethnic differences in burden of prevalent geriatric conditions and diabetic complications among older, insured adults with diabetes. An observational study was conducted among 115,538 diabetes patients, aged ³60, in an integrated health care system with uniform access to care. Compared with Whites, Asians and Filipinos were more likely to be underweight but had substantively lower prevalence of falls, urinary incontinence, polypharmacy, depression, and chronic pain, and were least likely of all groups to have at least one geriatric condition. African Americans had significantly lower prevalence of incontinence and falls, but higher prevalence of dementia; Latinos had a lower prevalence of falls. Except for end-stage renal disease (ESRD), Whites tended to have the highest rates of prevalent diabetic complications. Among these insured older adults, ethnic health patterns varied substantially; differences were frequently small and rates were often better among select minority groups, suggesting progress toward the Healthy People 2020 objective to reduce health disparities.

Authors: Karter AJ; Adams AS; Whitmer RA; Huang ES; et al.

J Aging Health. 2015 Aug;27(5):894-918. Epub 2015-02-05.

PubMed abstract

Reach and Validity of an Objective Medication Adherence Measure Among Safety Net Health Plan Members with Diabetes: A Cross-Sectional Study

With the expansion of Medicaid and low-cost health insurance plans among diverse patient populations, objective measures of medication adherence using pharmacy claims could advance clinical care and translational research for safety net care. However, safety net patients may experience fluctuating prescription drug coverage, affecting the performance of adherence measures. To evaluate the performance of continuous medication gap (CMG) for diverse, low-income managed care members with diabetes. We conducted this cross-sectional analysis using administrative and clinical data for 680 members eligible for a self-management support trial at a nonprofit, government-sponsored managed care plan. We applied CMG methodology to cardiometabolic medication claims for English- , Cantonese- , or Spanish-speaking members with diabetes. We examined inclusiveness (the proportion with calculable CMG) and selectivity (sociodemographic and medical differences from members without CMG). For validity, we examined unadjusted associations of suboptimal adherence (CMG?> ?20%) with suboptimal cardiometabolic control. 429 members (63%) had calculable CMG. Compared with members without CMG, members with CMG were younger, more likely employed, and had poorer glycemic control but had better blood pressure and lipid control. Suboptimal adherence occurred more frequently among members with poor cardiometabolic control than among members with optimal control (28% vs. 12%, P?=?0.02). CMG demonstrated acceptable inclusiveness and validity in a diverse, low-income safety net population, comparable with its performance in studies among other insured populations. CMG may provide a useful tool to measure adherence among increasingly diverse Medicaid populations, complemented by other strategies to reach those not captured by CMG.

Authors: Ratanawongsa N; Karter AJ; Quan J; Parker MM; Handley M; Sarkar U; Schmittdiel JA; Schillinger D

J Manag Care Spec Pharm. 2015 Aug;21(8):688-98.

PubMed abstract

Building Equity Improvement into Quality Improvement: Reducing Socioeconomic Disparities in Colorectal Cancer Screening as Part of Population Health Management

Improving colorectal cancer (CRC) screening rates for patients from socioeconomically disadvantaged backgrounds is a recognized public health priority. Our aim was to determine if implementation of a system-wide screening intervention could reduce disparities in the setting of improved overall screening rates. This was an interrupted time series (ITS) analysis before and after a population management intervention. Patients eligible for CRC screening (age 52-75 years without prior total colectomy) in an 18-practice research network from 15 June 2009 to 15 June 2012 participated in the study. The Technology for Optimizing Population Care (TopCare) intervention electronically identified patients overdue for screening and facilitated contact by letter or telephone scheduler, with or without physician involvement. Patients identified by algorithm as high risk for non-completion entered into intensive patient navigation. Patients were dichotomized as???high school diploma (? HS), an indicator of socioeconomic disadvantage, vs. >HS diploma (> HS). The monthly disparity between???HS and?>?HS with regard to CRC screening completion was examined. At baseline, 72% of 47,447 eligible patients had completed screening, compared with 75% of 51,442 eligible patients at the end of follow-up (p?HS patients in June 2009 (65.7% vs. 74.5%, p?

Authors: Berkowitz SA; Percac-Lima S; Ashburner JM; Chang Y; Zai AH; He W; Grant RW; Atlas SJ

J Gen Intern Med. 2015 Jul;30(7):942-9. Epub 2015-02-13.

PubMed abstract

Age and sex differences in long-term outcomes following implantable cardioverter-defibrillator placement in contemporary clinical practice: findings from the cardiovascular research network

Patient sex and age may influence rates of death after receiving an implantable cardioverter-defibrillator for primary prevention. Differences in outcomes other than mortality and whether these differences vary by heart failure symptoms, etiology, and left ventricular ejection fraction are not well characterized. We studied 2954 patients with left ventricular ejection fraction ?0.35 undergoing first-time implantable cardioverter-defibrillator for primary prevention within the Cardiovascular Research Network; 769 patients (26%) were women, and 2827 (62%) were aged >65 years. In a median follow-up of 2.4 years, outcome rates per 1000 patient-years were 109 for death, 438 for hospitalization, and 111 for heart failure hospitalizations. Procedure-related complications occurred in 8.36%. In multivariable models, women had significantly lower risks of death (hazard ratio 0.67, 95% CI 0.56 to 0.80) and heart failure hospitalization (hazard ratio 0.82, 95% CI 0.68 to 0.98) and higher risks for complications (hazard ratio 1.38, 95% CI 1.01 to 1.90) than men; patients aged >65 years had higher risks of death (hazard ratio 1.55, 95% CI 1.30 to 1.86) and heart failure hospitalization (hazard ratio 1.25, 95% CI 1.05 to 1.49) than younger patients. Age and sex differences were generally consistent in strata according to symptoms, etiology, and severity of left ventricular systolic dysfunction, except the higher risk of complications in women, which differed by New York Heart Association classification (P=0.03 for sex-New York Heart Association interaction), and the risk of heart failure hospitalization in older patients, which differed by etiology of heart failure (P=0.05 for age-etiology interaction). The burden of adverse outcomes after receipt of an implantable cardioverter-defibrillator for primary prevention is substantial and varies according to patient age and sex. These differences in outcome generally do not vary according to baseline heart failure characteristics.

Authors: Masoudi FA; Go AS; Greenlee RT; et al.

J Am Heart Assoc. 2015 Jun;4(6):e002005. Epub 2015-06-02.

PubMed abstract

The Complex Relationship of Race to Outcomes in Heart Failure with Preserved Ejection Fraction

An improved understanding of racial differences in the natural history, clinical characteristics, and outcomes of heart failure will have important clinical and public health implications. We assessed how clinical characteristics and outcomes vary across racial groups (whites, blacks, and Asians) in adults with heart failure with preserved ejection fraction. We identified all adults with heart failure with preserved ejection fraction between 2005 and 2008 from 4 health systems in the Cardiovascular Research Network using hospital principal discharge and ambulatory visit diagnoses. Among 13,437 adults with confirmed heart failure with preserved ejection fraction, 85.9% were white, 7.6% were black, and 6.5% were Asian. After adjustment for potential confounders and use of cardiovascular therapies, compared with whites, blacks (adjusted hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.62-0.85) and Asians (HR, 0.75; 95% CI, 0.64-0.87) had a lower risk of death from any cause. Compared with whites, blacks had a higher risk of hospitalization for heart failure (HR, 1.48; 95% CI, 1.29-1.68); no difference was observed for Asians compared with whites (HR, 1.01; 95% CI, 0.86-1.18). Compared with whites, no significant differences were detected in risk of hospitalization for any cause for blacks (HR, 1.03; 95% CI, 0.95-1.12) and Asians (HR, 0.93; 95% CI, 0.85-1.02). In a diverse population with heart failure with preserved ejection fraction, we observed complex relationships between race and important clinical outcomes. More detailed studies of large populations are needed to fully characterize the epidemiologic picture and to elucidate potential pathophysiologic and treatment-response differences that may relate to race.

Authors: Gurwitz JH; Magid DJ; Smith DH; Hsu G; Sung SH; Allen LA; McManus DD; Goldberg RJ; Go AS; Cardiovascular Research Network PRESERVE Study

Am J Med. 2015 Jun;128(6):591-600. Epub 2014-12-30.

PubMed abstract

Does Food Vendor Density Mediate the Association Between Neighborhood Deprivation and BMI?: A G-computation Mediation Analysis

In previous research, neighborhood deprivation was positively associated with body mass index (BMI) among adults with diabetes. We assessed whether the association between neighborhood deprivation and BMI is attributable, in part, to geographic variation in the availability of healthful and unhealthful food vendors. Subjects were 16,634 participants of the Diabetes Study of Northern California, a multiethnic cohort of adults living with diabetes. Neighborhood deprivation and healthful (supermarket and produce) and unhealthful (fast food outlets and convenience stores) food vendor kernel density were calculated at each participant’s residential block centroid. We estimated the total effect, controlled direct effect, natural direct effect, and natural indirect effect of neighborhood deprivation on BMI. Mediation effects were estimated using G-computation, a maximum likelihood substitution estimator of the G-formula that allows for complex data relations such as multiple mediators and sequential causal pathways. We estimated that if neighborhood deprivation was reduced from the most deprived to the least deprived quartile, average BMI would change by -0.73 units (95% confidence interval: -1.05, -0.32); however, we did not detect evidence of mediation by food vendor density. In contrast to previous findings, a simulated reduction in neighborhood deprivation from the most deprived to the least deprived quartile was associated with dramatic declines in both healthful and unhealthful food vendor density. Availability of food vendors, both healthful and unhealthful, did not appear to explain the association between neighborhood deprivation and BMI in this population of adults with diabetes.

Authors: Zhang YT; Laraia BA; Mujahid MS; Tamayo A; Blanchard SD; Warton EM; Kelly NM; Moffet HH; Schillinger D; Adler N; Karter AJ

Epidemiology. 2015 May;26(3):344-52.

PubMed abstract

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR]?=?1.28; 95% confidence interval [CI]?=?1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR?=?1.44; 95% CI?=?1.01, 2.07; low SES: HR?=?1.88; 95% CI?=?1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer-specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.

Authors: Keegan TH; Kurian AW; Gali K; Tao L; Lichtensztajn DY; Hershman DL; Habel LA; Caan BJ; Gomez SL

Am J Public Health. 2015 May;105(5):938-46. Epub 2015-03-19.

PubMed abstract

Racial/Ethnic differences in health care visits made before suicide attempt across the United States

Suicide is a public health concern, but little is known about the patterns of health care visits made before a suicide attempt, and whether those patterns differ by race/ethnicity. To examine racial/ethnic variation in the types of health care visits made before a suicide attempt, when those visits occur, and whether mental health or substance use diagnoses were documented. Retrospective, longitudinal study, 2009-2011. 22,387 individuals who attempted suicide and were enrolled in the health plan across 10 health systems in the Mental Health Research Network. Cumulative percentage of different types of health care visits made in the 52 weeks before a suicide attempt, by self-reported racial/ethnicity and diagnosis. Data were from the Virtual Data Warehouse at each site. Over 38% of the individuals made any health care visit within the week before their suicide attempt and ?95% within the preceding year; these percentages varied across racial/ethnic groups (P<0.001). White individuals had the highest percentage of visits (>41%) within 1 week of suicide attempt. Asian Americans were the least likely to make visits within 52 weeks. Hawaiian/Pacific Islanders had proportionally the most inpatient and emergency visits before an attempt, but were least likely to have a recorded mental health or substance use diagnosis. Overall, visits were most common in primary care and outpatient general medical settings. This study provides temporal evidence of racial/ethnic differences in health care visits made before suicide attempt. Health care systems can use this information to help focus the design and implementation of their suicide prevention initiatives.

Authors: Ahmedani BK; Hunkeler EM; Williams K; et al.

Med Care. 2015 May;53(5):430-5.

PubMed abstract

Multi-Ethnic Genome-Wide Association Study of Cerebral White Matter Hyperintensities on MRI

The burden of cerebral white matter hyperintensities (WMH) is associated with an increased risk of stroke, dementia, and death. WMH are highly heritable, but their genetic underpinnings are incompletely characterized. To identify novel genetic variants influencing WMH burden, we conducted a meta-analysis of multiethnic genome-wide association studies. We included 21 079 middle-aged to elderly individuals from 29 population-based cohorts, who were free of dementia and stroke and were of European (n=17 936), African (n=1943), Hispanic (n=795), and Asian (n=405) descent. WMH burden was quantified on MRI either by a validated automated segmentation method or a validated visual grading scale. Genotype data in each study were imputed to the 1000 Genomes reference. Within each ethnic group, we investigated the relationship between each single-nucleotide polymorphism and WMH burden using a linear regression model adjusted for age, sex, intracranial volume, and principal components of ancestry. A meta-analysis was conducted for each ethnicity separately and for the combined sample. In the European descent samples, we confirmed a previously known locus on chr17q25 (P=2.7×10(-19)) and identified novel loci on chr10q24 (P=1.6×10(-9)) and chr2p21 (P=4.4×10(-8)). In the multiethnic meta-analysis, we identified 2 additional loci, on chr1q22 (P=2.0×10(-8)) and chr2p16 (P=1.5×10(-8)). The novel loci contained genes that have been implicated in Alzheimer disease (chr2p21 and chr10q24), intracerebral hemorrhage (chr1q22), neuroinflammatory diseases (chr2p21), and glioma (chr10q24 and chr2p16). We identified 4 novel genetic loci that implicate inflammatory and glial proliferative pathways in the development of WMH in addition to previously proposed ischemic mechanisms.

Authors: Verhaaren BF; Sigurdsson S; Fornage M; et al.

Circ Cardiovasc Genet. 2015 Apr;8(2):398-409. Epub 2015-02-07.

PubMed abstract

Longitudinal study of acculturation and BMI change among Asian American men

Cross-sectional studies examining the association between Western acculturation and BMI in Asians have been inconsistent, and studies on BMI change are lacking. This study examined the associations between indicators of acculturation (generational status, length of US residence, and age at immigration) and overweight (BMI ?25kg/m(2)) as well as 5-year BMI changes in 7,073 Chinese, Japanese, Korean, Filipino, and Vietnamese men who lived in the US and were 44-71years old at baseline of the California Men’s Health Study (2002-2003). Indicators of acculturation were reported at baseline. Repeated clinical measures of BMI were extracted from electronic health records (2005-2012). Using generalized estimating equations we found that lower generational status, shorter duration of US residence and older age at immigration were inversely associated with being overweight. However, analysis of BMI curves using linear mixed models showed that shorter length of US residence and older age at immigration were associated with larger 5-year increases in BMI. Asian immigrants who were less acculturated had larger BMI increases as they became more acculturated but had not achieved overweight status. Healthy weight interventions among Asians immigrants may be most effective when targeting weight maintenance early in the process of acculturation.

Authors: Erber Oakkar E; Stevens J; Bradshaw PT; Cai J; Perreira KM; Popkin BM; Gordon-Larsen P; Young DR; Ghai NR; Caan B; Quinn VP

Prev Med. 2015 Apr;73:15-21. Epub 2015-01-17.

PubMed abstract

Race-Ethnic and Sex Differences in Left Ventricular Structure and Function: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

We investigated race-ethnic and sex-specific relationships of left ventricular (LV) structure and LV function in African American and white men and women at 43 to 55 years of age. The Coronary Artery Risk Development in Young Adults (CARDIA) Study enrolled African American and white adults, age 18 to 30 years, from 4 US field centers in 1985-1986 (Year-0) who have been followed prospectively. We included participants with echocardiographic assessment at the Year-25 examination (n=3320; 44% men, 46% African American). The end points of LV structure and function were assessed using conventional echocardiography and speckle-tracking echocardiography. In the multivariable models, we used, in addition to race-ethnic and gender terms, demographic (age, physical activity, and educational level) and cardiovascular risk variables (body mass index, systolic blood pressure, diastolic blood pressure, heart rate, presence of diabetes, use of antihypertensive medications, number of cigarettes/day) at Year-0 and -25 examinations as independent predictors of echocardiographic outcomes at the Year-25 examination (LV end-diastolic volume [LVEDV]/height, LV end-systolic volume [LVESV]/height, LV mass [LVM]/height, and LVM/LVEDV ratio for LV structural indices; LV ejection fraction [LVEF], Ell, and Ecc for systolic indices; and early diastolic and atrial ratio, mitral annulus early peak velocity, ratio of mitral early peak velocity/mitral annulus early peak velocity; ratio, left atrial volume/height, longitudinal peak early diastolic strain rate, and circumferential peak early diastolic strain rate for diastolic indices). Compared with women, African American and white men had greater LV volume and LV mass (P<0.05). For LV systolic function, African American men had the lowest LVEF as well as longitudinal (Ell) and circumferential (Ecc) strain indices among the 4 sex/race-ethnic groups (P<0.05). For LV diastolic function, African American men and women had larger left atrial volumes; African American men had the lowest values of Ell and Ecc for diastolic strain rate (P<0.05). These race/sex differences in LV structure and LV function persisted after adjustment. African American men have greater LV size and lower LV systolic and diastolic function compared to African American women and to white men and women. The reasons for these racial-ethnic differences are partially but not completely explained by established cardiovascular risk factors.

Authors: Kishi S; Wu CO; Lima JA; et al.

J Am Heart Assoc. 2015 Mar;4(3):e001264. Epub 2015-03-13.

PubMed abstract

Effects of Eliminating Drug Caps on Racial Differences in Antidepressant Use Among Dual Enrollees With Diabetes and Depression

Black patients with diabetes are at greater risk of underuse of antidepressants even when they have equal access to health insurance. This study aimed to evaluate the impact of removing a significant financial barrier to prescription medications (drug caps) on existing black-white disparities in antidepressant treatment rates among patients with diabetes and comorbid depression. We used an interrupted time series with comparison series design and a 5% representative sample of all fee-for-service Medicare and Medicaid dual enrollees to evaluate the removal of drug caps on monthly antidepressant treatment rates. We evaluated the impact of drug cap removal on racial gaps in treatment by modeling the month-to-month white-black difference in use within age strata (younger than 65 years of age or 65 years of age or older). We compared adult dual enrollees with diabetes and comorbid depression living in states with strict drug caps (n = 221) and those without drug caps (n = 1133) before the policy change. Our primary outcome measures were the proportion of patients with any antidepressant use per month and the mean standardized monthly doses (SMDs) of antidepressants per month. The removal of drug caps in strict drug cap states was associated with a sudden increase in the proportion of patients treated for depression (4 percentage points; 95% CI, 0.03-0.05, P < 0.0001) and in the intensity of antidepressant use (SMD: 0.05; 95% CI, 0.03-0.07, P < 0.001). Although antidepressant treatment rates increased for both white and black patients, the white-black treatment gap increased immediately after Part D (0.04 percentage points; 95% CI, 0.01-0.08) and grew over time (0.04 percentage points per month; 95% CI, 0.002-0.01; P < 0.001). Policies that remove financial barriers to medications may increase depression treatment rates among patients with diabetes overall while exacerbating treatment disparities. Tailored outreach may be needed to address nonfinancial barriers to mental health services use among black patients with diabetes.

Authors: Adams AS; Madden JM; et al.

Clin Ther. 2015 Mar 1;37(3):597-609. Epub 2015-01-22.

PubMed abstract

Diabetes and other comorbidities in breast cancer survival by race/ethnicity: The California Breast Cancer Survivorship Consortium (CBCSC)

The role of comorbidities in survival of patients with breast cancer has not been well studied, particularly in non-white populations. We investigated the association of specific comorbidities with mortality in a multiethnic cohort of 8,952 breast cancer cases within the California Breast Cancer Survivorship Consortium (CBCSC), which pooled questionnaire and cancer registry data from five California-based studies. In total, 2,187 deaths (1,122 from breast cancer) were observed through December 31, 2010. Using multivariable Cox proportional hazards regression, we estimated HRs and 95% confidence intervals (CI) for overall and breast cancer-specific mortality associated with previous cancer, diabetes, high blood pressure (HBP), and myocardial infarction. Risk of breast cancer-specific mortality increased among breast cancer cases with a history of diabetes (HR, 1.48; 95% CI, 1.18-1.87) or myocardial infarction (HR, 1.94; 95% CI, 1.27-2.97). Risk patterns were similar across race/ethnicity (non-Latina white, Latina, African American, and Asian American), body size, menopausal status, and stage at diagnosis. In subgroup analyses, risk of breast cancer-specific mortality was significantly elevated among cases with diabetes who received neither radiotherapy nor chemotherapy (HR, 2.11; 95% CI, 1.32-3.36); no increased risk was observed among those who received both treatments (HR, 1.13; 95% CI, 0.70-1.84; P(interaction) = 0.03). A similar pattern was found for myocardial infarction by radiotherapy and chemotherapy (P(interaction) = 0.09). These results may inform future treatment guidelines for patients with breast cancer with a history of diabetes or myocardial infarction. Given the growing number of breast cancer survivors worldwide, we need to better understand how comorbidities may adversely affect treatment decisions and ultimately outcome.

Authors: Wu AH; Kwan ML; Caan BJ; Vigen C; et al.

Cancer Epidemiol Biomarkers Prev. 2015 Feb;24(2):361-8. Epub 2014-11-25.

PubMed abstract

Treatment patterns for ductal carcinoma in situ from 2000-2010 across six integrated health plans

Considerable debate exists about the optimal treatment of ductal carcinoma in situ (DCIS). Using electronic data sources, we examined first course treatment patterns among women aged 18 years and older diagnosed with DCIS between 2000-2010 from six Kaiser Permanente (KP) regions. We calculated the proportion of patients receiving breast conserving surgery (BCS), BCS plus radiation therapy, unilateral mastectomy, bilateral mastectomy, and hormone therapy. Multinomial logistic regression was used to assess the association between patient characteristics and treatment. We included 9,437 women: 1,086 (11.5%) African-American; 1,455 (15.4%) Asian; 918 (9.7%) Hispanic; and 5,978 (63.3%) non-Hispanic white. Most cases (42.2%) received BCS plus radiation as their initial treatment. Nearly equal numbers of women received BCS without radiation (28.5%) or unilateral mastectomy (24.6%). Use of bilateral mastectomy was uncommon (4.7%), and most women (72.2%) did not receive hormone therapy has part of their first course treatment. We observed statistically significant differences in treatment patterns for DCIS by KP region and patient age. Predictably, nuclear grade and the presence of comorbidities were associated with first course treatment for DCIS. We observed statistically significant increases in BCS plus radiation therapy and bilateral mastectomy over time. Although still uncommon, the frequency of bilateral mastectomy increased from 2.7% in 2000 to 7.0% in 2010. We also observed differences in treatment by race/ethnicity. Our findings help illustrate the complex nature of DCIS treatment in the United States, and highlight the need for evidence based guidelines for DCIS care.

Authors: Feigelson HS; Carroll NM; Weinmann S; Haque R; Yu CL; Butler MG; Waitzfelder B; Wrenn MG; Capra A; McGlynn EA; Habel LA

Springerplus. 2015;4:24. Epub 2015-01-17.

PubMed abstract

Accuracy of parent-reported information for estimating prevalence of overweight and obesity in a race-ethnically diverse pediatric clinic population aged 3 to 12

There is conflicting evidence about the accuracy of estimates of childhood obesity based on parent-reported data. We assessed accuracy of child height, weight, and overweight/obesity classification in a pediatric clinic population based on parent data to learn whether accuracy differs by child age and race/ethnicity. Parents of patients ages 3-12 (n = 1,119) completed a waiting room questionnaire that asked about their child’s height and weight. Child’s height and weight was then measured and entered into the electronic health record (EHR) by clinic staff. The child’s EHR and questionnaire data were subsequently linked. Accuracy of parent-reported height, weight, overweight/obesity classification, and parent perception of child’s weight status were assessed using EHR data as the gold standard. Statistics were calculated for the full sample, two age groups (3-5, 6-12), and four racial/ethnic groups (nonHispanic White, Black, Latino, Asian). A parent-reported height was available for 59.1% of the children, weight for 75.6%, and weight classification for 53.0%. Data availability differed by race/ethnicity but not age group. Parent-reported height was accurate for 49.2% of children and weight for 58.2%. Latino children were less likely than nonHispanic Whites to have accurate height and weight data, and weight data were less accurate for 6-12 year than 3-5 year olds. Concordance of parent- and EHR-based classifications of the child as overweight/obese and obese was approximately 80% for all subgroups, with kappa statistics indicating moderate agreement. Parent-reported data significantly overestimated prevalence of overweight/obesity (50.2% vs. 35.2%) and obesity (32.1% vs. 19.4%) in the full sample and across all age and racial/ethnic subgroups. However, the percentages of parents who perceived their child to be overweight or very overweight greatly underestimated actual prevalence of overweight/obesity and obesity. Missing data did not bias parent-based overweight/obesity estimates and was not associated with child’s EHR weight classification or parental perception of child’s weight. While the majority of parents of overweight or obese children tend to be unaware that their child is overweight, use of parent-reported height and weight data for young children and pre-teens will likely result in overestimates of prevalence of youth overweight and obesity.

Authors: Gordon NP; Mellor RG

BMC Pediatr. 2015;15:5. Epub 2015-02-12.

PubMed abstract

Longitudinal study of body mass index in Asian men who immigrate to the US

Cross-sectional studies indicate that adaptation to Western norms, especially at a younger age, might explain the higher average body mass index (BMI) among Asians living in the United States (US) compared to Asians living in Asia. However, migrants differ from non-migrants in sociocultural factors that are difficult to measure and, thus, longitudinal studies on the same individuals prior to and after immigration are needed. The objective of this study was to determine differences in changes in BMI across age by residence (US or Asia) and age at immigration using longitudinal data on BMI prior to and after immigration. The California Men’s Health Study includes 1,549 foreign-born Asian men who were aged 44-71 at baseline in 2002-03. BMI at ages 30, 40, 50 and 60 was calculated using self-reported weight history and current height. Residence at each age decade and age at immigration were determined. Data were analyzed using generalized estimating equations. Ten-year BMI increases were smaller among Asians who lived in Asia prior to migrating to the US compared to those who already lived in the US. This effect was most evident be-tween ages 30-40 when Asians in Asia had a 0.69 kg/m2 (95% CI: -1.08, -0.30) smaller increase in BMI. Immigrants who moved to the US before age 40 experienced greater increases in BMI than immigrants who moved to the US at an older age. This study is the first to support the hypothesis that living in the US and younger age at immigration results in larger BMI increases in Asian men. Abstract available from the publisher.

Authors: Oakkar EE; Stevens J; Bradshaw PT; Cai J; Perreira KM; Popkin BM; Gordon-Larsen P; Young DR; Ghai NR; Caan B; Quinn VP

Asia Pac J Clin Nutr. 2015;24(4):701-9.

PubMed abstract

Representativeness of breast cancer cases in an integrated health care delivery system

Integrated health care delivery systems, with their comprehensive and integrated electronic medical records (EMR), are well-poised to conduct research that leverages the detailed clinical data within the EMRs. However, information regarding the representativeness of these clinical populations is limited, and thus the generalizability of research findings is uncertain. Using data from the population-based California Cancer Registry, we compared age-adjusted distributions of patient and neighborhood characteristics for three groups of breast cancer patients: 1) those diagnosed within Kaiser Permanente Northern California (KPNC), 2) non-KPNC patients from NCI-designated cancer centers, and 3) those from all other hospitals. KPNC patients represented 32 % (N = 36,109); cancer center patients represented 7 % (N = 7805); and all other hospitals represented 61 % (N = 68,330) of the total breast cancer patients from this geographic area during 1996-2009. Compared with cases from all other hospitals, KPNC had slightly fewer non-Hispanic Whites (70.6 % versus 74.4 %) but more Blacks (8.1 % versus 5.0 %), slightly more patients in the 50-69 age range and fewer in the younger and older age groups, a slightly lower proportion of in situ but higher proportion of stage I disease (41.6 % versus 38.9 %), were slightly less likely to reside in the lowest (4.2 % versus 6.5 %) and highest (36.2 % versus 39.0 %) socioeconomic status neighborhoods, and more likely to live in suburban metropolitan areas and neighborhoods with more racial/ethnic minorities. Cancer center patients differed substantially from patients from KPNC and all other hospitals on all characteristics assessed. All differences were statistically significant (p

Authors: Gomez SL; Shariff-Marco S; Von Behren J; Kwan ML; Kroenke CH; Keegan TH; Reynolds P; Kushi LH

BMC Cancer. 2015;15:688. Epub 2015-10-14.

PubMed abstract

Creating patient-centered health care systems to improve outcomes and reduce disparities

Health care delivery systems that are designed to understand and meet patient preferences for care have the potential to improve health outcomes and reduce disparities. Studies that rigorously assess patient care preferences in minority and underserved populations, stakeholder engagement, and policies that promote a diverse health care workforce that can address patient preferences are important levers for improving care for vulnerable populations.

Authors: Schmittdiel JA

Isr J Health Policy Res. 2015;4:42. Epub 2015-08-18.

PubMed abstract

Genome-wide association and admixture analysis of glaucoma in the Women’s Health Initiative

We report a genome-wide association study (GWAS) and admixture analysis of glaucoma in 12 008 African-American and Hispanic women (age 50-79 years) from the Women’s Health Initiative (WHI). Although GWAS of glaucoma have been conducted on several populations, this is the first to look at glaucoma in individuals of African-American and Hispanic race/ethnicity. Prevalent and incident glaucoma was determined by self-report from study questionnaires administered at baseline (1993-1998) and annually through 2005. For African Americans, there was a total of 658 prevalent cases, 1062 incident cases and 6067 individuals who never progressed to glaucoma. For our replication cohort, we used the WHI Hispanics, including 153 prevalent cases, 336 incident cases and 2685 non-cases. We found an association of African ancestry with glaucoma incidence in African Americans (hazards ratio 1.62, 95% CI 1.023-2.56, P = 0.038) and in Hispanics (hazards ratio 3.21, 95% CI 1.32-7.80, P = 0.011). Although we found that no previously identified glaucoma SNPs replicated in either the WHI African Americans or Hispanics, a risk score combining all previously reported hits was significant in African-American prevalent cases (P = 0.0046), and was in the expected direction in the incident cases, as well as in the Hispanic incident cases. Additionally, after imputing to 1000 Genomes, two less common independent SNPs were suggestive in African Americans, but had too low of an allele frequency in Hispanics to test for replication. These results suggest the possibility of a distinct genetic architecture underlying glaucoma in individuals of African ancestry.

Authors: Hoffmann TJ; Tang H; Thornton TA; Caan B; Haan M; Millen AE; Thomas F; Risch N

Hum Mol Genet. 2014 Dec 15;23(24):6634-43. Epub 2014-07-15.

PubMed abstract

Relation of serum uric acid levels and outcomes among patients hospitalized for worsening heart failure with reduced ejection fraction (from the efficacy of vasopressin antagonism in heart failure outcome study with tolvaptan trial).

We investigated the clinical profiles associated with serum uric acid (sUA) levels in a large cohort of patients hospitalized for worsening chronic heart failure with ejection fraction (EF) ≤40%, with specific focus on gender, race, and renal function based interactions. In 3,955 of 4,133 patients (96%) with baseline sUA data, clinical characteristics and outcomes were compared across sUA quartiles. The primary end points were all-cause mortality and a composite of cardiovascular mortality or heart failure hospitalization. Interaction analyses were performed for gender, race, and baseline renal function. Median follow-up was 9.9 months. Mean sUA was 9.1 ± 2.8 mg/dl and was higher in men than in women (9.3 ± 2.7 vs 8.7 ± 3.0 mg/dl, p 0.4). Adjusted interaction analyses for gender, race, and admission allopurinol use were not significant. In conclusion, sUA is commonly elevated in patients hospitalized for worsening chronic heart failure and reduced EF, especially in men and blacks. The prognostic use of sUA differs by baseline renal function, suggesting different biologic and pathophysiologic significance of sUA among those with and without significant renal dysfunction.

Authors: Vaduganathan, Muthiah M; Greene, Stephen J SJ; Ambrosy, Andrew P AP; Mentz, Robert J RJ; Subacius, Haris P HP; Chioncel, Ovidiu O; Maggioni, Aldo P AP; Swedberg, Karl K; Zannad, Faiez F; Konstam, Marvin A MA; Senni, Michele M; Givertz, Michael M MM; Butler, Javed J; Gheorghiade, Mihai M;

The American journal of cardiology. 2014 Dec 01;114(11):1713-21. Epub 2014-09-16.

PubMed abstract

Racial/ethnic differences in hip and diaphyseal femur fractures

Contemporary femur fracture rates were examined in northern California women and compared by race/ethnicity. During 2006-2012, hip fracture rates declined, but diaphyseal fracture rates increased, especially in Asians. Women with diaphyseal fracture were younger and more likely to be bisphosphonate-treated. These disparities in femur fracture should be further examined. The epidemiology of diaphyseal femur fracture differs from proximal femur (hip) fracture, although few studies have examined demographic variations in the current era. This study examines contemporary differences in low-energy femur fracture by race/ethnicity in a large, diverse integrated health-care delivery system. The incidence of hip and diaphyseal fracture in northern California women aged ?50 years old during 2006-2012 was examined. Hip (femoral neck and pertrochanteric) fractures were classified by hospital diagnosis codes, while diaphyseal (subtrochanteric and femoral shaft) fractures were further adjudicated based on radiologic findings. Demographic and clinical data were obtained from health plan databases. Fracture incidence was examined over time and by race/ethnicity. There were 10,648 (97.3 %) hip and 300 (2.7 %) diaphyseal fractures among 10,493 women. The age-adjusted incidence of hip fracture fell from 281 to 240 per 100,000 women and was highest for white women. However, diaphyseal fracture rates increased over time, with a significant upward trend in Asians (9 to 27 per 100,000) who also had the highest rate of diaphyseal fracture. Women with diaphyseal fracture were younger than women with hip fracture, more likely to be of Asian race and to have received bisphosphonate drugs. Women with longer bisphosphonate treatment duration were also more likely to have a diaphyseal fracture, especially younger Asian women. During 2006 to 2012, hip fracture rates declined, but diaphyseal fracture rates increased, particularly among Asian women. The association of diaphyseal fracture and bisphosphonate therapy should be further investigated with examination of fracture pattern.

Authors: Lo JC; Zheng P; Grimsrud CD; Chandra M; Ettinger B; Budayr A; Lau G; Baur MM; Hui RL; Neugebauer R

Osteoporos Int. 2014 Sep;25(9):2313-8. Epub 2014-06-26.

PubMed abstract

Association of African genetic ancestry with fasting glucose and HbA1c levels in non-diabetic individuals: the Boston Area Community Health (BACH) Prediabetes Study

To test among diabetes-free urban community-dwelling adults the hypothesis that the proportion of African genetic ancestry is positively associated with glycaemia, after accounting for other continental ancestry proportions, BMI and socioeconomic status (SES). The Boston Area Community Health cohort is a multi-stage 1:1:1 stratified random sample of self-identified African-American, Hispanic and white adults from three Boston inner city areas. We measured 62 ancestry informative markers, fasting glucose (FG), HbA1c, BMI and SES (income, education, occupation and insurance status) and analysed 1,387 eligible individuals (379 African-American, 411 Hispanic, 597 white) without clinical or biochemical evidence of diabetes. We used three-heritage multinomial linear regression models to test the association of FG or HbA1c with genetic ancestry proportion adjusted for: (1) age and sex; (2) age, sex and BMI; and (3) age, sex, BMI and SES. Mean age- and sex-adjusted FG levels were 5.73 and 5.54 mmol/l among those with 100% African or European ancestry, respectively. Using per cent European ancestry as the referent, each 1% increase in African ancestry proportion was associated with an age- and sex-adjusted FG increase of 0.0019 mmol/l (p = 0.01). In the BMI- and SES-adjusted model the slope was 0.0019 (p = 0.02). Analysis of HbA1c gave similar results. A greater proportion of African genetic ancestry is independently associated with higher FG levels in a non-diabetic community-based cohort, even accounting for other ancestry proportions, obesity and SES. The results suggest that differences between African-Americans and whites in type 2 diabetes risk may include genetically mediated differences in glucose homeostasis.

Authors: Meigs JB; Grant RW; Piccolo R; López L; Florez JC; Porneala B; Marceau L; McKinlay JB

Diabetologia. 2014 Sep;57(9):1850-8. Epub 2014-06-19.

PubMed abstract

The Association of Gender to Cardiovascular Outcomes After Coronary Artery Revascularization in Patients With End-Stage Renal Disease

Inadequate recruitment of women and an exclusion of patients with end-stage renal disease (ESRD) in coronary revascularization trials have led to knowledge gaps of gender-based outcomes. Women have equivalent cardiovascular outcomes when compared to men. We conducted a retrospective observational study utilizing Kaiser Permanente Northern California (KPNC) databases and identified 1015 adults with ESRD who underwent coronary revascularization between 1996 and 2008. We ascertained baseline characteristics, primary (mortality at 5 years) and secondary (myocardial infarction [MI] and repeat revascularization) outcomes from KPNC databases, state death certificates, and Social Security Administration files. A multivariable logistic regression was used to determine the association of gender to the prespecified outcomes. Men and women were similar in age (P = 0.23). The mean number of baseline comorbidities was higher in women (2.7, 95% confidence interval [CI]: 2.5-2.9) compared to men (2.3, 95% CI: 2.1-2.4, P = 0.0002). The risk-adjusted odds ratios (OR) of female gender to death at 5 years (OR: 1.12, 95% CI: 0.83-1.52), MI (OR: 1.19, 95% CI: 0.86-1.64), and repeat revascularization (OR: 1.01, 95% CI: 0.70-1.45) were similar to men. Age modified the effect of gender for the primary outcome death (Pinteraction < 0.048), with a trend toward worse outcomes in younger women and improved outcomes in older women. This effect was noted more in patients who underwent coronary artery bypass grafting. Although the overall relative risk of cardiovascular outcomes after coronary revascularization in ESRD was equivalent between men and women, age had a significant interaction with gender on overall mortality.

Authors: Krishnaswami A; Chang TI; Jang JJ; Leong TK; Go AS

Clin Cardiol. 2014 Sep;37(9):546-51. Epub 2014-06-30.

PubMed abstract

Update on Health Literacy and Diabetes

Inadequate literacy is common among patients with diabetes and may lead to adverse outcomes. The authors reviewed the relationship between literacy and health outcomes in patients with diabetes and potential interventions to improve outcomes. We reviewed 79 articles covering 3 key domains: (1) evaluation of screening tools to identify inadequate literacy and numeracy, (2) the relationships of a range of diabetes-related health outcomes with literacy and numeracy, and (3) interventions to reduce literacy-related differences in health outcomes. Several screening tools are available to assess patients’ print literacy and numeracy skills, some specifically addressing diabetes. Literacy and numeracy are consistently associated with diabetes-related knowledge. Some studies suggest literacy and numeracy are associated with intermediate outcomes, including self-efficacy, communication, and self-care (including adherence), but the relationship between literacy and glycemic control is mixed. Few studies have assessed more distal health outcomes, including diabetes-related complications, health care utilization, safety, or quality of life, but available studies suggest low literacy may be associated with increased risk of complications, including hypoglycemia. Several interventions appear to be effective in improving diabetes-related outcomes regardless of literacy status, but it is unclear if these interventions can reduce literacy-related differences in outcomes. Low literacy is associated with less diabetes-related knowledge and may be related to other important health outcomes. Further studies are needed to better elucidate pathways by which literacy skills affect health outcomes. Promising interventions are available to improve diabetes outcomes for patients with low literacy; more research is needed to determine their effectiveness outside of research settings.

Authors: Bailey SC; Karter AJ; Schillinger D; et al.

Diabetes Educ. 2014 Sep-Oct;40(5):581-604. Epub 2014-06-19.

PubMed abstract

Associations Between Antidepressant Adherence and Shared Decision-Making, Patient-Provider Trust, and Communication Among Adults with Diabetes: Diabetes Study of Northern California (DISTANCE)

Depression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient-provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence. To determine whether shared decision-making, patient-provider trust, or communication are associated with early stage and ongoing antidepressant adherence. Observational new prescription cohort study. Kaiser Permanente Northern California. One thousand five hundred twenty-three adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010. Exposures included items based on the Trust in Physicians and Interpersonal Processes of Care instruments and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) communication scale. Measures of adherence were estimated using validated methods with physician prescribing and pharmacy dispensing data: primary non-adherence (medication never dispensed), early non-persistence (dispensed once, never refilled), and new prescription medication gap (NPMG; proportion of time without medication during 12 months after initial prescription). After adjusting for potential confounders, patients’ perceived lack of shared decision-making was significantly associated with primary non-adherence (RR?=?2.42, p?

Authors: Bauer AM; Parker MM; Schillinger D; Katon W; Adler N; Adams AS; Moffet HH; Karter AJ

J Gen Intern Med. 2014 Aug;29(8):1139-47.

PubMed abstract

Maternal Acculturation and the Prenatal Care Experience

Acculturation may influence women’s perceptions of health care experiences and may explain the epidemiologic paradox, whereby foreign-born women have lower rates of adverse birth outcomes than United States (US)-born women. We evaluated the relationship between maternal acculturation and specific dimensions of prenatal interpersonal processes of care (IPC) in ethnically diverse women. Cross-sectional analysis of 1243 multiethnic, postpartum women who delivered at Kaiser Permanente Medical Center in Walnut Creek or San Francisco General Hospital. Women retrospectively reported on their experiences in seven domains of IPC during their pregnancy pertaining to communication, decision making, and interpersonal style. The primary independent variables were four measures of maternal acculturation: birthplace, English language proficiency, the number of years residing in the US, and age at immigration to the US. Generalized linear models, stratified by infant outcome, measured the association between each maternal acculturation measure and specific IPC domains while adjusting for type of health insurance, demographic, and reproductive factors. Approximately 60% of the sample was foreign-born, 36% reported low English proficiency, 43% had resided in the US <10 years, and 35% were age 20 years or older when they immigrated to the US. Over 64% of the women reported having public insurance during pregnancy. In adjusted analyses among women who delivered term and normal birth weight infants, less acculturated women and women with non-private health insurance were more likely to have higher mean IPC scores when compared to more acculturated or US-born women and women with private health insurance, respectively. In a large and ethnically diverse sample of childbearing women in Northern California, less acculturated pregnant women reported better prenatal care experiences than more acculturated and US-born women, another dimension of the "epidemiologic paradox." However, the relationship between acculturation and IPC, as reported during the postpartum period, differed according to infant outcomes.

Authors: Fuentes-Afflick E; Odouli R; Escobar GJ; Stewart AL; Hessol NA

J Womens Health (Larchmt). 2014 Aug;23(8):688-706. Epub 2014-06-30.

PubMed abstract

Changes in Use of Lipid-lowering Medications Among Black and White Dual Enrollees With Diabetes Transitioning From Medicaid to Medicare Part D Drug Coverage

The use of lipid-lowering agents is suboptimal among dual enrollees, particularly blacks. To determine whether the removal of restrictive drug caps under Medicare Part D reduced racial differences among dual enrollees with diabetes. An interrupted time series with comparison series design (ITS) cohort study. A total of 8895 black and white diabetes patients aged 18 years and older drawn from a nationally representative sample of fee-for-service dual enrollees (January 2004-December 2007) in states with and without drug caps before Part D. We examined the monthly (1) proportion of patients with any use of lipid-lowering therapies; and (2) intensity of use. Stratification measures included age (less than 65, 65 y and older), race (white vs. black), and sex. At baseline, lipid-lowering drug use was higher in no drug cap states (drug cap: 54.0% vs. nondrug cap: 66.8%) and among whites versus blacks (drug cap: 58.5% vs. 44.9%, no drug cap: 68.4% vs. 61.9%). In strict drug cap states only, Part D was associated with an increase in the proportion with any use [nonelderly: +0.07 absolute percentage points (95% confidence interval, 0.06-0.09), P<0.001; elderly: +0.08 (0.06-0.10), P<0.001] regardless of race. However, we found no evidence of a change in the white-black gap in the proportion of users despite the removal of a significant financial barrier. Medicare Part D was associated with increased use of lipid-lowering drugs, but racial gaps persisted. Understanding non-coverage-related barriers is critical in maximizing the potential benefits of coverage expansions for disparities reduction.

Authors: Adams AS; Madden JM; Zhang F; Soumerai SB; Gilden D; Griggs J; Trinacty CM; Bishop C; Ross-Degnan D

Med Care. 2014 Aug;52(8):695-703.

PubMed abstract

Prescription medication burden in patients with newly diagnosed diabetes: A SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) study

To understand the burden of medication use for patients with newly diagnosed diabetes both before and after diabetes diagnosis and to identify subpopulations of patients with newly diagnosed diabetes who face a relatively high drug burden. Retrospective cohort study. 11 integrated health systems in the United States. 196,654 insured adults 20 years of age or older newly diagnosed with type 1 or type 2 diabetes from January 2005 through December 2009. Number of unique therapeutic classes of drugs dispensed in the 12 months before and 12 months after diagnosis of diabetes in five categories: overall, antihypertensive agents, antihyperlipidemic agents, mental health agents, and antihyperglycemic agents (in the postdiagnosis period only). The mean number of drug classes used by newly diagnosed patients with diabetes is high before diagnosis (5.0) and increases significantly afterward (6.6). Of this increase, 81% is due to antihyperglycemic initiation and increased use of medications to control hypertension and lipid levels. Multivariate analyses showed that overall drug burden after diabetes diagnosis was higher in women, older, white, and obese patients, as well as among those with higher glycosylated hemoglobin concentrations and comorbidity levels (significant for all comparisons). The overall number of drug classes used by newly diagnosed patients with diabetes after diagnosis decreased slightly but significantly between 2005 and 2009. Patients newly diagnosed with diabetes face a substantially increased burden of medications used to control diabetes and other comorbidities. This study shows an increased focus on cardiovascular disease risk factor control after diagnosis of diabetes. However, total drug burden may be slightly decreasing over time.

Authors: Schmittdiel JA; Karter AJ; Steiner JF; et al.

J Am Pharm Assoc (2003). 2014 Jul-Aug;54(4):374-82.

PubMed abstract

Considering the Value of Dietary Assessment Data in Informing Nutrition-Related Health Policy

Dietary assessment has long been known to be challenged by measurement error. A substantial amount of literature on methods for determining the effects of error on causal inference has accumulated over the past decades. These methods have unrealized potential for improving the validity of data collected for research studies and national nutritional surveillance, primarily through the NHANES. Recently, the validity of dietary data has been called into question. Arguments against using dietary data to assess diet-health relations or to inform the nutrition policy debate are subject to flaws that fall into 2 broad areas: 1) ignorance or misunderstanding of methodologic issues; and 2) faulty logic in drawing inferences. Nine specific issues are identified in these arguments, indicating insufficient grasp of the methods used for assessing diet and designing nutritional epidemiologic studies. These include a narrow operationalization of validity, failure to properly account for sources of error, and large, unsubstantiated jumps to policy implications. Recent attacks on the inadequacy of 24-h recall-derived data from the NHANES are uninformative regarding effects on estimating risk of health outcomes and on inferences to inform the diet-related health policy debate. Despite errors, for many purposes and in many contexts, these dietary data have proven to be useful in addressing important research and policy questions. Similarly, structured instruments, such as the food frequency questionnaire, which is the mainstay of epidemiologic literature, can provide useful data when errors are measured and considered in analyses.

Authors: Hébert JR; Hurley TG; Steck SE; Miller DR; Tabung FK; Peterson KE; Kushi LH; Frongillo EA

Adv Nutr. 2014 Jul;5(4):447-55. Epub 2014-07-14.

PubMed abstract

Low Socioeconomic Status is Associated with Increased Risk for Hypoglycemia in Diabetes Patients: The Diabetes Study of Northern California (DISTANCE)

Social risk factors for hypoglycemia are not well understood. Cross-sectional analysis from the DISTANCE study, a multi-language, ethnically-stratified random sample of adults in the Kaiser Permanente Northern California diabetes registry, conducted in 2005-2006 (response rate 62%). Exposures were income and educational attainment; outcome was patient report of severe hypoglycemia. To test the association, we used multivariable logistic regression to adjust for demographic and clinical factors. 14,357 patients were included. Reports of severe hypoglycemia were common (11%), and higher in low-income vs. high-income (16% vs. 8.8) and low-education vs. high-education (11.9% vs. 8.9%) groups. In multivariable analysis, incomes of less than $15,000 (OR 1.51 95%CI 1.19-1.91), $15,000-$24,999 (OR 1.57 95%CI 1.27-1.94), and high school or less education (OR 1.42, 95% CI 1.24-1.63) were associated with increased hypoglycemia, similar to insulin use (OR 1.44 95%CI 1.19-1.74). Low income and educational attainment are important risk factors for hypoglycemia.

Authors: Berkowitz SA; Karter AJ; Lyles CR; Liu JY; Schillinger D; Adler NE; Moffet HH; Sarkar U

J Health Care Poor Underserved. 2014 May;25(2):478-90.

PubMed abstract

Intrinsic subtypes from PAM50 gene expression assay in a population-based breast cancer cohort: Differences by age, race, and tumor characteristics

Data are lacking to describe gene expression-based breast cancer intrinsic subtype patterns for population-based patient groups. We studied a diverse cohort of women with breast cancer from the Life After Cancer Epidemiology and Pathways studies. RNA was extracted from 1 mm punches from fixed tumor tissue. Quantitative reverse-transcriptase PCR was conducted for the 50 genes that comprise the PAM50 intrinsic subtype classifier. In a subcohort of 1,319 women, the overall subtype distribution based on PAM50 was 53.1% luminal A, 20.5% luminal B, 13.0% HER2-enriched, 9.8% basal-like, and 3.6% normal-like. Among low-risk endocrine-positive tumors (i.e., estrogen and progesterone receptor positive by immunohistochemistry, HER2 negative, and low histologic grade), only 76.5% were categorized as luminal A by PAM50. Continuous-scale luminal A, luminal B, HER2-enriched, and normal-like scores from PAM50 were mutually positively correlated. Basal-like score was inversely correlated with other subtypes. The proportion with non-luminal A subtype decreased with older age at diagnosis, P Trend < 0.0001. Compared with non-Hispanic Whites, African American women were more likely to have basal-like tumors, age-adjusted OR = 4.4 [95% confidence intervals (CI), 2.3-8.4], whereas Asian and Pacific Islander women had reduced odds of basal-like subtype, OR = 0.5 (95% CI, 0.3-0.9). Our data indicate that over 50% of breast cancers treated in the community have luminal A subtype. Gene expression-based classification shifted some tumors categorized as low risk by surrogate clinicopathologic criteria to higher-risk subtypes. Subtyping in a population-based cohort revealed distinct profiles by age and race.

Authors: Sweeney C; Kwan ML; Habel LA; Quesenberry CP; Kushi LH; Caan BJ; et al.

Cancer Epidemiol Biomarkers Prev. 2014 May;23(5):714-24. Epub 2014-02-12.

PubMed abstract

Cardiorespiratory fitness and cognitive function in middle age: The CARDIA Study

To investigate whether greater cardiorespiratory fitness (CRF) is associated with better cognitive function 25 years later. We studied 2,747 participants in the community-based Coronary Artery Risk Development in Young Adults Study of black and white men and women aged 18 to 30 years at recruitment in 1985-1986 (baseline year 0). Symptom-limited maximal treadmill test durations at years 0 and 20 provided measures of CRF. Cognitive tests at year 25 measured verbal memory (Rey Auditory Verbal Learning Test [RAVLT]), psychomotor speed (Digit Symbol Substitution Test [DSST]), and executive function (Stroop Test). Per minute of baseline CRF, the RAVLT was 0.12 words recalled higher (standard error [SE] = 0.03, p < 0.0001), the DSST was 0.92 digits higher (SE = 0.13, p < 0.0001), and the Stroop Test score was 0.52 lower (better performance, SE = 0.11, p < 0.0001), after accounting for race, sex, age, education, and clinical center. Compared with the lowest quartile of CRF, each cognitive test was 21% to 34% of an SD better in the highest CRF quartile. Further adjustment for lifestyle and clinical measures attenuated coefficients for RAVLT and DSST slightly, while the coefficient predicting the Stroop Test lost more than half its value (p = 0.07). Analysis in the subset of 1,957 participants who also completed the year-20 treadmill test showed that 20-year change in CRF was positively associated only with DSST (p < 0.001). Better verbal memory and faster psychomotor speed at ages 43 to 55 years were clearly associated with better CRF 25 years earlier.

Authors: Zhu N; Whitmer RA; Sternfeld B; et al.

Neurology. 2014 Apr 15;82(15):1339-46. Epub 2014-04-02.

PubMed abstract

Television viewing, bedroom television, and sleep duration from infancy to mid-childhood.

BACKGROUND: Television and insufficient sleep are associated with poor mental and physical health. This study assessed associations of TV viewing and bedroom TV with sleep duration from infancy to midchildhood.METHOD: We studied 1864 children in Project Viva. Parents reported children’s average daily TV viewing and sleep (at 6 months and annually from 1-7 years) and the presence of a bedroom TV (annually 4-7 years). We used mixed effects models to assess associations of TV exposures with contemporaneous sleep, adjusting for child age, gender, race/ethnicity, maternal education, and income.RESULTS: Six hundred forty-three children (35%) were racial/ethnic minorities; 37% of households had incomes ≤$70 000. From 6 months to 7 years, mean (SD) sleep duration decreased from 12.2 (2.0) hours to 9.8 (0.9) hours per day; TV viewing increased from 0.9 (1.2) hours to 1.6 (1.0) hours per day. At 4 years, 17% had a bedroom TV, rising to 23% at 7 years. Each 1 hour per day increase in lifetime TV viewing was associated with 7 minutes per day (95% confidence interval [CI]: 4 to 10) shorter sleep. The association of bedroom TV varied by race/ethnicity; bedroom TV was associated with 31 minutes per day shorter sleep (95% CI: 16 to 45) among racial/ethnic minority children, but not among white, non-Hispanic children (8 fewer minutes per day [95% CI: -19 to 2]).CONCLUSIONS: More TV viewing, and, among racial/ethnic minority children, the presence of a bedroom TV, were associated with shorter sleep from infancy to midchildhood.

Authors: Cespedes, Elizabeth M EM; Gillman, Matthew W MW; Kleinman, Ken K; Rifas-Shiman, Sheryl L SL; Redline, Susan S; Taveras, Elsie M EM

Pediatrics. 2014 May ;133(5):e1163-71. Epub 2014-04-14.

PubMed abstract

Racial/ethnic differences in dementia risk among older type 2 diabetes patients: The Diabetes and Aging Study

OBJECTIVE Although patients with type 2 diabetes have double the risk of dementia, potential racial/ethnic differences in dementia risk have not been explored in this population. We evaluated racial/ethnic differences in dementia and potential explanatory factors among older diabetic patients. RESEARCH DESIGN AND METHODS We identified 22,171 diabetic patients without preexisting dementia aged ?60 years (14,546 non-Hispanic whites, 2,484 African Americans, 2,363 Latinos, 2,262 Asians, 516 Native Americans) from the Kaiser Permanente Northern California Diabetes Registry. We abstracted prevalent medical history (1 January 1996 to 31 December 1997) and dementia incidence (1 January 1998 to 31 December 2007) from medical records and calculated age-adjusted incidence densities. We fit Cox proportional hazards models adjusted for age, sex, education, diabetes duration, and markers of clinical control. RESULTS Dementia was diagnosed in 3,796 (17.1%) patients. Age-adjusted dementia incidence densities were highest among Native Americans (34/1,000 person-years) and African Americans (27/1,000 person-years) and lowest among Asians (19/1,000 person-years). In the fully adjusted model, hazard ratios (95% CIs) (relative to Asians) were 1.64 (1.30-2.06) for Native Americans, 1.44 (1.24-1.67) for African Americans, 1.30 (1.15-1.47) for non-Hispanic whites, and 1.19 (1.02-1.40) for Latinos. Adjustment for diabetes-related complications and neighborhood deprivation index did not change the results. CONCLUSIONS Among type 2 diabetic patients followed for 10 years, African Americans and Native Americans had a 40-60% greater risk of dementia compared with Asians, and risk was intermediate for non-Hispanic whites and Latinos. Adjustment for sociodemographics, diabetes-related complications, and markers of clinical control did not explain observed differences. Future studies should investigate why these differences exist and ways to reduce them.

Authors: Mayeda ER; Karter AJ; Huang ES; Moffet HH; Haan MN; Whitmer RA

Diabetes Care. 2014 Apr;37(4):1009-15. Epub 2013-11-22.

PubMed abstract

Race and breast cancer survival by intrinsic subtype based on PAM50 gene expression

To evaluate whether differences in PAM50 breast cancer (BC) intrinsic (Luminal A, Luminal B, Basal-like, and HER2-enriched) subtypes help explain the Black-White BC survival disparity. Utilizing a stratified case-cohort design, this study included 1,635 women from the Pathways and Life After Cancer Epidemiology cohorts, selecting women with tumors based upon IHC classification, recurrences, and deaths.One millimeter punches were obtained from tumor tissue, and expression of the PAM50 genes for molecular subtype was determined by RT-qPCR of extracted RNA. Cox proportional hazards models were used to analyze associations between race and BC outcomes, adjusted for PAM50 BC subtype. All tests of statistical significance were two-sided. Black women had a higher prevalence of the Basal-like BC subtype. Adjusted for potential confounding variables and disease characteristics at diagnosis, Black women had higher risks of recurrence (HR 1.65, 95 % CI 1.06-2.57) and breast cancer-specific mortality (HR 1.71, 95 % CI 1.02-2.86) than White women, but adjusting further for subtype did not attenuate survival disparities. By contrast, Hispanic women had a lower risk of recurrence (HR 0.54, 95 % CI 0.30-0.96) than Whites. Among those with the Basal-like subtype, Black women had a similar recurrence risk as women in other race groups but a higher recurrence risk for all other subtypes. Hispanic women had a lower recurrence risk within each subtype, though associations were not significant, given limited power. Although Black women had a higher risk of the Basal-like subtype, which has poor prognosis, this did not explain the Black-White BC survival disparity.

Authors: Kroenke CH; Sweeney C; Kwan ML; Quesenberry CP; Weltzien EK; Habel LA; Castillo A; Bernard PS; Factor RE; Kushi LH; Caan BJ

Breast Cancer Res Treat. 2014 Apr;144(3):689-99. Epub 2014-03-07.

PubMed abstract

Asthma and physical activity in multiracial girls from three US sites

Studies comparing physical activity levels in children with and without asthma have had mixed results. Our objective was to investigate the association between asthma diagnosis and physical activity and to examine differences in these associations by race/ethnicity, weight status and caregiver education. We investigated the association between asthma (defined as report of physician-diagnosed asthma with at least one asthma related symptom) and measures of physical and sedentary activity in a study of 6- to 8-year-old girls in the Breast Cancer and the Environment Research Project. We compared reported activity and pedometer measurements among girls with and without asthma, and examined modification of these associations by race/ethnicity, weight status and caregiver education. Girls (n?=?1182) were included with 33.5% White, 4.8% Asian, 30.6% non Hispanic Black and 30.7% Hispanic. Asthma was present in 16.2% of girls. Overall, 38% of girls reported no participation in organized recreational activities and 58% had >2?h/day of television, video game and computer time combined. Girls with asthma whose parents were less educated reported fewer pedometer steps and less non-scheduled activity than girls without asthma with similar caregiver education level. Among girls with asthma, those on a controller medication had higher levels of sedentary activity and more structured physical activity but were less likely to report high intensity physical activity. Among girls whose parents are less educated, girls with asthma may have lower physical activity levels than girls without asthma. Use of a controller medication may be related to physical and sedentary activity.

Authors: Vangeepuram N; McGovern KJ; Teitelbaum S; Galvez MP; Pinney SM; Biro FM; Kushi LH; Wolff MS

J Asthma. 2014 Mar;51(2):193-9. Epub 2013-11-15.

PubMed abstract

Racial and Ethnic Differences in Health Care Utilization and Outcomes Among Ulcerative Colitis Patients in an Integrated Health-Care Organization

Current knowledge of racial disparities in healthcare utilization and disease outcomes for ulcerative colitis (UC) is limited. We sought to investigate these differences among Caucasian, African American, Asian, and Hispanic patients with ulcerative colitis in Kaiser Permanente, a large integrated health-care system in Northern California. This retrospective cohort study used computerized clinical data from 5,196 Caucasians, 387 African-Americans, 550 Asians, and 801 Hispanics with prevalent UC identified between 1996 and 2007. Healthcare utilization and outcomes were compared at one and five-year follow-up by use of multivariate logistic regression analysis. Compared with whites, the male-to-female ratio differed for African-Americans (0.68 vs. 0.91, p < 0.01) and Asians (1.3 vs. 0.91, p < 0.01). Asians had fewer co-morbid conditions (p < 0.01) than whites, whereas more African-Americans had hypertension and asthma (p < 0.01). Use of immunomodulators did not differ significantly among race and/or ethnic groups. Among Asians, 5-ASA use was highest (p < 0.05) and the incidence of surgery was lowest (p < 0.01). Prolonged steroid exposure was more common among Hispanics (p < 0.05 at 1-year) who also had more UC-related surgery (p < 0.01 at 5-year) and hospitalization (<0.05 at 5-year), although these differences were not significant in multivariate analysis. In this population of UC patients with good access to care, overall health-care utilization patterns and clinical outcomes were similar across races and ethnicity. Asians may have milder disease than other races whereas Hispanics had a trend toward more aggressive disease, although the differences we observed were modest. These differences may be related to biological factors or different treatment preferences.

Authors: Li D; Collins B; Velayos FS; Liu L; Lewis JD; Allison JE; Flowers NT; Hutfless S; Abramson O; Herrinton LJ

Dig Dis Sci. 2014 Feb;59(2):287-94. Epub 2013-10-31.

PubMed abstract

HIV/HCV coinfection ameliorates the atherogenic lipoprotein abnormalities of HIV infection

Higher levels of small low-density lipoprotein (LDL) and lower levels of high-density lipoprotein (HDL) subclasses have been associated with increased risk of cardiovascular disease. The extent to which HIV infection and HIV/hepatitis C virus (HCV) coinfection are associated with abnormalities of lipoprotein subclasses is unknown. Lipoprotein subclasses were measured by nuclear magnetic resonance (NMR) spectroscopy in plasma samples from 569 HIV-infected and 5948 control participants in the Fat Redistribution and Metabolic Change in HIV Infection (FRAM), Coronary Artery Risk Development in Young Adults (CARDIA), and Multi-Ethnic Study of Atherosclerosis (MESA) studies. Multivariable regression was used to estimate the association of HIV and HIV/HCV coinfection with lipoprotein measures with adjustment for demographics, lifestyle factors, and waist-to-hip ratio. Relative to controls, small LDL levels were higher in HIV-monoinfected persons (+381?nmol/l, P?<0.0001), with no increase seen in HIV/HCV coinfection (-16.6?nmol/l). Levels of large LDL levels were lower (-196?nmol/l, P?<0.0001) and small HDL were higher (+8.2??mol/l, P?

Authors: Wheeler AL; Scherzer R; Lee D; Delaney JA; Bacchetti P; Shlipak MG; Sidney S; Grunfeld C; Tien PC; Study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM)

AIDS. 2014 Jan 2;28(1):49-58.

PubMed abstract

Obesity and Mortality After Breast Cancer by Race/Ethnicity: The California Breast Cancer Survivorship Consortium

We investigated body size and survival by race/ethnicity in 11,351 breast cancer patients diagnosed from 1993 to 2007 with follow-up through 2009 by using data from questionnaires and the California Cancer Registry. We calculated hazard ratios and 95% confidence intervals from multivariable Cox proportional hazard model-estimated associations of body size (body mass index (BMI) (weight (kg)/height (m)(2)) and waist-hip ratio (WHR)) with breast cancer-specific and all-cause mortality. Among 2,744 ascertained deaths, 1,445 were related to breast cancer. Being underweight (BMI <18.5) was associated with increased risk of breast cancer mortality compared with being normal weight in non-Latina whites (hazard ratio (HR) = 1.91, 95% confidence interval (CI): 1.14, 3.20), whereas morbid obesity (BMI ? 40) was suggestive of increased risk (HR = 1.43, 95% CI: 0.84, 2.43). In Latinas, only the morbidly obese were at high risk of death (HR = 2.26, 95% CI: 1.23, 4.15). No BMI-mortality associations were apparent in African Americans and Asian Americans. High WHR (quartile 4 vs. quartile 1) was associated with breast cancer mortality in Asian Americans (HR = 2.21, 95% CI: 1.21, 4.03; P for trend = 0.01), whereas no associations were found in African Americans, Latinas, or non-Latina whites. For all-cause mortality, even stronger BMI and WHR associations were observed. The impact of obesity and body fat distribution on breast cancer patients' risk of death may vary across racial/ethnic groups.

Authors: Kwan ML; Caan BJ; Wu AH; et al.

Am J Epidemiol. 2014 Jan 1;179(1):95-111. Epub 2013-10-09.

PubMed abstract

Spatial pattern of body mass index among adults in the diabetes study of Northern California (DISTANCE)

The role that environmental factors, such as neighborhood socioeconomics, food, and physical environment, play in the risk of obesity and chronic diseases is not well quantified. Understanding how spatial distribution of disease risk factors overlap with that of environmental (contextual) characteristics may inform health interventions and policies aimed at reducing the environment risk factors. We evaluated the extent to which spatial clustering of extreme body mass index (BMI) values among a large sample of adults with diabetes was explained by individual characteristics and contextual factors. We quantified spatial clustering of BMI among 15,854 adults with diabetes from the Diabetes Study of Northern California (DISTANCE) cohort using the Global and Local Moran’s I spatial statistic. As a null model, we assessed the amount of clustering when BMI values were randomly assigned. To evaluate predictors of spatial clustering, we estimated two linear models to estimate BMI residuals. First we included individual factors (demographic and socioeconomic characteristics). Then we added contextual factors (neighborhood deprivation, food environment) that may be associated with BMI. We assessed the amount of clustering that remained using BMI residuals. Global Moran’s I indicated significant clustering of extreme BMI values; however, after accounting for individual socioeconomic and demographic characteristics, there was no longer significant clustering. Twelve percent of the sample clustered in extreme high or low BMI clusters, whereas, only 2.67% of the sample was clustered when BMI values were randomly assigned. After accounting for individual characteristics, we found clustering of 3.8% while accounting for neighborhood characteristics resulted in 6.0% clustering of BMI. After additional adjustment of neighborhood characteristics, clustering was reduced to 3.4%, effectively accounting for spatial clustering of BMI. We found substantial clustering of extreme high and low BMI values in Northern California among adults with diabetes. Individual characteristics explained somewhat more of clustering of the BMI values than did neighborhood characteristics. These findings, although cross-sectional, may suggest that selection into neighborhoods as the primary explanation of why individuals with extreme BMI values live close to one another. Further studies are needed to assess causes of extreme BMI clustering, and to identify any community level role to influence behavior change.

Authors: Laraia BA; Blanchard SD; Karter AJ; Jones-Smith JC; Warton M; Kersten E; Jerrett M; Moffet HH; Adler N; Schillinger D; Kelly M

Int J Health Geogr. 2014;13:48. Epub 2014-12-04.

PubMed abstract

Diabetes care and outcomes for American Indians and Alaska natives in commercial integrated delivery systems: a SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) Study

To compare cardiovascular disease risk factor testing rates and intermediate outcomes of care between American Indian/Alaska Native (AI/AN) patients with diabetes and non-Hispanic Caucasians enrolled in nine commercial integrated delivery systems in the USA. We used modified Poisson regression models to compare the annual testing rates and risk factor control levels for glycated haemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP); number of unique diabetes drug classes; insulin use; and oral diabetes drug medication adherence between insured AI/AN and non-Hispanic white adults with diabetes aged ?18 in 2011. 5831 AI/AN patients (1.8% of the cohort) met inclusion criteria. After adjusting for age, gender, comorbidities, insulin use, and geocoded socioeconomic status, AI/AN patients had similar rates of annual HbA1c, LDL-C, and SBP testing, and LDL-C and SBP control, compared with non-Hispanic Caucasians. However, AI/AN patients were significantly more likely to have HbA1c >9% (>74.9?mmol/mol; RR=1.47, 95% CI 1.38 to 1.58), and significantly less likely to adhere to their oral diabetes medications (RR=0.90, 95% CI 0.88 to 0.93) compared with non-Hispanic Caucasians. AI/AN patients in commercial integrated delivery systems have similar blood pressure and cholesterol testing and control, but significantly lower rates of HbA1c control and diabetes medication adherence, compared with non-Hispanic Caucasians. As more AI/ANs move to urban and suburban settings, clinicians and health plans should focus on addressing disparities in diabetes care and outcomes in this population.

Authors: Schmittdiel JA; Adams AS; Manson SM; et al.

BMJ Open Diabetes Res Care. 2014;2(1):e000043. Epub 2014-11-17.

PubMed abstract

The Multigroup Ethnic Identity Measure-Revised: Measurement Invariance Across Racial and Ethnic Groups

The Multigroup Ethnic Identity Measure-Revised (MEIM-R), a brief instrument assessing affiliation with one’s ethnic group, is a promising advance in the ethnic identity literature. However, equivalency of its measurement properties across specific racial and ethnic groups should be confirmed before using it in diverse samples. We examined (a) the psychometric properties of the MEIM-R, including factor structure, measurement invariance, and internal consistency reliability, and (b) levels of and differences in ethnic identity across multiple racial and ethnic groups and subgroups. Asian (n = 630), Black/African American (n = 58), Hispanic (n = 240), multiethnic (n = 160), and White (n = 375) women completed the MEIM-R as part of the “Gestational diabetes’ Effect on Moms” diabetes prevention trial in the Kaiser Permanente Northern California health care setting (N = 1,463; M age = 32.5 years, SD = 4.9). Multiple-groups confirmatory factor analyses provided provisional evidence of measurement invariance, i.e., an equal, correlated 2-factor structure, equal factor loadings, and equal item intercepts across racial and ethnic groups. Latent factor means for the 2 MEIM-R subscales, exploration and commitment, differed across groups; effect sizes ranging from small to large generally supported the notion of ethnic identity as more salient among people of color. Pending replication, good psychometric properties in this large and diverse sample of women support the future use of the MEIM-R. Preliminary evidence of measurement invariance suggests that the MEIM-R could be used to measure and compare ethnic identity across multiple racial and ethnic groups.

Authors: Brown SD; Unger Hu KA; Mevi AA; Hedderson MM; Shan J; Quesenberry CP; Ferrara A

J Couns Psychol. 2014 Jan;61(1):154-61. Epub 2013-11-04.

PubMed abstract

Onset of Breast Development in a Longitudinal Cohort

There is growing evidence of pubertal maturation occurring at earlier ages, with many studies based on cross-sectional observations. This study examined age at onset of breast development (thelarche), and the impact of BMI and race/ethnicity, in the 3 puberty study sites of the Breast Cancer and the Environment Research Program, a prospective cohort of >1200 girls. Girls, 6 to 8 years at enrollment, were followed longitudinally at regular intervals from 2004 to 2011 in 3 geographic areas: the San Francisco Bay Area, Greater Cincinnati, and New York City. Sexual maturity assessment using Tanner staging was conducted by using standardized observation and palpation methods by trained and certified staff. Kaplan-Meier analyses were used to describe age at onset of breast maturation by covariates. The age at onset of breast stage 2 varied by race/ethnicity, BMI at baseline, and site. Median age at onset of breast stage 2 was 8.8, 9.3, 9.7, and 9.7 years for African American, Hispanic, white non-Hispanic, and Asian participants, respectively. Girls with greater BMI reached breast stage 2 at younger ages. Age-specific and standardized prevalence of breast maturation was contrasted to observations in 2 large cross-sectional studies conducted 10 to 20 years earlier (Pediatric Research in Office Settings and National Health and Nutrition Examination Survey III) and found to have occurred earlier among white, non-Hispanic, but not African American girls. We observed the onset of thelarche at younger ages than previously documented, with important differences associated with race/ethnicity and BMI, confirming and extending patterns seen previously. These findings are consistent with temporal changes in BMI.

Authors: Biro FM; Kushi LH; Wolff MS; et al.

Pediatrics. 2013 Dec;132(6):1019-27. Epub 2013-11-04.

PubMed abstract

Self-Reported physical functioning and mortality among individuals with type 2 diabetes: insights from TRIAD

To examine the association between physical functioning and mortality in people with type 2 diabetes, and determine if this association differs by race/ethnicity in managed care. We studied 7894 type 2 diabetic patients in Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Physical functioning was assessed with the Short Form Health Survey. The National Death Index was searched for deaths over 10years of follow-up (2000-2009). At baseline, mean age was 61.7years, 50% were non-Hispanic White, 22% were Black, and 16% of participants reported good physical functioning. Over 10years, 28% of participants died; 39% due to cardiovascular disease. Relative to those reporting good functioning, those reporting poor physical functioning had a 39% higher all-cause death rate after adjusting for age, sex, race/ethnicity, education, income, body mass index, smoking, and comorbidities (Hazard Ratio=1.39; 95% Confidence Interval: 1.16, 1.67). Although Blacks were less likely than Whites to report good functioning (p<0.01), the association between functioning and mortality did not differ by race/ethnicity. In this managed care population, self-reported physical functioning was a robust independent predictor of mortality and may be a useful benchmark for tailoring clinical care.

Authors: Ylitalo KR; McEwen LN; Karter AJ; Lee P; Herman WH

J Diabetes Complicat. 2013 Nov-Dec;27(6):565-9. Epub 2013-07-23.

PubMed abstract

Socioeconomic Status and Lung Cancer: Unraveling the Contribution of Genetic Admixture

OBJECTIVES: We examined the relationship between genetic ancestry, socioeconomic status (SES), and lung cancer among African Americans and Latinos. METHODS: We evaluated SES and genetic ancestry in a Northern California lung cancer case-control study (1998-2003) of African Americans and Latinos. Lung cancer case and control participants were frequency matched on age, gender, and race/ethnicity. We assessed case-control differences in individual admixture proportions using the 2-sample t test and analysis of covariance. Logistic regression models examined associations among genetic ancestry, socioeconomic characteristics, and lung cancer. RESULTS: Decreased Amerindian ancestry was associated with higher education among Latino control participants and greater African ancestry was associated with decreased education among African lung cancer case participants. Education was associated with lung cancer among both Latinos and African Americans, independent of smoking, ancestry, age, and gender. Genetic ancestry was not associated with lung cancer among African Americans. CONCLUSIONS: Findings suggest that socioeconomic factors may have a greater impact than genetic ancestry on lung cancer among African Americans. The genetic heterogeneity and recent dynamic migration and acculturation of Latinos complicate recruitment; thus, epidemiological analyses and findings should be interpreted cautiously.

Authors: Aldrich MC; Selvin S; Wrensch MR; Sison JD; Hansen HM; Quesenberry CP Jr; Seldin MF; Barcellos LF; Buffler PA; Wiencke JK

Am J Public Health. 2013 Oct;103(10):e73-80. Epub 2013 Aug 15.

PubMed abstract

The California Breast Cancer Survivorship Consortium (CBCSC): prognostic factors associated with racial/ethnic differences in breast cancer survival

Racial/ethnic disparities in mortality among US breast cancer patients are well documented. Our knowledge of the contribution of lifestyle factors to disease prognosis is based primarily on non-Latina Whites and is limited for Latina, African American, and Asian American women. To address this knowledge gap, the California Breast Cancer Survivorship Consortium (CBCSC) harmonized and pooled interview information (e.g., demographics, family history of breast cancer, parity, smoking, alcohol consumption) from six California-based breast cancer studies and assembled corresponding cancer registry data (clinical characteristics, mortality), resulting in 12,210 patients (6,501 non-Latina Whites, 2,060 African Americans, 2,032 Latinas, 1,505 Asian Americans, 112 other race/ethnicity) diagnosed with primary invasive breast cancer between 1993 and 2007. In total, 3,047 deaths (1,570 breast cancer specific) were observed with a mean (SD) follow-up of 8.3 (3.5) years. Cox proportional hazards regression models were fit to data to estimate hazards ratios (HRs) and 95 % confidence intervals (CIs) for overall and breast cancer-specific mortality. Compared with non-Latina Whites, the HR of breast cancer-specific mortality was 1.13 (95 % CI 0.97-1.33) for African Americans, 0.84 (95 % CI 0.70-1.00) for Latinas, and 0.60 (95 % CI 0.37-0.97) for Asian Americans after adjustment for age, tumor characteristics, and select lifestyle factors. The CBCSC represents a large and racially/ethnically diverse cohort of breast cancer patients from California. This cohort will enable analyses to jointly consider a variety of clinical, lifestyle, and contextual factors in attempting to explain the long-standing disparities in breast cancer outcomes.

Authors: Wu AH; Kwan ML; Caan BJ; Sposto R; et al.

Cancer Causes Control. 2013 Oct;24(10):1821-36. Epub 2013-07-18.

PubMed abstract

African American race but not genome-wide ancestry is negatively associated with atrial fibrillation among postmenopausal women in the Women’s Health Initiative

Atrial fibrillation (AF) is the most common arrhythmia in women and is associated with higher rates of stroke and death. Rates of AF are lower in African American subjects compared with European Americans, suggesting European ancestry could contribute to AF risk. The Women’s Health Initiative (WHI) Observational Study (OS) followed up 93,676 women since the mid 1990s for various cardiovascular outcomes including AF. Multivariate Cox hazard regression analysis was used to measure the association between African American race and incident AF. A total of 8,119 African American women from the WHI randomized clinical trials and OS were genotyped on the Affymetrix Human SNP Array 6.0. Genome-wide ancestry and previously reported single nucleotide polymorphisms associated with AF in European cohorts were tested for association with AF using multivariate logistic regression analyses. Self-reported African American race was associated with lower rates of AF (hazard ratio 0.43, 95% CI 0.32-0.60) in the OS, independent of demographic and clinical risk factors. In the genotyped cohort, there were 558 women with AF. By contrast, genome-wide European ancestry was not associated with AF. None of the single nucleotide polymorphisms previously associated with AF in European populations, including rs2200733, were associated with AF in the WHI African American cohort. African American race is significantly and inversely correlated with AF in postmenopausal women. The etiology of this association remains unclear and may be related to unidentified environmental differences. Larger studies are necessary to identify genetic determinants of AF in African Americans.

Authors: Perez MV; Hoffmann TJ; Tang H; Thornton T; Stefanick ML; Larson JC; Kooperberg C; Reiner AP; Caan B; Iribarren C; Risch N

Am Heart J. 2013 Sep;166(3):566-72.

PubMed abstract

Obesity and the Food Environment: Income and Ethnicity Differences Among People With Diabetes: The Diabetes Study of Northern California (DISTANCE)

It is unknown whether any association between neighborhood food environment and obesity varies according to individual income and/or race/ethnicity. The objectives of this study were to test whether there was an association between food environments and obesity among adults with diabetes and whether this relationship differed according to individual income or race/ethnicity. Subjects (n = 16,057) were participants in the Diabetes Study of Northern California survey. Kernel density estimation was used to create a food environment score for each individual’s residence address that reflected the mix of healthful and unhealthful food vendors nearby. Logistic regression models estimated the association between the modeled food environment and obesity, controlling for confounders, and testing for interactions between food environment and race/ethnicity and income. The authors found that more healthful food environments were associated with lower obesity in the highest income groups (incomes 301-600% and >600% of U.S. poverty line) among whites, Latinos, and Asians. The association was negative, but smaller and not statistically significant, among high-income blacks. On the contrary, a more healthful food environment was associated with higher obesity among participants in the lowest-income group (<100% poverty threshold), which was statistically significant for black participants in this income category. These findings suggest that the availability of healthful food environments may have different health implications when financial resources are severely constrained.

Authors: Jones-Smith JC; Karter AJ; Warton EM; Kelly M; Kersten E; Moffet HH; Adler N; Schillinger D; Laraia BA

Diabetes Care. 2013 Sep;36(9):2697-705. Epub 2013-05-01.

PubMed abstract

Risk of Coronary Disease in South Asian Americans

Authors: Hajra A; Li Y; Siu S; Udaltsova N; Armstrong MA; Friedman GD; Klatsky AL

J Am Coll Cardiol. 2013 Aug 13;62(7):644-5. Epub 2013 Jun 13.

PubMed abstract

Adverse Clinical Events Among Medicare Beneficiaries Using Antipsychotic Drugs: Linking Health Insurance Benefits and Clinical Needs

OBJECTIVE: Medicare Part D provides formulary protections for antipsychotics but does not exempt these drugs from cost-sharing. We investigated the impact of Part D coverage on antipsychotic drug spending, adherence, and clinical outcomes among beneficiaries with varying indications for use. METHODS: We conducted a historical cohort study of Medicare Advantage beneficiaries who received antipsychotic drugs, with diagnoses of schizophrenia or bipolar disorder or with no mental health diagnoses (N=10,190). Half had a coverage gap; half had no gap because of low-income subsidies. Using fixed effects regression models, we examined changes in spending and adherence as beneficiaries experienced cost-sharing increases after reaching the gap. We examined changes in hospitalizations and emergency department visits using proportional hazard models. RESULTS: Across all diagnostic groups, total monthly expenditure on antipsychotic drugs decreased with cost-sharing increases in the gap compared with those with no gap (eg, schizophrenia: -$123 95% confidence interval [-$138, -$108]), and out-of-pocket spending increased (eg, schizophrenia: $104 [$98, $110]). Adherence similarly decreased, with the largest declines among those with schizophrenia (-20.6 percentage points [-22.3, -18.9] in proportion of days covered). Among beneficiaries with schizophrenia and bipolar disorder, hospitalizations and emergency department visit rates increased with cost-sharing increases (eg, schizophrenia: hazard ratio=1.32 [1.06, 1.65] for all hospitalizations), but did not among subjects without mental health diagnoses. Clinical event rates did not change among beneficiaries with low-income subsidies without gaps. CONCLUSIONS: There is evidence of interruptions in antipsychotic use attributable to Part D cost-sharing. Adverse events increased among beneficiaries with approved indications for use, but not among beneficiaries without such indications.

Authors: Fung V; Price M; Busch AB; Landrum MB; Fireman B; Nierenberg A; Dow WH; Hui R; Frank R; Newhouse JP; Hsu J

Med Care. 2013 Jul;51(7):614-21.

PubMed abstract

Genome-wide Characterization of Shared and Distinct Genetic Components that Influence Blood Lipid Levels in Ethnically Diverse Human Populations

Blood lipid concentrations are heritable risk factors associated with atherosclerosis and cardiovascular diseases. Lipid traits exhibit considerable variation among populations of distinct ancestral origin as well as between individuals within a population. We performed association analyses to identify genetic loci influencing lipid concentrations in African American and Hispanic American women in the Women’s Health Initiative SNP Health Association Resource. We validated one African-specific high-density lipoprotein cholesterol locus at CD36 as well as 14 known lipid loci that have been previously implicated in studies of European populations. Moreover, we demonstrate striking similarities in genetic architecture (loci influencing the trait, direction and magnitude of genetic effects, and proportions of phenotypic variation explained) of lipid traits across populations. In particular, we found that a disproportionate fraction of lipid variation in African Americans and Hispanic Americans can be attributed to genomic loci exhibiting statistical evidence of association in Europeans, even though the precise genes and variants remain unknown. At the same time, we found substantial allelic heterogeneity within shared loci, characterized both by population-specific rare variants and variants shared among multiple populations that occur at disparate frequencies. The allelic heterogeneity emphasizes the importance of including diverse populations in future genetic association studies of complex traits such as lipids; furthermore, the overlap in lipid loci across populations of diverse ancestral origin argues that additional knowledge can be gleaned from multiple populations.

Authors: Coram MA; Risch NJ; Tang H; et al.

Am J Hum Genet. 2013 Jun 6;92(6):904-16. Epub 2013-05-30.

PubMed abstract

Sex-stratified Genome-wide Association Studies Including 270,000 Individuals Show Sexual Dimorphism in Genetic Loci for Anthropometric Traits

Given the anthropometric differences between men and women and previous evidence of sex-difference in genetic effects, we conducted a genome-wide search for sexually dimorphic associations with height, weight, body mass index, waist circumference, hip circumference, and waist-to-hip-ratio (133,723 individuals) and took forward 348 SNPs into follow-up (additional 137,052 individuals) in a total of 94 studies. Seven loci displayed significant sex-difference (FDR<5%), including four previously established (near GRB14/COBLL1, LYPLAL1/SLC30A10, VEGFA, ADAMTS9) and three novel anthropometric trait loci (near MAP3K1, HSD17B4, PPARG), all of which were genome-wide significant in women (P<5x10(-8)), but not in men. Sex-differences were apparent only for waist phenotypes, not for height, weight, BMI, or hip circumference. Moreover, we found no evidence for genetic effects with opposite directions in men versus women. The PPARG locus is of specific interest due to its role in diabetes genetics and therapy. Our results demonstrate the value of sex-specific GWAS to unravel the sexually dimorphic genetic underpinning of complex traits.

Authors: Randall JC; Iribarren C; Schlessinger D; et al.

PLoS Genet. 2013 Jun;9(6):e1003500. Epub 2013 Jun 6.

PubMed abstract

Neighborhood Deprivation and Change in BMI Among Adults With Type 2 Diabetes: The Diabetes Study of Northern California (DISTANCE)

To compare associations between neighborhood deprivation and measures of BMI change among adults with type 2 diabetes. Using data from the Kaiser Permanente Diabetes Study of Northern California (DISTANCE) survey, we estimated the association between neighborhood deprivation and two measures of BMI change over 3 years: 1) a continuous measure and 2) a categorical measure of clinically substantive BMI loss or gain (?7% of baseline BMI) versus stable BMI. The sample included 13,609 adults. On average, there was little change in BMI (-0.12, SD 3.07); 17.0 and 16.1% had clinically substantive BMI loss or gain, respectively, at follow-up. There was a positive association between neighborhood deprivation and BMI change for adults in the most versus least-deprived quartile of neighborhood deprivation (? = 0.22, P = 0.02) in adjusted models. In addition, relative to the least-deprived quartile (Q1), adults in more-deprived quartiles of neighborhood deprivation were more likely to experience either substantive BMI loss (Q2 relative risk ratio 1.19, 95% CI 1.00-1.41; Q3 1.20, 1.02-1.42; Q4 1.30, 1.08-1.55) or gain (Q2 1.25, 1.04-1.49; Q3 1.24, 1.04-1.49; Q4 1.45, 1.20-1.75). Greater neighborhood deprivation was positively associated with BMI change among adults with diabetes as well as with clinically substantive BMI loss or gain. Findings stress the importance of allowing for simultaneous associations with both gain and loss in future longitudinal studies of neighborhood deprivation and weight change, which may be particularly true for studies of patients with diabetes for whom both weight loss and gain have health implications.

Authors: Stoddard PJ; Laraia BA; Warton EM; Moffet HH; Adler NE; Schillinger D; Karter AJ

Diabetes Care. 2013 May;36(5):1200-8.

PubMed abstract

Black Race Is Not Protective Against Hazardous Bilirubin Levels

Although black race is considered protective against hyperbilirubinemia, black infants appear at increased risk of kernicterus. We found that although black infants have a lower risk of developing total serum bilirubin levels >/= 20 mg/dL than white infants, they appear at greater risk of developing levels >/= 30 mg/dL.

Authors: Wickremasinghe AC; Kuzniewicz MW; Newman TB

J Pediatr. 2013 May;162(5):1068-9. Epub 2013 Feb 10.

PubMed abstract

Racial Disparities in Posttraumatic Stress After Diagnosis of Localized Breast Cancer; The BQUAL Study

BACKGROUND: Little is known about the development of posttraumatic stress disorder (PTSD) over time among women diagnosed with breast cancer. This study examines changes in PTSD symptoms in the first 6 months after diagnosis and assesses racial/ethnic differences in PTSD symptomatology over time. METHODS: We recruited women with newly diagnosed breast cancer, stages I to III, from three sites in the United States. Three telephone interviews were conducted: baseline at about 2 to 3 months after diagnosis, first follow-up at 4 months after diagnosis, and second follow-up at 6 months after diagnosis. We measured traumatic stress in each interview using the Impact of Events Scale; recorded sociodemographic, tumor, and treatment factors; and used generalized estimating equations and polytomous logistic regression modeling to examine the associations between variables of interest and PTSD. RESULTS: Of 1139 participants, 23% reported symptoms consistent with a diagnosis of PTSD at baseline, 16.5% at first follow-up, and 12.6% at the second follow-up. Persistent PTSD was observed among 12.1% participants, as defined by having PTSD at two consecutive interviews. Among participants without PTSD at baseline, 6.6% developed PTSD at the first follow-up interview. Younger age at diagnosis, being black (odds ratio [OR] = 1.48 vs white, 95% confidence interval [CI] =1.04 to 2.10), and being Asian (OR = 1.69 vs white, 95% CI = 1.10 to 2.59) were associated with PTSD. CONCLUSIONS: Nearly one-quarter of women newly diagnosed with breast cancer reported symptoms consistent with PTSD shortly after diagnosis, with increased risk among black and Asian women. Early identification of PTSD may present an opportunity to provide interventions to manage symptoms.

Authors: Vin-Raviv N; Hillyer GC; Hershman DL; Galea S; Leoce N; Bovbjerg DH; Kushi LH; Kroenke C; Lamerato L; Ambrosone CB; Valdimorsdottir H; Jandorf L; Mandelblatt JS; Tsai WY; Neugut AI

J Natl Cancer Inst. 2013 Apr 17;105(8):563-72. Epub 2013 Feb 21.

PubMed abstract

Pregnancy Glycemia in Mexican-American Women Without Diabetes or Gestational Diabetes and Programming for Childhood Obesity

In the present study, we estimated the association between pregnancy glucose levels and offspring body mass index (BMI) z scores at 2, 3.5, 5, and 7 years of age, as well as z score trajectories across this age range, among Mexican-American women without diabetes or gestational diabetes. Beginning in 1999-2000, the Center for the Health Assessment of Mothers and Children of Salinas prospectively followed women from Monterey County, California (52 obese and 214 nonobese women) and their children. Plasma glucose values obtained 1 hour after a 50-g oral glucose load comprised the exposure. Offspring BMIs were compared with national data to calculate z scores. Increasing pregnancy glucose levels were associated with increased offspring BMI z scores at 7 years of age; a 1-mmol/L increase in glucose corresponded to an increase of 0.11 (standard deviation = 0.044) z-score units (P < 0.05). In nonobese women only, the mean z score over this age range increased with increasing glucose levels. The average BMI z score at 4.5 years of age increased by 0.12 (standard error, 0.059) units for each 1-mmol/L increase in glucose (P = 0.04). In obese women only, increasing glucose was associated with increases in BMI z score over time (P = 0.07). Whether interventions to reduce glucose values in women free of disease could mitigate childhood obesity remains unknown.

Authors: Ehrlich SF; Rosas LG; Ferrara A; King JC; Abrams B; Harley KG; Hedderson MM; Eskenazi B

Am J Epidemiol. 2013 Apr 15;177(8):768-75. Epub 2013 Mar 15.

PubMed abstract

Impact of Gestational Diabetes Mellitus on Pubertal Changes in Adiposity and Metabolic Profiles in Latino Offspring

OBJECTIVE: To examine the impact of maternal gestational diabetes mellitus (GDM) status on longitudinal changes in adiposity and metabolic variables in overweight Latino offspring (from age 8-20 years) across puberty. STUDY DESIGN: This longitudinal cohort of 210 overweight Latino children was measured annually for a period of 3 +/- 1 years for Tanner stage through physical examination, adiposity by dual-energy X-ray absorptiometry and magnetic resonance imaging, lipids, and glucose and insulin action via the oral glucose tolerance test and frequently sampled intravenous glucose tolerance test. Linear mixed-effects modeling estimated the impact of maternal GDM status on baseline and changes in adiposity and metabolic variables across puberty. RESULTS: In our cohort, 22% of offspring were from GDM pregnancies. At baseline, the GDM offspring were heavier at birth, more likely to have a family history of type 2 diabetes, and less likely to have been breastfed (for any duration). Compared with the non-GDM offspring, the GDM offspring had greater increases in total body fat (+6.5% vs +4.5%; P = .03) and steeper declines in acute insulin response (-39% vs -17%; P < .001) and disposition index (-57% vs -35%; P < .001) across Tanner stages, independent of ethnicity, sex, breastfeeding status, family history of diabetes, and baseline and changes in body composition. CONCLUSION: These findings confirm the elevated risk for excess adiposity and type 2 diabetes in GDM offspring, and further underscore the need for interventions targeting Latino GDM and their offspring.

Authors: Davis JN; Gunderson EP; Gyllenhammer LE; Goran MI

J Pediatr. 2013 Apr;162(4):741-5. Epub 2012 Nov 10.

PubMed abstract

Health Literacy and Antidepressant Medication Adherence Among Adults with Diabetes; The Diabetes Study of Northern California (DISTANCE)

Previous studies have reported that health literacy limitations are associated with poorer disease control for chronic conditions, but have not evaluated potential associations with medication adherence. To determine whether health literacy limitations are associated with poorer antidepressant medication adherence. Observational new prescription cohort follow-up study. Adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010 (N?=?1,366) at Kaiser Permanente Northern California. Validated three-item self-report scale measured health literacy. Discrete indices of adherence based on pharmacy dispensing data according to validated methods: primary non-adherence (medication never dispensed); early non-persistence (dispensed once, never refilled); non-persistence at 180 and 365 days; and new prescription medication gap (NPMG; proportion of time that the person is without medication during 12 months after the prescription date). Seventy-two percent of patients were classified as having health literacy limitations. After adjusting for sociodemographic and clinical covariates, patients with health literacy limitations had significantly poorer adherence compared to patients with no limitations, whether measured as early non-persistence (46 % versus 38 %, p < 0.05), non-persistence at 180 days (55 % versus 46 %, p < 0.05), or NPMG (41 % versus 36%, p < 0.01). There were no significant associations with primary adherence or non-persistence at 365 days.Poorer antidepressant adherence among adults with diabetes and health literacy limitations may jeopardize the continuation and maintenance phases of depression pharmacotherapy. Findings underscore the importance of national efforts to address health literacy, simplify health communications regarding treatment options, improve public understanding of depression treatment, and monitor antidepressant adherence.

Authors: Bauer AM; Schillinger D; Parker MM; Katon W; Adler N; Adams AS; Moffet HH; Karter AJ

J Gen Intern Med. 2013 Sep;28(9):1181-7. Epub 2013-03-20.

PubMed abstract

Does the association between depressive symptoms and cardiovascular mortality risk vary by race? Evidence from the Health and Retirement Study

OBJECTIVE:To test whether the association between depressive symptoms and cardiovascular disease (CVD) mortality is stronger among Blacks than Whites.DESIGN, SETTING AND PARTICIPANTS:2,638 Black and 15,132 White participants from a prospective, observational study of community-dwelling Health and Retirement Study participants (a nationally representative sample of U.S. adults aged > or = 50). Average follow-up was 9.2 years.OUTCOME MEASURE:Cause of death (per ICD codes) and month of death were identified from National Death Index linkages.METHODS:The associations between elevated depressive symptoms and mortality from stroke, ischemic heart disease (IHD), or total CVD were assessed using Cox proportional hazards models to estimate adjusted hazard ratios (HRs). We used interaction terms for race by depressive symptoms to assess effect modification (multiplicative scale).RESULTS:For both Whites and Blacks, depressive symptoms were associated with a significantly elevated hazard of total CVD mortality (Whites: HR=1.46; 95% CI: 1.33, 1.61; Blacks: HR=1.42, 95% CI: 1.10, 1.83). Adjusting for health and socioeconomic covariates, Whites with elevated depressive symptoms had a 13% excess hazard of CVD mortality (HR=1.13, 95% CI: 1.03, 1.25) compared to Whites without elevated depressive symptoms. The HR in Blacks was similar, although the confidence interval included the null (HR=1.12, 95% CI: .86, 1.46). The hazard associated with elevated depressive symptoms did not differ significantly by race (P>.15 for all comparisons). Patterns were similar in analyses restricted to respondents age > or =65.CONCLUSION:Clinicians should consider the depressive state of either Black or White patients as a potential CVD mortality risk factor.

Authors: Capistrant BD; Gilsanz P; Moon JR; Kosheleva A; Patton KK; Glymour MM

​Ethn Dis. 2013 Spring;23(2):155-60.

PubMed abstract

Patient reported interpersonal processes of care and perceived social position: The Diabetes Study of Northern California (DISTANCE)

A patient’s sense of his/her standing in the social hierarchy may impact interpersonal processes of care (IPC) within the patient-provider encounter. We investigated the association of perceived social position with patient-reported IPC. We used survey data from the Diabetes Study of Northern California (DISTANCE), studying 11,105 insured patients with diabetes cared for in an integrated healthcare delivery system. Perceived social position was based on the MacArthur subjective social status ladder. Patient-reported IPC was based on a combined scale adapted from the Consumer Assessment of Health Plans Study provider communication subscale and the Trust in Physicians scale. Lower perceived social position was associated with poorer reported IPC (p<0.001). The relationship remained statistically significant after controlling for age, sex, race/ethnicity, depressive symptoms, physical functioning, income and education. Beyond objective measures of SES, patients' sense of where they fall in the social hierarchy may represent a pathway between social position and patient satisfaction with the quality of patient-provider communication in chronic disease. Interventions to address disparities in communication in primary care should incorporate notions of patients' social position.

Authors: Moskowitz D; Lyles CR; Karter AJ; Adler N; Moffet HH; Schillinger D

Patient Educ Couns. 2013 Mar;90(3):392-8. Epub 2011-08-19.

PubMed abstract

Elevated Rates of Diabetes in Pacific Islanders and Asian Subgroups: The Diabetes Study of Northern California (DISTANCE)

OBJECTIVE: We estimated the prevalence and incidence of diabetes among specific subgroups of Asians and Pacific Islanders (APIs) in a multiethnic U.S. population with uniform access to care. RESEARCH DESIGN AND METHODS: This prospective cohort analysis included 2,123,548 adult members of Kaiser Permanente Northern California, including 1,704,363 with known race/ethnicity (white, 56.9%; Latino, 14.9%; African American, 8.0%; Filipino, 4.9%; Chinese, 4.0%; multiracial, 2.8%; Japanese, 0.9%; Native American, 0.6%; Pacific Islander, 0.5%; South Asian, 0.4%; and Southeast Asian, Korean, and Vietnamese, 0.1% each). We calculated age-standardized (to the 2010 U.S. population) and sex-adjusted diabetes prevalence at baseline and incidence (during the 2010 calendar year). Poisson models were used to estimate relative risks. RESULTS: There were 210,632 subjects with prevalent diabetes as of 1 January 2010 and 15,357 incident cases of diabetes identified during 2010. The crude diabetes prevalence was 9.9% and the incidence was 8.0 cases per 1,000 person-years and, after standardizing by age and sex to the 2010 U.S. Census, 8.9% and 7.7 cases per 1,000 person-years. There was considerable variation among the seven largest API subgroups. Pacific Islanders, South Asians, and Filipinos had the highest prevalence (18.3, 15.9, and 16.1%, respectively) and the highest incidence (19.9, 17.2, and 14.7 cases per 1,000 person-years, respectively) of diabetes among all racial/ethnic groups, including minorities traditionally considered high risk (e.g., African Americans, Latinos, and Native Americans). CONCLUSIONS: High rates of diabetes among Pacific Islanders, South Asians, and Filipinos are obscured by much lower rates among the large population of Chinese and several smaller Asian subgroups.

Authors: Karter AJ; Schillinger D; Adams AS; Moffet HH; Liu J; Adler NE; Kanaya AM

Diabetes Care. 2013 Mar;36(3):574-9. Epub 2012 Oct 15.

PubMed abstract

Racial/ethnic differences in use and duration of adjuvant hormonal therapy for breast cancer in the Women’s Health Initiative

BACKGROUND: Five-year breast cancer survival rates are lower among Hispanic and African-American women than among Non-Hispanic White women. Differences in breast cancer treatment likely play a role. Adjuvant hormonal therapies increase overall survival among women with hormone receptor-positive breast cancer. METHODS: We examined racial/ethnic differences in use and duration of adjuvant hormonal therapy among 3,588 postmenopausal women enrolled in the Women’s Health Initiative (WHI) Extension Study. Women diagnosed with hormone receptor-positive localized or regional stage breast cancer after study enrollment were surveyed between September 2009 and August 2010 and asked to recall prior use and duration of adjuvant hormonal breast cancer therapy. ORs comparing self-reported use and duration with race/ethnicity (Hispanic, African-American, Asian/Pacific Islander vs. Non-Hispanic White) were estimated using multivariable-adjusted logistic regression. RESULTS: Of the 3,588 women diagnosed from 1994 to 2009; 3,039 (85%) reported any use of adjuvant hormonal therapy, and 67% of women reporting ever-use who were diagnosed before 2005 reported using adjuvant hormonal therapy for the optimal duration of 5 years or more. In adjusted analysis, no statistically significant differences in use or duration by race/ethnicity were observed. CONCLUSIONS: This study did not find significant differences in use or duration of use of adjuvant hormonal therapy by race/ethnicity. Impact: Findings should be confirmed in other population-based samples, and potential reasons for discontinuation of therapy across all racial/ethnic groups should be explored. Cancer Epidemiol Biomarkers Prev; 22(3); 365-73. (c)2012 AACR.

Authors: Livaudais JC; Lacroix A; Chlebowski RT; Li CI; Habel LA; Simon MS; Thompson B; Erwin DO; Hubbell FA; Coronado GD

Cancer Epidemiol Biomarkers Prev. 2013 Mar;22(3):365-73. Epub 2012 Dec 28.

PubMed abstract

Variation of Adenoma Prevalence by Age, Sex, Race, and Colon Location in a Large Population: Implications for Screening and Quality Programs

BACKGROUND & AIMS: Reliable community-based colorectal adenoma prevalence estimates are needed to inform colonoscopy quality standards and to estimate patient colorectal cancer risks; however, minimal data exist from populations with large numbers of diverse patients and examiners. METHODS: We evaluated the prevalence of adenomas detected by sex, age, race/ethnicity, and colon location among 20,792 Kaiser Permanente Northern California members >/=50 years of age who received a screening colonoscopy examination (102 gastroenterologists, 2006-2008). RESULTS: Prevalence of detected adenomas increased more rapidly with age in the proximal colon (adjusted odds ratio [OR], 2.39; 95% confidence interval [CI], 2.05-2.80; 70-74 vs 50-54 years) than in the distal colon (OR, 1.89; 95% CI, 1.63-2.19). Prevalence was higher among men vs women at all ages (OR, 1.77; 95% CI, 1.66-1.89), increasing in men from 25% to 39% at >/=70 years and in women from 15% at 50-54 years to 26% (P < .001). Proximal adenoma prevalence was higher among blacks than whites (OR, 1.26; 95% CI, 1.04-1.54), although total prevalence was similar, including persons <60 years old (OR, 1.17; 95% CI, 0.91-1.50). CONCLUSIONS: Prevalence of detected adenomas increases substantially with age and is much higher in men; proximal adenomas are more common among blacks than whites, although the total prevalence and the prevalence for ages <60 years were similar by race. These demographic differences are such that current adenoma detection guidelines may not be valid, without adjustment, for comparing providers serving different populations. The variation in prevalence and location may also have implications for the effectiveness of screening methods in different demographic groups.

Authors: Corley DA; Jensen CD; Marks AR; Zhao WK; de Boer J; Levin TR; Doubeni C; Fireman BH; Quesenberry CP

Clin Gastroenterol Hepatol. 2013 Feb;11(2):172-80. Epub 2012 Sep 14.

PubMed abstract

Sex differences in cardiovascular outcomes in patients with incident hypertension

BACKGROUND:: The time of initial hypertension diagnosis represents an opportunity to assess subsequent risk of adverse cardiovascular outcomes. The extent to which women and men with newly identified hypertension are at a similar risk for adverse cardiovascular events, including chronic kidney disease (CKD), is not well known. METHODS:: Among women and men with incident hypertension from 2001 to 2006 enrolled in the Cardiovascular Research Network (CVRN) Hypertension Registry, we compared incident events including all-cause death; hospitalization for myocardial infarction (MI), heart failure or stroke; and the development of CKD. Multivariable models were adjusted for patient demographic and clinical characteristics. RESULTS:: Among 177 521 patients with incident hypertension, 55% were women. Compared with men, women were older, more likely white and had more kidney disease at baseline. Over median 3.2 years (interquartile range 1.6-4.8) of follow-up, after adjustment, women were equally likely to be hospitalized for heart failure [hazard ratio 0.90, 95% confidence interval (CI) 0.76-1.07] and were significantly less likely to die of any cause (hazard ratio 0.85, 95% CI 0.80-0.90) or be hospitalized for MI (hazard ratio 0.44, 95% CI 0.39-0.50) or stroke (hazard ratio 0.68, 95% CI 0.60-0.77) compared with men. Women were significantly more likely to develop CKD (9.60 vs. 7.15%; adjusted hazard ratio 1.17, 95% CI 1.12-1.22) than men. CONCLUSION:: In this cohort with incident hypertension, women were more likely to develop CKD and less likely to develop other cardiovascular outcomes compared with men. Future studies should investigate the potential reasons for these sex differences.

Authors: Daugherty SL; Masoudi FA; Zeng C; Ho PM; Margolis KL; O'Connor PJ; Go AS; Magid DJ

J Hypertens. 2013 Feb;31(2):271-7.

PubMed abstract

Interpersonal influences and attitudes about adjuvant therapy treatment decisions among non-metastatic breast cancer patients: an examination of differences by age and race/ethnicity in the BQUAL study

Patients are increasingly involved in cancer treatment decisions and yet little research has explored factors that may affect patient attitudes and beliefs about their therapeutic choices. This paper examines psychosocial factors (e.g., attitudes, social support), provider-related factors (e.g., communication, trust), and treatment considerations in a prospective study of a sample of non-metastatic breast cancer patients eligible for chemotherapy and/or hormonal therapy (BQUAL cohort). The data come from a multisite cohort study of white, black, Hispanic, and Asian non-metastatic breast cancer patients recruited in New York City, Northern California, and Detroit, Michigan. Baseline surveys were conducted over the telephone between 2006 and 2010 among a total of 1,145 women. Most participants were white (69 %), had more than a high school education (76 %), and were diagnosed with stage I disease (51 %). The majority of women reported discussing chemotherapy and hormonal therapy with their doctor (90 and 83 %, respectively); these discussions primarily took place with medical oncologists. Nearly a quarter of women reported that the treatment decision was difficult, and the majority were accompanied to the doctor (76 %) and involved a friend or family member in making the decision (54 %). Positive considerations (e.g., beliefs about treatment reducing risk of recurrence) were important in making treatment decisions. Participants preferred a shared decision-making style, but results suggested that there is room for improvement in terms of actual patient’s involvement in making the decision and provider communication, particularly among black patients. Patients 65 years and older reported fewer provider discussions of chemotherapy, poorer patient-provider communication, higher rates of being assisted by family members in making the decision, and more negative attitudes and beliefs toward treatment.

Authors: Shelton RC; Clarke Hillyer G; Hershman DL; Leoce N; Bovbjerg DH; Mandelblatt JS; Kushi LH; Lamerato L; Nathanson SD; Ambrosone CB; Neugut AI

Breast Cancer Res Treat. 2013 Feb;137(3):817-28. Epub 2012 Dec 22.

PubMed abstract

Health System Factors and Antihypertensive Adherence in a Racially and Ethnically Diverse Cohort of New Users

BACKGROUND: The purpose of this study was to identify potential health system solutions to suboptimal use of antihypertensive therapy in a diverse cohort of patients initiating treatment. METHODS: Using a hypertension registry at Kaiser Permanente Northern California, we conducted a retrospective cohort study of 44 167 adults (age, >/=18 years) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between race/ethnicity, specific health system factors, and early nonpersistence (failing to refill the first prescription within 90 days) and nonadherence (<80% of days covered during the 12 months following the start of treatment), respectively, controlling for sociodemographic and clinical risk factors. RESULTS: More than 30% of patients were early nonpersistent and 1 in 5 were nonadherent to therapy. Nonwhites were more likely to exhibit both types of suboptimal medication-taking behavior compared with whites. In logistic regression models adjusted for sociodemographic, clinical, and health system factors, nonwhite race was associated with early nonpersistence (black: odds ratio, 1.56 [95% CI, 1.43-1.70]; Asian: 1.40 [1.29-1.51]; Hispanic: 1.46 [1.35-1.57]) and nonadherence (black: 1.55 [1.37-1.77]; Asian: 1.13 [1.00-1.28]; Hispanic: 1.46 [1.31-1.63]). The likelihood of early nonpersistence varied between Asians and Hispanics by choice of first-line therapy. In addition, racial and ethnic differences in nonadherence were appreciably attenuated when medication co-payment and mail-order pharmacy use were accounted for in the models. CONCLUSIONS: Racial/ethnic differences in medication-taking behavior occur early in the course of treatment. However, health system strategies designed to reduce patient co-payments, ease access to medications, and optimize the choice of initial therapy may be effective tools in narrowing persistent gaps in the use of these and other clinically effective therapies.

Authors: Adams AS; Uratsu C; Dyer W; Magid D; O'Connor P; Beck A; Butler M; Ho PM; Schmittdiel JA

JAMA Intern Med. 2013 Jan 14;173(1):54-61.

PubMed abstract

Variation in vitamin D supplementation among adults in a multi-race/ethnic health plan population, 2008

BACKGROUND: Vitamin D may have a role in many chronic conditions in addition to bone health. Nutritional surveys among Americans have reported high levels of vitamin D insufficiency, especially among Blacks and Latinos. Our study examined variation in vitamin D supplementation practices in an adult health plan population by age, gender, and race-ethnicity. METHODS: Self-report data from a 2008 general health survey in a large Northern California health plan were used to characterize number and types of sources of vitamin D supplementation (multivitamin, calcium with D, singular D) among women and men aged 25-85, overall, by race-ethnicity, and for obese, diabetic, and hypertensive subgroups. RESULTS: In this population, 40% of women and 54% of men 50 is associated with higher reported intake of calcium with D. Black and Latina women aged 25-85 and Filipinas in the

Authors: Gordon NP; Caan BJ; Asgari MM

Nutr J. 2012 Dec 11;11:104.

PubMed abstract

Clinical characteristics, bone mineral density and non-vertebral osteoporotic fracture outcomes among post-menopausal U.S. South Asian Women

PURPOSE: There is limited data pertaining to osteoporotic fractures among North American women of South Asian (SA) descent. This study examines fracture incidence and risk factors among post-menopausal SA, Chinese and White women undergoing mineral density (BMD) testing within a large healthcare organization in Northern California. METHODS: Using data from a retrospective study of women aged 50-85 years with femoral neck BMD measured between 1997 and 2003, we identified a subset of women of SA race and an age-matched subgroup of Chinese (1:5) and White (1:10) women and examined rates of incident wrist, humerus and hip fractures up to 10 years following BMD. Clinical and demographic risk factors were identified using health plan databases. Multivariable Cox regression analyses were conducted to examine predictors of incident fractures. RESULTS: The study cohort included 449 SA, 2245 Chinese and 4490 White women, with an average age of 58.4 +/- 6.1 years. The prevalence of femoral neck osteoporosis was higher among SA (8.9%) compared to White (6.5%) women and tended to be lower than Chinese (11.9%) women. More SA (7.1%) and White (9.6%) women had prior fracture compared to Chinese women (4.5%) and racial differences in smoking, rheumatoid arthritis, glucocorticoid use and hormone replacement therapy were seen. During a median of 8.4 years follow-up, wrist fracture incidence was similar among SA and White women (286 and 303 per 100,000 person-years, respectively) but significantly lower among Chinese women (130 per 100,000 person-years). In multivariable analyses, lower BMD, prior fracture and White and SA race (compared to Chinese race), were associated with a higher relative rate of wrist fracture. Lower BMD, prior fracture, older age and White but not SA race were also associated with a higher relative rate of non-vertebral (wrist, humerus or hip) fractures. CONCLUSIONS: Post-menopausal South Asian women differed from Chinese and White women with respect to prevalence of femoral neck osteoporosis, certain risk factors and site of osteoporotic fracture. These findings support the need for more studies examining fracture risk and outcomes specific to SA women residing in the U.S. to inform clinical decisions relevant to fracture risk.

Authors: Khandelwal S; Chandra M; Lo JC

Bone. 2012 Dec;51(6):1025-8. Epub 2012 Aug 19.

PubMed abstract

Detection of Atrial Fibrillation After Stroke and the Risk of Recurrent Stroke

Failure to expeditiously diagnose atrial fibrillation (AF) as the cause of ischemic stroke has unclear consequences. We studied the association between detection of AF after discharge and the risk of recurrent stroke. We followed a prospectively assembled cohort of patients hospitalized for stroke for 1 year for new diagnoses of AF and recurrent stroke. We compared rates of recurrent stroke in patients with a new diagnosis of AF and those without a new diagnosis of AF after discharge using Kaplan-Meier survival statistics. We conducted Cox proportional hazards analysis of the diagnosis and timing of AF and recurrent stroke after adjustment for age, sex, race, preexisting AF, hypertension, dyslipidemia, diabetes, previous stroke, and use of antithrombotic and statin medications. Among 5575 patients with stroke, 113 (2.0%) received a new diagnosis of AF after discharge, and 221 (4.0%) had recurrent stroke. At 1 year, the KaplanMeier rate of recurrent stroke was 18.9% in those with a new diagnosis of AF and 4.5% in others, including those with AF diagnosed before or during the index hospitalization (P = .001). The association between a new diagnosis of AF and stroke recurrence persisted after adjustment for potential confounders (hazard ratio, 5.6; 95% confidence interval, 3.4-9.1). A new diagnosis of AF after discharge for stroke is associated with an increased risk of recurrent stroke, even compared with patients with known AF. These findings identify a subset of patients at high risk for recurrent stroke and highlight the importance of timely detection of AF in patients with stroke.

Authors: Kamel H; Johnson DR; Hegde M; Go AS; Sidney S; Sorel M; Hills NK; Johnston SC

J Stroke Cerebrovasc Dis. 2012 Nov;21(8):726-31. Epub 2011 May 5.

PubMed abstract

Recruitment of Hispanics into an Observational Study of Chronic Kidney Disease: The Hispanic Chronic Renal Insufficiency Cohort Study Experience

Despite the large burden of chronic kidney disease (CKD) in Hispanics, this population has been underrepresented in research studies. We describe the recruitment strategies employed by the Hispanic Chronic Renal Insufficiency Cohort Study, which led to the successful enrollment of a large population of Hispanic adults with CKD into a prospective observational cohort study. Recruitment efforts by bilingual staff focused on community clinics with Hispanic providers in high-density Hispanic neighborhoods in Chicago, academic medical centers, and private nephrology practices. Methods of publicizing the study included church meetings, local Hispanic print media, Spanish television and radio stations, and local health fairs. From October 2005 to July 2008, we recruited 327 Hispanics aged 21-74 years with mild-to-moderate CKD as determined by age-specific estimated glomerular filtration rate (eGFR). Of 716 individuals completing a screening visit, 49% did not meet eGFR inclusion criteria and 46% completed a baseline visit. The mean age at enrollment was 57.1 and 67.1% of participants were male. Approximately 75% of enrolled individuals were Mexican American, 15% Puerto Rican, and 10% had other Latin American ancestry. Eighty two percent of participants were Spanish-speakers. Community-based and academic primary care clinics yielded the highest percentage of participants screened (45.9% and 22.4%) and enrolled (38.2% and 24.5%). However, academic and community-based specialty clinics achieved the highest enrollment yield from individuals screened (61.9% to 71.4%). A strategy focused on primary care and nephrology clinics and the use of bilingual recruiters allowed us to overcome barriers to the recruitment of Hispanics with CKD.

Authors: Lora CM; Ricardo AC; Brecklin CS; Fischer MJ; Rosman RT; Carmona E; Lopez A; Balaram M; Nessel L; Tao KK; Xie D; Kusek JW; Go AS; Lash JP

Contemp Clin Trials. 2012 Nov;33(6):1238-44. Epub 2012 Jul 27.

PubMed abstract

Ethnic variability in bone geometry as assessed by hip structure analysis: Findings from the hip strength across the menopausal transition study

Racial/ethnic origin plays an important role in fracture risk. Racial/ethnic differences in fracture rates cannot be fully explained by bone mineral density (BMD). Studies examining the influence of bone geometry and strength on fracture risk have focused primarily on older adults and have not included people from diverse racial/ethnic backgrounds. Our goal was to explore racial/ethnic differences in hip geometry and strength in a large sample of midlife women. We performed Hip Structure Analysis (HSA) on hip DXA scans from 1942 pre- and early peri-menopausal women. The sample included Caucasian (50%), African American (27%), Chinese (11%) and Japanese (12%) women, age 42-52 years. HSA was performed using software developed at John’s Hopkins University. African American women had higher conventional (8.4-9.7%) and HSA BMD (5.4-19.8%) than other groups with the exception being Japanese women who had the highest HSA BMD (9.7-31.4%). HSA indices associated with more favorable geometry and greater strength and resistance to fracture were more prevalent in African American and Japanese women. Femurs of African American women had a smaller outer diameter, a larger cross-sectional area and section modulus, and a lower buckling ratio. Japanese women presented a different pattern with a higher section modulus and lower buckling ratio, similar to African American women, but a wider outer diameter; this was offset by a greater cross-sectional area and a more centrally located centroid. Chinese women had similar conventional BMD as Caucasian women but a smaller neck region area and HSA BMD at both regions. They also had a smaller cross-sectional area and section modulus, a more medially located centroid, and a higher buckling ratio than Caucasian women. The observed biomechanical differences may help explain racial/ethnic variability in fracture rates. Future research should explore the contribution of hip geometry to fracture risk across all race/ethnicities. (c) 2012 American Society for Bone and Mineral Research.

Authors: Danielson ME; Beck TJ; Lian Y; Karlamangla AS; Greendale GA; Ruppert K; Lo J; Greenspan S; Vuga M; Cauley JA

J Bone Miner Res. 2012 Oct 8.

PubMed abstract

Increased risk for respiratory distress among white, male, late preterm and term infants

OBJECTIVE: To determine whether race/ethnicity and sex independently increase risk of respiratory distress syndrome (RDS) in late preterm and term infants. STUDY DESIGN: Using a cohort design, we studied the risk of RDS associated with race/ethnicity and sex in infants with gestational age (GA) 34 to 42 weeks born between 1 January 2000 and 31 December 2009 (n=286 454) within 12 hospitals in the Northern California Kaiser Permanente Medical Care Program. RESULT: Male sex (adjusted odds ratio (aOR) 1.68; 95% confidence interval 1.45 to 1.93) and White race/ethnicity (vs Asians (aOR 0.57; 95% confidence interval 0.47 to 0.70), Blacks (aOR 0.66; 95% confidence interval 0.50 to 0.87), and Hispanics (aOR 0.76; 95% confidence interval 0.64 to 0.90)) independently increase risk for RDS regardless of GA. A GA <39 weeks, operative delivery, maternal diabetes, and chorioamnionitis also increased RDS risk in this cohort. CONCLUSION: Male sex and White race/ethnicity independently increase risk for RDS in late preterm and term infants. Timing of elective delivery should acknowledge these risks.

Authors: Anadkat JS; Kuzniewicz MW; Chaudhari BP; Cole FS; Hamvas A

J Perinatol. 2012 Oct;32(10):780-5. Epub 2012 Jan 5.

PubMed abstract

Antihypertensive Drugs and Lip Cancer in Non-Hispanic Whites

BACKGROUND: In screening pharmaceuticals for possible carcinogenic effects we noted an association between lip cancer risk and the photosensitizing antihypertensive drugs hydrochlorothiazide and nifedipine. In this study, we further characterized the risk of lip cancer associated with these and other commonly used antihypertensive drugs. METHODS: In a comprehensive medical care program, we evaluated prescriptions dispensed and cancer occurrence from August 1, 1994, to February 29, 2008. We identified 712 patients with lip cancer (cases) and 22,904 comparison individuals (controls) matched for age, sex, and cohort year of entry in the susceptible group, non-Hispanic whites. We determined use, at least 2 years before diagnosis or control index date, of the commonly prescribed diuretics hydrochlorothiazide and hydrochlorothiazide combined with triamterene, the angiotensin-converting enzyme inhibitor lisinopril, the calcium channel blocker nifedipine, and the beta-adrenergic blocker atenolol, the only nonphotosensitizer agent studied. We analyzed the use of each drug exclusively and regardless of use of the others, and focused on duration of use. Conditional logistic regression was used for analysis of matched case-control sets, with control for cigarette smoking. RESULTS: At least a 5-year supply of a drug yielded the following odds ratios (95% CIs), respectively, compared with no use: hydrochlorothiazide, 4.22 (2.82-6.31); hydrochlorothiazide-triamterene, 2.82 (1.74-4.55); lisinopril, 1.42 (0.95-2.13); nifedipine, 2.50 (1.29-4.84); and atenolol, 1.93 (1.29-2.91). When the other drugs were excluded, the odds ratio for atenolol was reduced to 0.54 (0.07-4.08). CONCLUSION: These data support an increased risk of lip cancer in non-Hispanic whites receiving treatment for hypertension with long-term use of photosensitizing drugs.

Authors: Friedman GD; Asgari MM; Warton EM; Chan J; Habel LA

Arch Intern Med. 2012 Sep 10;172(16):1246-51.

PubMed abstract

Patterns of Adjuvant Hormonal Therapy Use in the Northern California Breast Cancer Family Registry

BACKGROUND: In the United States, 5-year breast cancer survival is highest among Asian American women, followed by non-Hispanic white, Hispanic, and African American women. Breast cancer treatment disparities may play a role. We examined racial/ethnic differences in adjuvant hormonal therapy use among women aged 18-64 years, diagnosed with hormone receptor-positive breast cancer, using data collected by the Northern California Breast Cancer Family Registry (NC-BCFR), and explored changes in use over time. METHODS: Odds ratios (OR) comparing self-reported ever-use by race/ethnicity (African American, Hispanic, non-Hispanic white vs. Asian American) were estimated using multivariable adjusted logistic regression. Analyses were stratified by recruitment phase (phase I, diagnosed January 1995-September 1998, phase II, diagnosed October 1998-April 2003) and genetic susceptibility, as cases with increased genetic susceptibility were oversampled. RESULTS: Among 1385 women (731 phase I, 654 phase II), no significant racial/ethnic differences in use were observed among phase I or phase II cases. However, among phase I cases with no susceptibility indicators, African American and non-Hispanic white women were less likely than Asian American women to use hormonal therapy (OR 0.20, 95% confidence interval [CI]0.06-0.60; OR 0.40, CI 0.17-0.94, respectively). No racial/ethnic differences in use were observed among women with 1+ susceptibility indicators from either recruitment phase. CONCLUSIONS: Racial/ethnic differences in adjuvant hormonal therapy use were limited to earlier diagnosis years (phase I) and were attenuated over time. Findings should be confirmed in other populations but indicate that in this population, treatment disparities between African American and Asian American women narrowed over time as adjuvant hormonal treatments became more commonly prescribed.

Authors: Livaudais JC; Li C; John EM; Terry MB; Daly M; Buys SS; Habel L; Thompson B; Yanez ND; Coronado GD

J Womens Health (Larchmt). 2012 Sep;21(9):950-8. Epub 2012 Jun 25.

PubMed abstract

Prevalence of cervical insufficiency in polycystic ovarian syndrome

BACKGROUND: Pregnant women with polycystic ovarian syndrome (PCOS) experience a greater rate of adverse obstetrical outcomes compared with non-PCOS women. We examined the prevalence and incidence of cervical insufficiency (CI) in a community cohort of pregnant women with and without PCOS. METHODS: A retrospective cohort study was conducted within a large integrated health care delivery system among non-diabetic PCOS women with second or third trimester delivery during 2002-2005 (singleton or twin gestation). PCOS was defined by Rotterdam criteria. A non-PCOS comparison group matched for delivery year and hospital facility was used to estimate the background rate of CI. Women were designated as having new CI diagnosed in the index pregnancy (based on cervical dilation and/or cervical shortening) and prior CI based on prior diagnosis of CI with prophylactic cerclage placed in the subsequent pregnancy. RESULTS: We identified 999 PCOS women, of whom 29 (2.9%) had CI. There were 18 patients with new CI and 11 with prior CI having prophylactic cerclage placement; four CI patients had twin gestation. In contrast, only five (0.5%) non-PCOS women had CI: two with new CI and three with prior CI. The proportion of newly diagnosed incident CI (1.8 versus 0.2%) or prevalent CI (2.9 versus 0.5%) was significantly greater for PCOS compared with non-PCOS pregnant women (both P < 0.01). Among PCOS women, CI prevalence was particularly high among South Asians (7.8%) and Blacks (17.5%) compared with Whites (1%) and significantly associated with gonadotropin use (including in vitro fertilization). Overall, the PCOS status was associated with an increased odds of prevalent CI pregnancy (adjusted odds ratio 4.8, 95% confidence interval 1.5-15.4), even after adjusting for maternal age, nulliparity, race/ethnicity, body mass index and fertility treatment. CONCLUSION: In this large and ethnically diverse PCOS cohort, we found that CI occurred with a higher than expected frequency in PCOS women, particularly among South Asian and Black women. PCOS women with CI were also more likely to have received gonadotropin therapy. Future studies should examine whether natural and hormone-altered PCOS is a risk factor for CI, the role of race/ethnicity, fertility drugs and consideration for heightened mid-trimester surveillance in higher risk subgroups of pregnant women with PCOS.

Authors: Feigenbaum SL; Crites Y; Hararah MK; Yamamoto MP; Yang J; Lo JC

Hum Reprod. 2012 Sep;27(9):2837-42. Epub 2012 Jun 14.

PubMed abstract

Non-initiation of adjuvant hormonal therapy in women with hormone receptor-positive breast cancer: The Breast Cancer Quality of Care Study (BQUAL)

Adjuvant hormonal therapy for non-metastatic hormone receptor (HR)-positive breast cancer decreases risk of breast cancer recurrence and increases survival. However, some women do not initiate this life-saving treatment. We used a prospective cohort design to investigate factors related to non-initiation of hormonal therapy among women with newly diagnosed, non-metastatic HR-positive breast cancer recruited from three U.S. sites. Serial interviews were conducted at baseline and during treatment to examine sociodemographic factors, tumor characteristics, and treatment decision-making factors. Multivariate modeling assessed associations between variables of interest and hormonal therapy initiation. Of 1,050 breast cancer patients recruited, 725 (69 %) had HR-positive breast cancer, of whom 87 (12.0 %) based on self-report and 122 (16.8 %) based on medical record/pharmacy fill rates did not initiate hormonal therapy. In a multivariable analysis, non-initiation of hormonal therapy, defined by medical record/pharmacy, was associated with having greater negative beliefs about efficacy of treatment (OR 1.42, 95 % CI 1.18-1.70). Non-initiation was less likely in those who found the quality of patient/physician communication to be higher (OR 0.96, 95 % CI 0.93-0.99), the hormonal therapy treatment decision an easy one to make (OR 0.45, 95 % CI 0.23-0.90) or neither easy nor difficult (OR 0.34, 95 % CI 0.20-0.58); and had more positive beliefs about hormonal therapy efficacy (OR 0.40, 95 % CI 0.34-0.62). Factors influencing non-initiation of adjuvant hormonal therapy are complex and influenced by patient beliefs regarding treatment efficacy and side effects. Educational interventions to women about the benefits of hormonal therapy may decrease negative beliefs and increase hormone therapy initiation.

Authors: Neugut AI; Kushi LH; Hershman DL; et al.

Breast Cancer Res Treat. 2012 Jul;134(1):419-28. Epub 2012 Apr 22.

PubMed abstract

Racial/Ethnic Disparities in the Prevalence of Gestational Diabetes by BMI

OBJECTIVE: To examine whether the association between gestational diabetes mellitus (GDM) and BMI category varies by racial/ethnic group. RESEARCH DESIGN AND METHODS: In a cohort of 123,040 women without recognized pregravid diabetes who delivered babies between 1995 and 2006 at Kaiser Permanente of Northern California, we examined racial/ethnic disparities in the prevalence of GDM by BMI category and the population-attributable risk (PAR) associated with overweight/obesity. RESULTS: Among all racial/ethnic groups, the age-adjusted prevalence of GDM increased with increasing BMI (kg/m(2)) category. However, Asian and Filipina women had a prevalence of GDM of 9.9 and 8.5%, respectively, at a BMI of 22.0-24.9 kg/m(2), whereas in Hispanic, non-Hispanic white, and African American women, the prevalence of GDM was >8.0% at a higher BMI, such as 28-30, 34-36, and >/=37 kg/m(2), respectively. The estimated PARs suggest that the percentage of GDM that could be prevented if all pregnant women were of normal weight (BMI <25.0 kg/m(2)) ranging from 65% for African American women to only 23% among Asian women. CONCLUSIONS: Clinicians should be aware that the BMI thresholds for increased risk of GDM varies by racial/ethnic group and that the risk is high even at relatively low BMI cutoffs in Asian and Filipina women. Asian women may benefit from different prevention strategies in addition to weight management.

Authors: Hedderson M; Ehrlich S; Sridhar S; Darbinian J; Moore S; Ferrara A

Diabetes Care. 2012 Jul;35(7):1492-8. Epub 2012 May 22.

PubMed abstract

Soy food intake after diagnosis of breast cancer and survival: an in-depth analysis of combined evidence from cohort studies of US and Chinese women

BACKGROUND: Soy isoflavones have antiestrogenic and anticancer properties but also possess estrogen-like properties, which has raised concern about soy food consumption among breast cancer survivors. OBJECTIVE: We prospectively evaluated the association between postdiagnosis soy food consumption and breast cancer outcomes among US and Chinese women by using data from the After Breast Cancer Pooling Project. DESIGN: The analysis included 9514 breast cancer survivors with a diagnosis of invasive breast cancer between 1991 and 2006 from 2 US cohorts and 1 Chinese cohort. Soy isoflavone intake (mg/d) was measured with validated food-frequency questionnaires. HRs and 95% CIs were estimated by using delayed-entry Cox regression models, adjusted for sociodemographic, clinical, and lifestyle factors. RESULTS: After a mean follow-up of 7.4 y, we identified 1171 total deaths (881 from breast cancer) and 1348 recurrences. Despite large differences in soy isoflavone intake by country, isoflavone consumption was inversely associated with recurrence among both US and Chinese women, regardless of whether data were analyzed separately by country or combined. No heterogeneity was observed. In the pooled analysis, consumption of >/=10 mg isoflavones/d was associated with a nonsignificant reduced risk of all-cause (HR: 0.87; 95% CI: 0.70, 1.10) and breast cancer-specific (HR: 0.83; 95% CI: 0.64, 1.07) mortality and a statistically significant reduced risk of recurrence (HR: 0.75; 95% CI: 0.61, 0.92). CONCLUSION: In this large study of combined data on US and Chinese women, postdiagnosis soy food consumption of >/=10 mg isoflavones/d was associated with a nonsignificant reduced risk of breast cancer-specific mortality and a statistically significant reduced risk of recurrence. One of the studies included in the After Breast Cancer Pooling Project, the Women’s Healthy Eating & Living Study, was registered at as NCT00003787.

Authors: Nechuta SJ; Caan BJ; Chen WY; Lu W; Chen Z; Kwan ML; Flatt SW; Zheng Y; Zheng W; Pierce JP; Shu XO

Am J Clin Nutr. 2012 Jul;96(1):123-32. Epub 2012 May 30.

PubMed abstract

Minority recruitment into clinical trials: experimental findings and practical implications

Racial and ethnic minorities in the US suffer disproportionately from obesity and related comorbidities, yet remain underrepresented in health research. To date, research on practical strategies to improve minority reach and recruitment into clinical trials is primarily descriptive rather than experimental. Within a randomized behavioral weight management trial for obese women, this recruitment experiment examined whether two characteristics of direct mail letters, an ethnically-targeted statement and personalization, increased the response rate among minority women. The ethnically-targeted statement noted ethnic-specific information about health risks of obesity. Personalized letters included recipients’ names/addresses in the salutation and a handwritten signature on high-quality letterhead. Of women sent direct mail letters (N=30,000), those sent letters with the ethnically-targeted statement were more likely to respond than women sent letters with the generic statement, 0.8% (n=121) vs. 0.6% (n=90) respectively, p=.03, a 34.4% increase. Women sent personalized letters were no more likely to respond than women sent non-personalized letters, p=.53. In the weight management trial itself, of 267 women randomized into the trial, 33.7% (n=90) were minorities. Of minority women randomized into the trial, 68.9% (n=62) were recruited by direct mail letters: 75.8% (n=47) of those were sent a letter and 24.2% (n=15) were referred by friends/family who were sent a letter. The results indicate that a simple modification to a standard recruitment letter can have a meaningful impact on minority reach and recruitment rates. Practical implications include using ethnically-targeted, non-personalized direct mail letters and recruiting through friends/family at no additional cost.

Authors: Brown SD; Lee K; Schoffman DE; King AC; Crawley LM; Kiernan M

Contemp Clin Trials. 2012 Jul;33(4):620-3. Epub 2012 Mar 16.

PubMed abstract

Racial and ethnic differences in the prevalence of placenta previa

OBJECTIVE: The objective of this study is to determine the prevalence of placenta previa among different racial and ethnic groups. STUDY DESIGN: We conducted a retrospective cohort study to examine the prevalence of placenta previa among five major racial and ethnic groups: African American, Asian, Caucasian, Hispanic and Native American. We included all deliveries >/= 20 weeks gestation from a large northern Californian Health Maintenance Organization from 1995-2006. A multivariable logistic regression model was used to control for potential confounders. RESULT: Of the 394 083 deliveries in our cohort, 1580 (0.40%) were complicated by placenta previa. The prevalence of placenta previa was: Asian 0.64%, Native American 0.60%, African American 0.44%, Caucasian 0.36%, Hispanic 0.34% and unknown 0.31% (P<0.001). In our multivariable logistic regression model, only Asians (odds ratio (OR) 1.73, 95% confidence intervals (CI) 1.53-1.95) and African Americans (OR 1.43, 95% CI 1.19-1.72) were at increased risk for having placenta previa, compared with Caucasians. CONCLUSION: Asian women have the highest prevalence of placenta previa.

Authors: Kim LH; Caughey AB; Laguardia JC; Escobar GJ

J Perinatol. 2012 Apr;32(4):260-4. Epub 2011 Jun 30.

PubMed abstract

Pathophysiologic differences among asians, native hawaiians, and other pacific islanders and treatment implications

Authors: Hsu WC; Karter A; Arakaki R; et al.

Diabetes Care. 2012 May;35(5):1189-98.

PubMed abstract

Ethnic Differences in Appointment-Keeping and Implications for the Patient-Centered Medical Home-Findings from the Diabetes Study of Northern California (DISTANCE)

OBJECTIVE: To examine ethnic differences in appointment-keeping in a managed care setting. DATA SOURCES/STUDY SETTING: Kaiser Permanente Diabetes Study of Northern California (DISTANCE), 2005-2007, n = 12,957. STUDY DESIGN: Cohort study. Poor appointment-keeping (PAK) was defined as missing >1/3 of planned, primary care appointments. Poisson regression models were used to estimate ethnic-specific relative risks of PAK (adjusting for demographic, socio-economic, health status, and facility effects). DATA COLLECTION/EXTRACTION METHODS: Administrative/electronic health records and survey responses. PRINCIPAL FINDINGS: Poor appointment-keeping rates differed >2-fold across ethnicities: Latinos (12 percent), African Americans (10 percent), Filipinos (7 percent), Caucasians (6 percent), and Asians (5 percent), but also varied by medical center. Receiving >50 percent of outpatient care via same-day appointments was associated with a 4-fold greater PAK rate. PAK was associated with 20, 30, and 40 percent increased risk of elevated HbA1c (>7 percent), low-density lipoprotein (>100 mm/dl), and systolic blood pressure (>130 mmHg), respectively. CONCLUSIONS: Latinos and African Americans were at highest risk of missing planned primary care appointments. PAK was associated with a greater reliance on same-day visits and substantively poorer clinical outcomes. These results have important implications for public health and health plan policy, as primary care rapidly expands toward open access to care supported by the patient-centered medical home model.

Authors: Parker MM; Moffet HH; Schillinger D; Adler N; Fernandez A; Ciechanowski P; Karter AJ

Health Serv Res. 2012 Apr;47(2):572-93. Epub 2011 Oct 27.

PubMed abstract

The Relationship Between Neighborhood Characteristics and Recruitment into Adolescent Family-Based Substance Use Prevention Programs

Youth in disadvantaged neighborhoods are at risk for poor health outcomes. Characteristics of these neighborhoods may translate into intensified risk due to barriers utilizing preventive care such as substance use prevention programs. While family-level risks affect recruitment into prevention programs; few studies have addressed the influence of neighborhood risks. This study consists of 744 families with an 11- to 12-year-old child recruited for a family-based substance use prevention program. Using US Census data; logistic regressions showed neighborhoods were related to recruitment; beyond individual characteristics. Greater neighborhood unemployment was related to decreased agreement to participate in the study and lower rates of high school graduation were related to lower levels of actual enrolment. Conversely; higher rates of single-female-headed households were related to increased agreement. Recruitment procedures may need to recognize the variety of barriers and enabling forces within the neighborhood in developing different strategies for the recruitment of youth and their families.

Authors: Byrnes HF; Miller BA; Aalborg AE; Keagy CD

J Behav Health Serv Res. 2012 Apr;39(2):174-89.

PubMed abstract

Place matters: Neighborhood deprivation and cardiometabolic risk factors in the Diabetes Study of Northern California (DISTANCE)

While neighborhood deprivation is associated with prevalence of chronic diseases, it is not well understood whether neighborhood deprivation is also associated with cardiometabolic risk factors among adults with chronic disease. Subjects (n = 19,804) from the Diabetes Study of Northern California (DISTANCE) cohort study, an ethnically-stratified, random sample of members of Kaiser Permanente Northern California (KPNC), an integrated managed care consortium, with type 2 diabetes who completed a survey between 2005 and 2007 and who lived in a 19 county study area were included in the analyses. We estimated the association between a validated neighborhood deprivation index (NDI) and four cardiometabolic risk factors: body mass index (BMI = kg/m(2)), glycosylated hemoglobin (A1c), low density lipoproteins (LDL) and systolic blood pressure (SBP) using multi-level models. Outcomes were modeled in their continuous form and as binary indicators of poor control (severe obesity: BMI >/=35, poor glycemic control: A1c >/=9%, hypercholesterolemia: LDL >/=130 mg/dL, and hypertension: SBP >/=140 mmHg). BMI, A1c and SBP increased monotonically across quartiles of NDI (p < 0.001 in each case); however, LDL was significantly associated with NDI only when comparing the most to the least deprived quartile. NDI remained significantly associated with BMI and A1c after adjusting for individual level factors including income and education. A linear trend (p < 0.001) was observed in the relative risk ratios for dichotomous indicators of severe obesity, poor glycemic control, and 2 or more poorly controlled cardiometabolic risk factors across NDI quartile. In adjusted models, higher levels of neighborhood deprivation were positively associated with indicators of cardiometabolic risk among adults with diabetes, suggesting that neighborhood level deprivation may influence individual outcomes. However, longitudinal data are needed to test the causal direction of these relationships.

Authors: Laraia BA; Karter AJ; Warton EM; Schillinger D; Moffet HH; Adler N

Soc Sci Med. 2012 Apr;74(7):1082-90. Epub 2012 Jan 28.

PubMed abstract

Genetic variants and environmental factors associated with hormonal markers of ovarian reserve in Caucasian and African American women

BACKGROUND: The ovarian reserve (number and quality of oocytes) is correlated with reproductive potential as well as somatic health, and is likely to have multiple genetic and environmental determinants. Several reproductive hormones are closely linked with the oocyte pool and thus can serve as surrogate markers of ovarian reserve. However, we know little about the underlying genes or genetic variants. METHODS: We analyzed genetic variants across the genome associated with two hormonal markers of ovarian reserve, FSH and anti-Mullerian hormone, in a reproductively normal population of Caucasian (n = 232) and African American (n = 200) women, aged 25-45 years. We also examined the effects of environmental or lifestyle factors on ovarian reserve phenotypes. RESULTS: We identified one variant approaching genome-wide significance (rs6543833; P= 8.07 x 10(-)(8)) and several nominal variants nearby and within the myeloid-associated differentiation marker-like (MYADML) gene, that were associated with FSH levels in African American women; these were validated in Caucasian women. We also discovered effects of smoking and oral contraceptive use on ovarian reserve phenotypes, with alterations in several reproductive hormones. CONCLUSIONS: This work is the largest study on ovarian reserve in women of reproductive age and is the only genome-wide study on ovarian reserve markers. The genes containing or near the identified variants have no known roles in ovarian biology and represent interesting candidate genes for future investigations. The discovery of genetic markers may lead to better long-range predictions of declining ovarian function, with implications for reproductive and somatic health.

Authors: Schuh-Huerta SM; Johnson NA; Rosen MP; Sternfeld B; Cedars MI; Reijo Pera RA

Hum Reprod. 2012 Feb;27(2):594-608. Epub 2011 Nov 24.

PubMed abstract

Formal and informal substance use treatment utilization and alcohol abstinence over seven years: Is the relationship different for blacks and whites?

BACKGROUND: This study examines whether the effects of formal substance use treatment utilization and Alcoholics Anonymous (AA) on 30-day abstinence vary for black versus white Americans. METHODS: The current analysis utilizes data from a longitudinal sample of 1013 black and white, dependent and problem drinkers across a 7-year period. Participants were identified through a probability survey in the general population and consecutive intakes in chemical dependency treatment programs in a California County. Generalized Estimating Equations assessing interactions between race and treatment utilization incorporated variables from four post-baseline interviews, controlling for baseline variables. RESULTS: Formal treatment utilization was associated with 30-day abstinence (OR:1.6, 95%CI: 1.3, 2.1), yet this relationship did not differ for blacks and whites. In contrast, there was a significant interaction between AA utilization, race and 30-day abstinence. While both whites and blacks who attended AA were more likely to report 30-day abstinence compared to their non-AA attending counterparts (white OR:4.0, 95%CI: 3.2-5.1 and black OR:2.2, 95%CI: 1.5-3.2), the relationship was stronger for whites. Among those who did not attend AA, blacks were more likely than whites to be abstinent. Post hoc analyses suggest that these latter findings may be related to greater religiosity and ‘drier’ social networks among black Americans. CONCLUSIONS: While utilization of formal treatment may yield similar benefits for blacks and whites, AA utilization may be more important for maintaining abstinence among whites than blacks. Future research should investigate racial differences in social network drinking patterns and religious reinforcement of sobriety, and the role these may play in AA outcomes.

Authors: Avalos LA; Mulia N

Drug Alcohol Depend. 2012 Feb 1;121(1-2):73-80. Epub 2011 Sep 21.

PubMed abstract

Telomerase, telomere length, and coronary artery calcium in black and white men in the CARDIA study

OBJECTIVE: To evaluate whether telomerase activity, measured in circulating blood leukocytes, might be associated with prevalent atherosclerosis, or predict future coronary artery disease risk. METHODS AND RESULTS: We examined associations of telomerase activity levels measured at year 15 in the Coronary Artery Risk Development in Young Adults (CARDIA) Study with prevalent coronary artery calcium (CAC), progressive CAC at year 20, and incident CAC between years 15 and 20, in 440 black and white men aged 33-45 years. Telomere length was also measured in a subset of participants (N=129). In age-adjusted analyses, higher telomerase activity levels were associated with black race/ethnicity, lower socioeconomic status, higher C-reactive protein levels, and smoking. In multivariate-adjusted analysis, higher quartiles of telomerase were cross-sectionally associated with greater odds of prevalent CAC at year 15 (quartile 2: OR=1.32, 95% CI: 0.54-3.23; quartile 3: OR=1.40, 95% CI: 0.60-3.30; quartile 4: OR=3.27, 95% CI: 1.39-7.71 compared with quartile 1, p-continuous=0.012) and progressive CAC at year 20, but telomerase was not significantly associated with incidence of newly detectable CAC. Higher telomerase activity levels predicted greater CAC progression at year 20 among persons with short telomere length; low telomerase and short TL predicted less CAC progression. CONCLUSION: Telomerase activity in leukocytes was associated with calcified atherosclerotic plaque, and was also a predictor of advancing plaque among persons with short telomeres.

Authors: Kroenke CH; Pletcher MJ; Lin J; Blackburn E; Adler N; Matthews K; Epel E

Atherosclerosis. 2012 Feb;220(2):506-12. Epub 2011 Nov 9.

PubMed abstract

Evaluating Racial/Ethnic Disparities in Lower Urinary Tract Symptoms in Men

PURPOSE: We examined whether there are racial/ethnic disparities in lower urinary tract symptoms in men. MATERIALS AND METHODS: Racial/ethnic disparities were examined using the American Urological Association symptom index in 2 large cohorts, including the California Men’s Health Study and the Research Program in Genes, Environment and Health. Prevalence and incidence were calculated in each age and race/ethnicity strata. Multivariate analysis was done to assess the association between race/ethnicity and lower urinary tract symptoms. RESULTS: The lower urinary tract symptom prevalence increased with age in each racial/ethnic category (p <0.05). The mean +/- SD age adjusted American Urological Association symptom index score for black, Hispanic, other/mixed, nonHispanic white and Asian men was 9.57 +/- 5.83, 9.35 +/- 6.30, 9.32 +/- 6.22, 8.99 +/- 5.89 and 8.41 +/- 5.59, respectively. In multivariate models Hispanic and black men were at increased risk for moderate lower urinary tract symptoms than white men while only Hispanic men were at higher risk for severe lower urinary tract symptoms. Asian men were at lower risk for moderate or severe lower urinary tract symptoms than white men. The incident rate of lower urinary tract symptoms increased with increasing baseline age for almost all racial/ethnic groups (range 32% to 56%). Asian and Hispanic men were at lower risk for incident lower urinary tract symptoms than white men even after adjusting for sociodemographic factors, health related behaviors and comorbidity. CONCLUSIONS: Racial/ethnic disparities in lower urinary tract symptoms persist after accounting for putative and established risk factors.

Authors: Van Den Eeden SK; Shan J; Jacobsen SJ; Aaronsen D; Haque R; Quinn VP; Quesenberry CP Jr; Urologic Diseases in America Project

J Urol. 2012 Jan;187(1):185-9. Epub 2011 Nov 17.

PubMed abstract

​Dermatologic care in the homeless and underserved populations: observations from the Venice Family Clinic

​Dermatologic care in the homeless and impoverished urban underserved populations is rarely described despite the wide prevalence of skin concerns in this population. Because the homeless population may be subject to increased sun exposure compared to the nonhomeless population, they also may be at increased risk for skin cancer. We sought to describe the spectrum of dermatologic diseases seen in a free clinic in Venice, California–the Venice Family Clinic (VFC)–as well as the differences in diagnoses between the homeless and nonhomeless patients seen at this clinic. A retrospective chart review was performed of dermatology patients (N = 82) seen at VFC throughout the 2006 calendar year. The homeless population (n = 22) was found to have more diagnoses of malignant/premalignant growths (25% [16/64] of all homeless diagnoses) compared to their nonhomeless (n = 60) counterparts (6.1% [8/132] of all nonhomeless diagnoses; P < .0001). This difference was sustained when ethnicity was controlled, with 29.6% [16/54] of diagnoses in the homeless white group consisting of malignant/ premalignant growths compared to 8.9% [4/45] of diagnoses in the nonhomeless white cohort (P < .005). Homeless patients may have a higher incidence of skin cancers and precancerous skin lesions due to increased sun exposure and/or limited access to dermatologic care.

Authors: Grossberg AL; Carranza D, Lamp; K, Chiu MW; Lee C; Craft N

​Cutis. 2012 Jan;89(1):25-32.

PubMed abstract

Closing the gap: eliminating health care disparities among Latinos with diabetes using health information technology tools and patient navigators

Latinos have higher rates of diabetes and diabetes-related complications compared to non-Latinos. Clinical diabetes self-management tools that rely on innovative health information technology (HIT) may not be widely used by Latinos, particularly those that have low literacy or numeracy, low income, and/or limited English proficiency. Prior work has shown that tailored diabetes self-management educational interventions are feasible and effective in improving diabetes knowledge and physiological measures among Latinos, especially those interventions that utilize tailored coaching and navigator programs. In this article, we discuss the role of HIT for diabetes management in Latinos and describe a novel ‘eNavigator’ role that we are developing to increase HIT adoption and thereby reduce health care disparities.

Authors: Lopez L; Grant RW

J Diabetes Sci Technol. 2012 Jan 1;6(1):169-76.

PubMed abstract

A genome-wide association search for type 2 diabetes genes in african americans

African Americans are disproportionately affected by type 2 diabetes (T2DM) yet few studies have examined T2DM using genome-wide association approaches in this ethnicity. The aim of this study was to identify genes associated with T2DM in the African American population. We performed a Genome Wide Association Study (GWAS) using the Affymetrix 6.0 array in 965 African-American cases with T2DM and end-stage renal disease (T2DM-ESRD) and 1029 population-based controls. The most significant SNPs (n = 550 independent loci) were genotyped in a replication cohort and 122 SNPs (n = 98 independent loci) were further tested through genotyping three additional validation cohorts followed by meta-analysis in all five cohorts totaling 3,132 cases and 3,317 controls. Twelve SNPs had evidence of association in the GWAS (P<0.0071), were directionally consistent in the Replication cohort and were associated with T2DM in subjects without nephropathy (P<0.05). Meta-analysis in all cases and controls revealed a single SNP reaching genome-wide significance (P<2.5x10(-8)). SNP rs7560163 (P = 7.0x10(-9), OR (95% CI) = 0.75 (0.67-0.84)) is located intergenically between RND3 and RBM43. Four additional loci (rs7542900, rs4659485, rs2722769 and rs7107217) were associated with T2DM (P<0.05) and reached more nominal levels of significance (P<2.5x10(-5)) in the overall analysis and may represent novel loci that contribute to T2DM. We have identified novel T2DM-susceptibility variants in the African-American population. Notably, T2DM risk was associated with the major allele and implies an interesting genetic architecture in this population. These results suggest that multiple loci underlie T2DM susceptibility in the African-American population and that these loci are distinct from those identified in other ethnic populations.

Authors: Palmer ND; Ferrara A; Bowden DW; et al.

PLoS One. 2012;7(1):e29202. Epub 2012 Jan 4.

PubMed abstract

Central Obesity, Leptin and Cognitive Decline: The Sacramento Area Latino Study on Aging

BACKGROUND/AIMS: Central obesity is a risk factor for cognitive decline. Leptin is secreted by adipose tissue and has been associated with better cognitive function. Aging Mexican Americans have higher levels of obesity than non-Hispanic Whites, but no investigations examined the relationship between leptin and cognitive decline among them or the role of central obesity in this association. METHODS: We analyzed 1,480 dementia-free older Mexican Americans who were followed over 10 years. Cognitive function was assessed every 12-15 months with the Modified Mini Mental State Exam (3MSE) and the Spanish and English Verbal Learning Test (SEVLT). RESULTS: For females with a small waist circumference (

Authors: Zeki Al Hazzouri A; Haan MN; Whitmer RA; Yaffe K; Neuhaus J

Dement Geriatr Cogn Disord. 2012;33(6):400-9. Epub 2012 Jul 17.

PubMed abstract

OBAYA (obesity and adverse health outcomes in young adults): feasibility of a population-based multiethnic cohort study using electronic medical records

ABSTRACT: BACKGROUND: Although obesity is a risk factor for many chronic diseases, we have only limited knowledge of the magnitude of these associations in young adults. A multiethnic cohort of young adults was established to close current knowledge gaps; cohort demographics, cohort retention, and the potential influence of migration bias were investigated. METHODS: For this population-based cross-sectional study, demographics, and measured weight and height were extracted from electronic medical records of 1,929,470 patients aged 20 to 39 years enrolled in two integrated health plans in California from 2007 to 2009. RESULTS: The cohort included about 84.4% of Kaiser Permanente California members in this age group who had a medical encounter during the study period and represented about 18.2% of the underlying population in the same age group in California. The age distribution of the cohort was relatively comparable to the underlying population in California Census 2010 population, but the proportion of women and ethnic/racial minorities was slightly higher. The three-year retention rate was 68.4%. CONCLUSION: These data suggest the feasibility of our study for medium-term follow-up based on sufficient membership retention rates. While nationwide 6% of young adults are extremely obese, we know little to adequately quantify the health burden attributable to obesity, especially extreme obesity, in this age group. This cohort of young adults provides a unique opportunity to investigate associations of obesity-related factors and risk of cancer in a large multiethnic population.

Authors: Koebnick C; Smith N; Huang K; Martinez MP; Clancy HA; Williams AE; Kushi LH

Popul Health Metr. 2012 Aug 21;10(1):15.

PubMed abstract

A comparison of lifestyle and behavioral cardiovascular disease risk factors between Asian Indian and White non-Hispanic men

OBJECTIVE: We compared lifestyle CVD risk factors between Asian Indian and White non-Hispanic men within categories of BMI. DESIGN/SETTING/PARTICIPANTS: Participants included 51,901 White non-Hispanic men and 602 Asian Indian men enrolled in the California Men’s Health Study cohort. Men were aged 45-69 years and members of Kaiser Permanente Southern or Northern California at baseline (2001-2002). MAIN OUTCOME MEASURES: Lifestyle characteristics including diet, physical activity, alcohol intake and smoking were collected from a survey. Multivariable logistic regression, adjusting for demographics, was performed. RESULTS: Asian Indians more often reported a healthy BMI (18.5-24.9), and consumed < 30% calories from fat within each BMI category (healthy weight and overweight/obese). Among healthy weight men, Asian Indians were less likely to eat -5 fruit and vegetables a day. Overall, Asian Indians were more likely to have never smoked and to abstain from alcohol. Asian Indians were less likely to report moderate/vigorous physical activity > or = 3.5 hours/week. No differences were found in sedentary activity. CONCLUSIONS: We identified health behaviors that were protective (lower fat intake, lower levels of smoking and alcohol) and harmful (lower levels of physical activity and fruit and vegetable intake) for cardiovascular health among the Asian Indians in comparison to White non-Hispanics. Results stratified by BMI were similar to those overall. However, the likelihood of consuming a low fat diet was lower among healthy weight men, while fruit and vegetable consumption, physical activity and alcohol intake was greater. These results suggest risk factors other than lifestyle behaviors may be important contributors to CVD in the Asian Indian population.

Authors: Ghai NR; Jacobsen SJ; Ahmed AT; Haque R; Rhoads GG; Quinn VP; Van den Eeden SK

Ethn Dis. 2012 Spring;22(2):168-74.

PubMed abstract

Racial/ethnic differences in initiation of adjuvant hormonal therapy among women with hormone receptor-positive breast cancer

Mortality after breast cancer diagnosis is known to vary by race/ethnicity even after adjustment for differences in tumor characteristics. As adjuvant hormonal therapy decreases risk of recurrence and increases overall survival among women with hormone receptor-positive tumors, treatment disparities may play a role. We explored racial/ethnic differences in initiation of adjuvant hormonal therapy, defined as two or more prescriptions for tamoxifen or aromatase inhibitor filled within the first year after diagnosis of hormone receptor-positive localized or regional-stage breast cancer. The sample included women diagnosed with breast cancer enrolled in Kaiser Permanente Northern California (KPNC). Odds ratios [OR] and 95% confidence intervals [CI] compared initiation by race/ethnicity (Hispanic, African American, Chinese, Japanese, Filipino, and South Asian vs. non-Hispanic White [NHW]) using logistic regression. Covariates included age and year of diagnosis, area-level socioeconomic status, co-morbidities, tumor stage, histology, grade, breast cancer surgery, radiation and chemotherapy use. Our sample included 13,753 women aged 20-79 years, diagnosed between 1996 and 2007, and 70% initiated adjuvant hormonal therapy. In multivariable analysis, Hispanic and Chinese women were less likely than NHW women to initiate adjuvant hormonal therapy ([OR] = 0.82; [CI] 0.71-0.96 and [OR] = 0.78; [CI] 0.63-0.98, respectively). Within an equal access, insured population, lower levels of initiation of adjuvant hormonal therapy were found for Hispanic and Chinese women. Findings need to be confirmed in other insured populations and the reasons for under-initiation among these groups need to be explored.

Authors: Livaudais JC; Hershman DL; Habel L; Kushi L; Gomez SL; Li CI; Neugut AI; Fehrenbacher L; Thompson B; Coronado GD

Breast Cancer Res Treat. 2012 Jan;131(2):607-17. Epub 2011 Sep 16.

PubMed abstract

Provider factors and patient-reported healthcare discrimination in the Diabetes Study of California (DISTANCE)

OBJECTIVE: We examined provider-level factors and reported discrimination in the healthcare setting. METHODS: With data from the Diabetes Study of Northern California (DISTANCE) – a race-stratified survey of diabetes patients in Kaiser Permanente Northern California – we analyzed patient-reported racial/ethnic discrimination from providers. Primary exposures were characteristics of the primary care provider (PCP, who coordinates care in this system), including specialty/type, and patient-provider relationship variables, including racial concordance. RESULTS: Subjects (n=12,151) included 20% black, 20% Latino, 23% Asian, 30% white, and 6% other patients, with 2-8% reporting discrimination by racial/ethnic group. Patients seeing nurse practitioners as their PCP (OR=0.09; 95% CI: 0.01-0.67) and those rating their provider higher on communication (OR=0.70; 95% CI: 0.66-0.74) were less likely to report discrimination, while those with more visits (OR=1.10; 95% CI: 1.03-1.18) were more likely to report discrimination. Racial concordance was not significant once adjusting for patient race/ethnicity. CONCLUSIONS: Among diverse diabetes patients in managed care, provider type and communication were significantly related to patient-reported discrimination. PRACTICE IMPLICATIONS: Given potential negative impacts on patient satisfaction and treatment decisions, future studies should investigate which interpersonal aspects of the provider-patient relationship reduce patient perceptions of unfair treatment.

Authors: Lyles CR; Karter AJ; Young BA; Spigner C; Grembowski D; Schillinger D; Adler N

Patient Educ Couns. 2011 Dec;85(3):e216-24. Epub 2011 May 24.

PubMed abstract

A case-control study of asphalt and tar exposure and lung cancer in minorities

OBJECTIVES: Considerable controversy surrounds the carcinogenic potential of asphalt and tar. Since minority individuals may have had relatively high historical exposures, we investigated asphalt and tar exposure and lung cancer risk among African Americans and Latino Americans. METHODS: We conducted a case-control study of lung cancer among African Americans and Latino Americans in the San Francisco Bay area (422 cases, 894 controls). A questionnaire was used to obtain detailed work histories and exposure information. Self-reported exposure to asphalt and tar as well as other factors (e.g., smoking, automobile exhaust, and asbestos) were evaluated as predictors of lung cancer risk. Potential effect modification by cytochrome P450 (CYP) 1A1 was also explored. RESULTS: Self-reported duration of exposure to asphalt and tar was associated with a statistically significant excess risk of lung cancer in the overall population (OR: 1.11, 95% CI: 1.01-1.22), evaluating risk per year of exposure. Years of exposure to automobile exhaust (OR: 1.02, 95% CI: 1.00-1.05) and asbestos (OR: 1.04, 95% CI: 1.02-1.06) were also associated with statistically significant elevations in risk. In Latino Americans, the lung cancer risks associated with polycyclic aromatic hydrocarbon-related exposures were consistently higher in the CYP1A1 wild-type subjects as compared to the variant genotype subjects, and the interaction was statistically significant for smoking and the CYP1A1 M2 polymorphism (P-value(interaction) = 0.02). CONCLUSIONS: These data are consistent with the literature suggesting that exposure to asphalt and tar may increase risk of lung cancer. However, it was not possible to separate the effects and asphalt and tar in this study. Am. J. Ind. Med. (c) 2011 Wiley-Liss, Inc.

Authors: McClean MD; Kelsey KT; Sison JD; Quesenberry CP Jr; Wrensch MR; Wiencke JK

Am J Ind Med. 2011 Nov;54(11):811-8. Epub 2011 Aug 31.

PubMed abstract

Ethnic differences in the development of albuminuria: the DISTANCE study

Objectives: To determine whether ethnic differences in the incidence of albuminuria are present in patients with diabetes, and to identify social, behavioral, and provider factors that explain ethnic differences. Study Design: Survey follow-up design with a race-stratified baseline survey (2005-2006) in diabetic patients from a nonprofit, fully integrated healthcare system in Northern California. We followed the 10,596 respondents (30% whites, 20% blacks, 23% Hispanics, 14% Asians, and 13% Filipinos) without evidence of prevalent albuminuria at baseline. Methods: Incident albuminuria was defined by positive dipstick urinalysis (>1) or urine albumin to creatinine level (>30 mg/g), and confirmed with repeat testing at least 3 months later. Results: The 27,292 person-years of observation yielded 981 incident albuminuria events. Agestandardized rates of albuminuria (per 1000 person-years) ranged from 13.6 (95% confidence interval [CI] 10.5-17.0) in whites to 27.8 (CI 18.2- 38.3) in blacks. In fully adjusted Cox models, the hazard ratio for blacks (1.22, 95% CI 1.09-1.38), Asians (1.35, 95% CI 1.13-1.61), and Filipinos (1.93, 95% CI 1.61-2.32), but not Hispanics, was significantly greater than it was for whites. In some cases, point estimates changed markedly from the base model when fully adjusted for potential confounders. Moreover, adjustment for an array of potentially mediating factors explained only a small proportion of the observed ethnic disparities. Conclusions: Despite uniform medical care coverage, Filipinos, blacks, and Asians with diabetes developed albuminuria at higher rates than white and Hispanic adults.

Authors: Choi AI; Karter AJ; Liu JY; Young BA; Go AS; Schillinger D

Am J Manag Care. 2011 Nov;17(11):737-45.

PubMed abstract

Genetic variants in novel pathways influence blood pressure and cardiovascular disease risk

Blood pressure is a heritable trait influenced by several biological pathways and responsive to environmental stimuli. Over one billion people worldwide have hypertension (>/=140 mm Hg systolic blood pressure or >/=90 mm Hg diastolic blood pressure). Even small increments in blood pressure are associated with an increased risk of cardiovascular events. This genome-wide association study of systolic and diastolic blood pressure; which used a multi-stage design in 200;000 individuals of European descent; identified sixteen novel loci: six of these loci contain genes previously known or suspected to regulate blood pressure (GUCY1A3-GUCY1B3; NPR3-C5orf23; ADM; FURIN-FES; GOSR2; GNAS-EDN3); the other ten provide new clues to blood pressure physiology. A genetic risk score based on 29 genome-wide significant variants was associated with hypertension; left ventricular wall thickness; stroke and coronary artery disease; but not kidney disease or kidney function. We also observed associations with blood pressure in East Asian; South Asian and African ancestry individuals. Our findings provide new insights into the genetics and biology of blood pressure; and suggest potential novel therapeutic pathways for cardiovascular disease prevention.

Authors: International Consortium for Blood Pressure Genome-Wide Association Studies; Galan P; Guarrera S; Rice KM; Bergman R; et al.

Nature. 2011 Sep 11;478(7367):103-9.

PubMed abstract

Patient-Reported Racial/Ethnic Healthcare Provider Discrimination and Medication Intensification in the Diabetes Study of Northern California (DISTANCE)

BACKGROUND: Racial/ethnic minority patients are more likely to report experiences with discrimination in the healthcare setting, potentially leading to reduced access to appropriate care; however, few studies evaluate reports of discrimination with objectively measured quality of care indicators. OBJECTIVE: To evaluate whether patient-reported racial/ethnic discrimination by healthcare providers was associated with evidence of poorer quality care measured by medication intensification. RESEARCH DESIGN AND PARTICIPANTS: Baseline data from the Diabetes Study of Northern California (DISTANCE), a random, race-stratified sample from the Kaiser Permanente Diabetes Registry from 2005-2006, including both survey and medical record data. MAIN MEASURES: Self-reported healthcare provider discrimination (from survey data) and medication intensification (from electronic prescription records) for poorly controlled diabetes patients (A1c >/=9.0%; systolic BP >/=140 mmHg or diastolic BP >/=90 mmHg; low-density lipoprotein (LDL) >/=130 mg/dl). KEY RESULTS: Of 10,409 eligible patients, 21% had hyperglycemia, 14% had hyperlipidemia, and 32% had hypertension. Of those with hyperglycemia, 59% had their medications intensified, along with 40% with hyperlipidemia, 33% with hypertension, and 47% in poor control of any risk factor. In adjusted log-binomial GEE models, discrimination was not associated with medication intensification [RR = 0.96 (95% CI: 0.74, 1.24) for hyperglycemia, RR = 1.23 (95% CI: 0.93, 1.63) for hyperlipidemia, RR = 1.06 (95% CI: 0.69, 1.61) for hypertension, and RR = 1.08 (95% CI: 0.88, 1.33) for the composite cohort]. CONCLUSIONS: We found no evidence that patient-reported healthcare discrimination was associated with less medication intensification. While not associated with this technical aspect of care, discrimination could still be associated with other aspects of care (e.g., patient-centeredness, communication).

Authors: Lyles CR; Karter AJ; Young BA; Spigner C; Grembowski D; Schillinger D; Adler N

J Gen Intern Med. 2011 Oct;26(10):1138-44. Epub 2011 May 6.

PubMed abstract

Gender differences in quality of life among long-term colorectal cancer survivors with ostomies

PURPOSE/OBJECTIVES: To describe how gender shapes the concerns and adaptations of long-term (i.e., more than five years) colorectal cancer survivors with ostomies. DESIGN: Qualitative study using content analysis of focus group content. SETTING: Oregon, southwestern Washington, and northern California. SAMPLE: Four female and four male focus groups (N = 33) selected from 282 quantitative survey participants with health-related quality-of-life (HRQOL) scores in the highest or lowest quartile. METHODS: Eight focus groups discussed the challenges of living with an ostomy. Content was recorded, transcribed, and analyzed using directive and summative content analysis. MAIN RESEARCH VARIABLES: HRQOL domains of physical, psychological, social, and spiritual well-being. FINDINGS: All groups reported avoiding foods that cause gas or rapid transit and discussed how limiting the amount of food eaten controlled the output. All groups discussed physical activities, getting support from friends and family, and the importance of being resilient. Both genders identified challenges with sexuality and intimacy. Coping and adjustment difficulties mostly were discussed by women, with men only discussing these issues to a small extent. Difficulties with sleep primarily were identified by women with low HRQOL. Problems with body image and depression were discussed only by women with low HRQOL. CONCLUSIONS: Common issues included diet management, physical activity, social support, and sexuality. Although both genders identified challenges, women described more specific psychological and social issues than men. IMPLICATIONS FOR NURSING: Application of these gender-based differences can inform educational interventions for colorectal cancer survivors with ostomies.

Authors: Grant M; McMullen CK; Altschuler A; Mohler MJ; Hornbrook MC; Herrinton LJ; Wendel CS; Baldwin CM; Krouse RS

Oncol Nurs Forum. 2011 Sep;38(5):587-96.

PubMed abstract

Epidemiology of peripartum cardiomyopathy: incidence, predictors, and outcomes

OBJECTIVES: To estimate the incidence, describe the mortality, and identify independent predictors of peripartum cardiomyopathy, a very serious cardiovascular complication of pregnancy associated with maternal morbidity and mortality among otherwise healthy women without prior heart disease. METHODS: We identified all cases of diagnosed heart failure that occurred among women within 1 month before to 5 months after delivery of a liveborn neonate in Kaiser Permanente Northern California delivery hospitals between 1995 and 2004. Incident peripartum cardiomyopathy was confirmed from medical records documenting dilated cardiomyopathy with reduced left ventricular systolic function after excluding women with prior heart failure or valvular disease. Data sources included medical records, electronic clinical databases, and state birth and death files. RESULTS: Among 227,224 eligible women, we confirmed 110 recognized peripartum cardiomyopathy cases (incidence: 4.84 per 10,000 live births, 95% confidence interval 3.98-5.83). Independent predictors included maternal age of 25 years or older, non-Hispanic African American and Filipino groups, parity of 4 or greater, multiple gestation, severe anemia, pre-existing and pregnancy-related hypertensive disorders, and hemolysis, elevated liver enzymes, low platelets syndrome. Maternal death rate (per 1,000 person-years) was higher among cases (6.12) than noncases (0.23; P<.001). Neonates whose mothers developed peripartum cardiomyopathy experienced poorer clinical outcomes. CONCLUSION: Within a large, diverse northern California population, 1 of every 2,066 women delivering a liveborn neonate had recognized, confirmed peripartum cardiomyopathy, which was associated with higher maternal and neonatal death rates and worse neonatal outcomes. Several readily available patient characteristics can be used to identify women at risk for this severe pregnancy complication. LEVEL OF EVIDENCE: II.

Authors: Gunderson EP; Croen LA; Chiang V; Yoshida CK; Walton D; Go AS

Obstet Gynecol. 2011 Sep;118(3):583-91.

PubMed abstract

Ethnicity and risk of hospitalization for asthma and chronic obstructive pulmonary disease

PURPOSE: To identify ethnic differences for risk of hospitalization for asthma and chronic obstructive pulmonary disease (COPD). METHODS: We undertook a cohort study with 126,019 participants: 55% whites, 27% blacks, 11% Asians, and 4% Hispanics. To estimate asthma and COPD risk, we used Cox proportional hazards models adjusted for age, sex, body mass index, education, smoking, and alcohol intake. End points were hospitalizations for asthma or COPD. RESULTS: Compared with whites, relative risks (RR) with 95% confidence intervals (95% CI) for asthma among other groups were: blacks, 1.7 (1.4-2.0); Hispanics, 0.9 (0.6-1.4); and Asians, 1.6 (1.2-2.1). Among Asians, increased risk was concentrated in Filipino men and women and South Asian men. For COPD, whites were at highest risk; RR of blacks was 0.9 (0.7-1.0); Hispanics, 0.6 (0.3- 0.9); and Asians, 0.4 (0.3-0.6). COPD risk among Asians was lowest in Chinese with RR of 0.3 (0.1-0.5). CONCLUSIONS: Ethnic disparities in risk of asthma and COPD as well as between both diseases exist, especially for Asian Americans, who have high asthma risk and low COPD risk. While residual confounding for smoking or other environmental factors could be partially responsible, genetic factors in Asians may be involved in decreased COPD risk.

Authors: Tran HN; Siu S; Iribarren C; Udaltsova N; Klatsky AL

Ann Epidemiol. 2011 Aug;21(8):615-22. Epub 2011 Mar 17.

PubMed abstract

Social disparities in internet patient portal use in diabetes: evidence that the digital divide extends beyond access

The authors investigated use of the internet-based patient portal,, among a well-characterized population of adults with diabetes in Northern California. Among 14,102 diverse patients, 5671 (40%) requested a password for the patient portal. Of these, 4311 (76%) activated their accounts, and 3922 (69%), logged on to the patient portal one or more times; 2990 (53%) participants viewed laboratory results, 2132 (38%) requested medication refills, 2093 (37%) sent email messages, and 835 (15%) made medical appointments. After adjustment for age, gender, race/ethnicity, immigration status, educational attainment, and employment status, compared to non-Hispanic Caucasians, African-Americans and Latinos had higher odds of never logging on (OR 2.6 (2.3 to 2.9); OR 2.3 (1.9 to 2.6)), as did those without an educational degree (OR compared to college graduates, 2.3 (1.9 to 2.7)). Those most at risk for poor diabetes outcomes may fall further behind as health systems increasingly rely on the internet and limit current modes of access and communication.

Authors: Sarkar U; Karter AJ; Liu JY; Adler NE; Nguyen R; Lopez A; Schillinger D

J Am Med Inform Assoc. 2011 May 1;18(3):318-21. Epub 2011 Jan 24.

PubMed abstract

Age-dependent gender differences in hypertension management

OBJECTIVE: Despite gender-neutral guidelines, prior studies suggest that women have lower rates of hypertension control and these differences may vary with age. Accordingly, we compared rates of hypertension control between women and men as a function of age. METHODS: Within three integrated healthcare systems in the Cardiovascular Research Network, we studied all patients seen from 2001 to 2007 with incident hypertension. Within 1 year of cohort entry, patient’s hypertension was categorized as controlled based upon achieving guideline-recommended blood pressure levels, recognized if hypertension was diagnosed or a hypertension medication dispensed, and treated based on hypertension medications dispensed. Multivariable logistic regression models assessed the association between gender and 1-year hypertension outcomes, adjusted for patient characteristics. RESULTS: Among the 152,561 patients with incident hypertension, 55.6% were women. Compared to men, women were older, had more kidney disease and more blood pressure measures during follow-up. Overall, men tended to have lower rates of hypertension control compared to women (41.2 vs. 45.7%, adjusted odds ratio 0.93, 95% confidence interval 0.91-0.95). A significant gender by age interaction was found with men aged 18-49 having 17% lower odds of hypertension control and men aged at least 65 having 12% higher odds of hypertension control compared to women of similar ages (P<0.001). CONCLUSION: In this incident hypertension cohort, younger men and older women had lower rates of hypertension control compared to similarly aged peers. Future studies should investigate why gender differences vary by age in order to plan appropriate means of improving hypertension management regardless of gender or age.

Authors: Daugherty SL; Masoudi FA; Ellis JL; Ho PM; Schmittdiel JA; Tavel HM; Selby JV; O'Connor PJ; Margolis KL; Magid DJ

J Hypertens. 2011 May;29(5):1005-11.

PubMed abstract

Primary Language, Income and the Intensification of Anti-glycemic Medications in Managed Care: the (TRIAD) Study

BACKGROUND: Patients who speak Spanish and/or have low socioeconomic status are at greater risk of suboptimal glycemic control. Inadequate intensification of anti-glycemic medications may partially explain this disparity. OBJECTIVE: To examine the associations between primary language, income, and medication intensification. DESIGN: Cohort study with 18-month follow-up. PARTICIPANTS: One thousand nine hundred and thirty-nine patients with Type 2 diabetes who were not using insulin enrolled in the Translating Research into Action for Diabetes Study (TRIAD), a study of diabetes care in managed care. MEASUREMENTS: Using administrative pharmacy data, we compared the odds of medication intensification for patients with baseline A1c >/= 8%, by primary language and annual income. Covariates included age, sex, race/ethnicity, education, Charlson score, diabetes duration, baseline A1c, type of diabetes treatment, and health plan. RESULTS: Overall, 42.4% of patients were taking intensified regimens at the time of follow-up. We found no difference in the odds of intensification for English speakers versus Spanish speakers. However, compared to patients with incomes <$15,000, patients with incomes of $15,000-$39,999 (OR 1.43, 1.07-1.92), $40,000-$74,999 (OR 1.62, 1.16-2.26) or >$75,000 (OR 2.22, 1.53-3.24) had increased odds of intensification. This latter pattern did not differ statistically by race. CONCLUSIONS: Low-income patients were less likely to receive medication intensification compared to higher-income patients, but primary language (Spanish vs. English) was not associated with differences in intensification in a managed care setting. Future studies are needed to explain the reduced rate of intensification among low income patients in managed care.

Authors: Duru OK; Bilik D; McEwen LN; Brown AF; Karter AJ; Curb JD; Marrero DG; Lu SE; Rodriguez M; Mangione CM

J Gen Intern Med. 2011 May;26(5):505-11. Epub 2010 Dec 21.

PubMed abstract

Adherence to laboratory test requests by patients with diabetes: the Diabetes Study of Northern California (DISTANCE)

OBJECTIVES: To estimate rates and predictors of clinical laboratory test completion by patients with diabetes after provider referral. STUDY DESIGN: Prospective cohort study. METHODS: Among 186,306 adult members with diabetes in Kaiser Permanente Northern California, we searched the electronic medical records (July 1, 2008, to June 30, 2009) of each patient for the first outpatient order to obtain the following laboratory tests commonly used to measure risk factor control or adverse effects of pharmacotherapy: levels of glycosylated hemoglobin, low density lipoprotein cholesterol, serum creatinine, urinary albumin, or creatine kinase (the latter only among persons using statins). We measured laboratory test attendance as completion of an order (including time to results) within 6 months of the referral date and looked for variations by subgroups. RESULTS: Laboratory test attendance ranged from 86% for glycosylated hemoglobin level to 73% for serum creatinine level. Time to laboratory test attendance was a median of 7 to 11 days and a mean of 25 to 30 days. Laboratory test attendance was more likely for women and older patients or for orders after a face-to-face provider visit and was less likely for orders by a pharmacist. However, most variations (even by laboratory copayment) were small or not clinically substantive. In subanalyses, we observed no clinically significant variations by race/ethnicity, socioeconomic status, trust in provider, or patient-provider communication and found no association with depressive symptoms, health literacy, or English fluency. CONCLUSION: The fact that 1 in 7 patients did not complete laboratory tests within 6 months of the provider referral may help explain why healthcare services seem to fall short of optimal diabetes care.

Authors: Moffet HH; Parker MM; Sarkar U; Schillinger D; Fernandez A; Adler NE; Adams AS; Karter AJ

Am J Manag Care. 2011 May;17(5):339-44.

PubMed abstract

Father absence, body mass index, and pubertal timing in girls: differential effects by family income and ethnicity

PURPOSE: Numerous studies show associations between father absence and girls’ early puberty. However, most research has been retrospective, focused on menarche, and failed to consider body mass index (BMI), ethnicity, and income in the analyses. This study resolves these scientific gaps. METHODS: This was a prospective study of 444 girls aged 6-8 years and their caregivers (96% mothers). Data were collected annually in clinic, including weight, height, and Tanner stage for breast and pubic hair. Caregivers reported on father absence and demographics. This report focuses on the assessment of father absence at baseline and 2 years of follow-up for pubertal outcomes. Cox proportional hazards regression models were used to test whether father absence at baseline predicted pubertal onset by follow-up visit 2. BMI was assumed to be in the causal pathway. Differences by ethnicity and income were examined. RESULTS: Income and ethnicity moderated associations between father absence and pubertal onset when adjusting for BMI. Father absence predicted earlier onset of breast development only in higher-income families and onset of pubic hair development only in higher-income African Americans families. BMI was not related to father absence and therefore was not in the causal pathway. CONCLUSION: Among girls from higher-income families, father absence was linked to earlier puberty. This was particularly true for African Americans in terms of pubic hair development. These effects are not explained by body weight. Future research is needed to identify social and biophysiological mechanisms through which father absence, ethnicity, and income affect the pubertal onset.

Authors: Deardorff J; Ekwaru JP; Kushi LH; Ellis BJ; Greenspan LC; Mirabedi A; Landaverde EG; Hiatt RA

J Adolesc Health. 2011 May;48(5):441-7. Epub 2010 Sep 20.

PubMed abstract

Heterogeneity of diabetes outcomes among asians and pacific islanders in the US; the diabetes study of northern california (DISTANCE)

OBJECTIVE: Ethnic minorities with diabetes typically have lower rates of cardiovascular outcomes and higher rates of end-stage renal disease (ESRD) compared with whites. Diabetes outcomes among Asian and Pacific Islander subgroups have not been disaggregated. RESEARCH DESIGN AND METHODS: We performed a prospective cohort study (1996-2006) of patients enrolled in the Kaiser Permanente Northern California Diabetes Registry. There were 64,211 diabetic patients, including whites (n = 40,286), blacks (n = 8,668), Latinos (n = 7,763), Filipinos (n = 3,572), Chinese (n = 1,823), Japanese (n = 951), Pacific Islanders (n = 593), and South Asians (n = 555), enrolled in the registry. We calculated incidence rates (means +/- SD; 7.2 +/- 3.3 years follow-up) and created Cox proportional hazards models adjusted for age, educational attainment, English proficiency, neighborhood deprivation, BMI, smoking, alcohol use, exercise, medication adherence, type and duration of diabetes, HbA(1c), hypertension, estimated glomerular filtration rate, albuminuria, and LDL cholesterol. Incidence of myocardial infarction (MI), congestive heart failure, stroke, ESRD, and lower-extremity amputation (LEA) were age and sex adjusted. RESULTS: Pacific Islander women had the highest incidence of MI, whereas other ethnicities had significantly lower rates of MI than whites. Most nonwhite groups had higher rates of ESRD than whites. Asians had ~60% lower incidence of LEA compared with whites, African Americans, or Pacific Islanders. Incidence rates in Chinese, Japanese, and Filipinos were similar for most complications. For the three macrovascular complications, Pacific Islanders and South Asians had rates similar to whites. CONCLUSIONS: Incidence of complications varied dramatically among the Asian subgroups and highlights the value of a more nuanced ethnic stratification for public health surveillance and etiologic research.

Authors: Kanaya AM; Adler N; Moffet HH; Liu J; Schillinger D; Adams A; Ahmed AT; Karter AJ

Diabetes Care. 2011 Apr;34(4):930-7. Epub 2011 Feb 24.

PubMed abstract

Missed opportunities in cardiovascular disease prevention?: low rates of hypertension recognition for women at medicine and obstetrics-gynecology clinics

Younger women use both internal medicine and obstetrics-gynecology (OBGYN) clinics as primary sources of health care. However, the role of OBGYN clinics in cardiovascular disease prevention is largely unexplored. The objective of this study was to examine rates of hypertension recognition in women<50 years of age who presented with elevated blood pressures in family practice and internal medicine (medicine) OBGYN clinics and to compare these rates across clinic type. The study's population consisted of 34 627 nonpregnant women ages 18 to 49 years with new-onset hypertension (defined as 2 consecutive visits with elevated blood pressures of systolic blood pressure>/=140 mm Hg or diastolic blood pressure>/=90 mm Hg with no previous hypertension history) from 2002 to 2006. Multivariate logistic regressions predicting the clinical recognition of hypertension (a recorded diagnosis of hypertension and/or an antihypertensive prescription by any provider within 1 year of the second elevated blood pressure) assessed the association between hypertension recognition and the clinic where the second elevated blood pressure was recorded. Analysis showed that hypertension was recognized in <33% of women with new-onset hypertension. Women whose second consecutive elevated blood pressure was recorded in OBGYN clinics were less likely to be recognized as having hypertension within 12 months by any provider compared with women whose second consecutive elevated blood pressure was recorded in a medicine clinic (odds ratio: 0.51 [95% CI: 0.48 to 0.54]). This study suggests that further attention be paid to identifying and treating cardiovascular disease risk factors in women<50 years of age presenting in both medicine and OBGYN clinics and that improved coordination across care settings has the potential to improve cardiovascular disease prevention in young women.

Authors: Schmittdiel J; Selby JV; Swain B; Daugherty SL; Leong TK; Ho M; Margolis KL; O'Connor P; Magid DJ; Bibbins-Domingo K

Hypertension. 2011 Apr;57(4):717-22. Epub 2011 Feb 21.

PubMed abstract

Socioeconomic status and polycystic ovary syndrome

BACKGROUND: Polycystic ovary syndrome (PCOS) is a common metabolic-endocrine disorder in women and is associated with a number of metabolic morbidities. We examined the association of PCOS and its components with socioeconomic status (SES) over the life course to explore the role of the environment on the development of PCOS. METHODS: Participants included 1163 women, aged 34-39, from the Coronary Artery Risk Development in Young Adults (CARDIA) Women’s Study, examined at year 16 of the CARDIA study (2001). PCOS was defined according to the 1990 National Institutes of Health (NIH) criteria. RESULTS: Logistic regression models, adjusted for age, body mass index (BMI), waist circumference, and oral contraceptive (OC) use, demonstrated a statistically significant association between those women with low parental education/high personal education and PCOS (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.4). CONCLUSIONS: Our results indicate that women who experienced low childhood SES are at increased risk of PCOS, but this risk is limited to those who have personally attained a high level of education. More research is needed to determine the childhood socioeconomic factors that might influence this risk and whether conditions associated with upward life mobility play a role or if this group of at-risk women is simply more likely to recall the symptoms that define PCOS.

Authors: Merkin SS; Azziz R; Seeman T; Calderon-Margalit R; Daviglus M; Kiefe C; Matthews K; Sternfeld B; Siscovick D

J Womens Health (Larchmt). 2011 Mar;20(3):413-9. Epub 2011 Feb 16.

PubMed abstract

Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE)

BACKGROUND: A significant proportion of US Latinos with diabetes have limited English proficiency (LEP). Whether language barriers in health care contribute to poor glycemic control is unknown. OBJECTIVE: To assess the association between limited English proficiency (LEP) and glycemic control and whether this association is modified by having a language-concordant physician. DESIGN: Cross-sectional, observational study using data from the 2005-2006 Diabetes Study of Northern California (DISTANCE). Patients received care in a managed care setting with interpreter services and self-reported their English language ability and the Spanish language ability of their physician. Outcome was poor glycemic control (glycosylated hemoglobin A1c > 9%). KEY RESULTS: The unadjusted percentage of patients with poor glycemic control was similar among Latino patients with LEP (n = 510) and Latino English-speakers (n = 2,683), and higher in both groups than in whites (n = 3,545) (21% vs 18% vs. 10%, p < 0.005). This relationship differed significantly by patient-provider language concordance (p < 0.01 for interaction). LEP patients with language-discordant physicians (n = 115) were more likely than LEP patients with language-concordant physicians (n = 137) to have poor glycemic control (27.8% vs 16.1% p = 0.02). After controlling for potential demographic and clinical confounders, LEP Latinos with language-concordant physicians had similar odds of poor glycemic control as Latino English speakers (OR 0.89; CI 0.53-1.49), whereas LEP Latinos with language-discordant physicians had greater odds of poor control than Latino English speakers (OR 1.76; CI 1.04-2.97). Among LEP Latinos, having a language discordant physician was associated with significantly poorer glycemic control (OR 1.98; CI 1.03-3.80). CONCLUSIONS: Language barriers contribute to health disparities among Latinos with diabetes. Limited English proficiency is an independent predictor for poor glycemic control among insured US Latinos with diabetes, an association not observed when care is provided by language-concordant physicians. Future research should determine if strategies to increase language-concordant care improve glycemic control among US Latinos with LEP.

Authors: Fernandez A; Schillinger D; Warton EM; Adler N; Moffet HH; Schenker Y; Salgado MV; Ahmed A; Karter AJ

J Gen Intern Med. 2011 Feb;26(2):170-6. Epub 2010 Sep 29.

PubMed abstract

Racial variation in lipoprotein-associated phospholipase A in older adults

BACKGROUND: Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) is a predictor of cardiovascular events that has been shown to vary with race. The objective of this study was to examine factors associated with this racial variation. METHODS: We measured Lp-PLA(2) mass and activity in 714 healthy older adults with no clinical coronary heart disease and not taking dyslipidemia medication. We evaluated the association between race and Lp-PLA(2) mass and activity levels after adjustment for various covariates using multivariable linear regression. These covariates included age, sex, diabetes, hypertension, body mass index, lipid measurements, C-reactive protein, smoking status, physical activity, diet, income, and education level. We further examined genetic covariates that included three single nucleotide polymorphisms shown to be associated with Lp-PLA(2) activity levels. RESULTS: The mean age was 66 years. Whites had the highest Lp-PLA(2) mass and activity levels, followed by Hispanics and Asians, and then African-Americans; in age and sex adjusted analyses, these differences were significant for each non-White race as compared to Whites (p < 0.0001). For example, African-Americans were predicted to have a 55.0 ng/ml lower Lp-PLA(2) mass and 24.7 nmol/ml-min lower activity, compared with Whites, independent of age and sex (p < 0.0001). After adjustment for all covariates, race remained significantly correlated with Lp-PLA(2) mass and activity levels (p < 0.001) with African-Americans having 44.8 ng/ml lower Lp-PLA(2) mass and 17.3 nmol/ml-min lower activity compared with Whites (p < 0.0001). CONCLUSION: Biological, lifestyle, demographic, and select genetic factors do not appear to explain variations in Lp-PLA(2) mass and activity levels between Whites and non-Whites, suggesting that Lp-PLA(2) mass and activity levels may need to be interpreted differently for various races.

Authors: Lee KK; Fortmann SP; Varady A; Fair JM; Go AS; Quertermous T; Hlatky MA; Iribarren C

BMC Cardiovasc Disord. 2011 Jun 29;11:38.

PubMed abstract

Correlates of patient-reported racial/ethnic health care discrimination in the Diabetes Study of Northern California (DISTANCE)

OBJECTIVES: We examined possible determinants of self-reported health care discrimination. METHODS: We examined survey data from the Diabetes Study of Northern California (DISTANCE), a race-stratified sample of Kaiser diabetes patients. Respondents reported perceived discrimination, and regression models examined socioeconomic, acculturative, and psychosocial correlates. RESULTS: Subjects (n=17,795) included 20% Blacks, 23% Latinos, 13% East Asians, 11% Filipinos, and 27% Whites. Three percent and 20% reported health care and general discrimination. Health care discrimination was more frequently reported by minorities (ORs ranging from 2.0 to 2.9 compared with Whites) and those with poorer health literacy (OR=1.10, 95% CI: 1.04-1.16), limited English proficiency (OR=1.91, 95% CI: 1.32-2.78), and depression (OR=1.53, 95% CI: 1.10-2.13). CONCLUSIONS: In addition to race/ethnicity, health literacy and English proficiency may be bases of discrimination. Evaluation is needed to determine whether patients are treated differently or more apt to perceive discrimination, and whether depression fosters and/or follows perceived discrimination.

Authors: Lyles CR; Karter AJ; Young BA; Spigner C; Grembowski D; Schillinger D; Adler NE

J Health Care Poor Underserved. 2011;22(1):211-25.

PubMed abstract

Socioeconomic status, race and COPD health outcomes

BACKGROUND: Although chronic obstructive pulmonary disease (COPD) is a common cause of death and disability, little is known about the effects of socioeconomic status (SES) and race-ethnicity on health outcomes. METHODS: The aim of this study is to determine the independent impacts of SES and race-ethnicity on COPD severity status, functional limitations and acute exacerbations of COPD among patients with access to healthcare. Data were used from the Function, Living, Outcomes and Work cohort study of 1202 Kaiser Permanente Northern California Medical Care Plan members with COPD. RESULTS: Lower educational attainment and household income were consistently related to greater disease severity, poorer lung function and greater physical functional limitations in cross-sectional analysis. Black race was associated with greater COPD severity, but these differences were no longer apparent after controlling for SES variables and other covariates (comorbidities, smoking, body mass index and occupational exposures). Lower education and lower income were independently related to a greater prospective risk of acute COPD exacerbation (HR 1.5; 95% CI 1.01 to 2.1; and HR 2.1; 95% CI 1.4 to 3.4, respectively). CONCLUSION: Low SES is a risk factor for a broad array of adverse COPD health outcomes. Clinicians and disease management programs should consider SES as a key patient-level marker of risk for poor outcomes.

Authors: Eisner MD; Blanc PD; Omachi TA; Yelin EH; Sidney S; Katz PP; Ackerson LM; Sanchez G; Tolstykh I; Iribarren C

J Epidemiol Community Health. 2011 Jan;65(1):26-34. Epub 2009 Oct 23.

PubMed abstract

Familial aggregation of Parkinson’s disease in a multiethnic community-based case-control study

To assess the familial aggregation of Parkinson’s disease (PD), we compared the cumulative incidence of PD among first-degree relatives of PD cases and controls. We identified newly diagnosed patients with PD (n = 573) during 1994 to 1995 within Kaiser Permanente Medical Care Program of Northern California and recruited 496 cases (87%) for the case-control study. Of 720 eligible controls matched by birth year and sex to cases, 541 (75%) agreed to participate. Information on family history of PD and other neurodegenerative diseases was obtained by in-person structured interview. We used the reconstructed cohort approach that provides a better estimate of the risk. The cumulative incidence of PD was significantly higher among relatives of PD patients compared with relatives of controls (2.0 vs. 0.7%; relative risk (RR) = 3.4, 95% confidence interval (CI) 1.9-5.9; P = 0.0001). The degree of familial aggregation was higher among first-degree relatives of Hispanic PD cases compared with Hispanic controls (3.7% vs. 0.4%; RR = 8.5, 95% CI 1.0-68.9) than it was among non-Hispanic Caucasian cases and controls (2.0% vs. 0.8%; RR = 2.7, 95% CI 1.5-5.1; P = 0.02). The familial aggregation of PD was stronger among the siblings of PD cases (RR = 5.4, 95% CI 1.8-16.0) than among parents (RR = 2.7, 95% CI 1.3-5.2). The incidence and familial aggregation of PD is highest among Hispanics, warranting further studies of genetic and environmental risk factors in the Hispanic population.

Authors: Shino MY; McGuire V; Van Den Eeden SK; Tanner CM; Popat R; Leimpeter A; Bernstein AL; Nelson LM

Mov Disord. 2010 Nov 15;25(15):2587-94.

PubMed abstract

Meta-analysis identifies 13 new loci associated with waist-hip ratio and reveals sexual dimorphism in the genetic basis of fat distribution

Waist-hip ratio (WHR) is a measure of body fat distribution and a predictor of metabolic consequences independent of overall adiposity. WHR is heritable, but few genetic variants influencing this trait have been identified. We conducted a meta-analysis of 32 genome-wide association studies for WHR adjusted for body mass index (comprising up to 77,167 participants), following up 16 loci in an additional 29 studies (comprising up to 113,636 subjects). We identified 13 new loci in or near RSPO3, VEGFA, TBX15-WARS2, NFE2L3, GRB14, DNM3-PIGC, ITPR2-SSPN, LY86, HOXC13, ADAMTS9, ZNRF3-KREMEN1, NISCH-STAB1 and CPEB4 (P = 1.9 x 10 to P = 1.8 x 10) and the known signal at LYPLAL1. Seven of these loci exhibited marked sexual dimorphism, all with a stronger effect on WHR in women than men (P for sex difference = 1.9 x 10(3) to P = 1.2 x 10(1)(3)). These findings provide evidence for multiple loci that modulate body fat distribution independent of overall adiposity and reveal strong gene-by-sex interactions.

Authors: Heid IM; Iribarren C; MAGIC; et al.

Nat Genet. 2010 Nov;42(11):949-60. Epub 2010 Oct 10.

PubMed abstract

Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter?

BACKGROUND: Patient-physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient-physician communication. OBJECTIVE: To examine the association of patient race/ethnicity and language and patient-physician race/ethnicity and language concordance on medication adherence rates for a large cohort of diabetes patients in an integrated delivery system. DESIGN: We studied 131,277 adult diabetes patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient and physician race/ethnicity and language on adherence to CVD medications, after controlling for patient and physician characteristics. RESULTS: Ten percent of African American, 11 % of Hispanic, 63% of Asian, and 47% of white patients had same race/ethnicity physicians. 24% of Spanish-speaking patients were linguistically concordant with their physicians. African American (46%), Hispanic (49%) and Asian (52%) patients were significantly less likely than white patients (58%) to be in good adherence to all of their CVD medications (p<0.001). Spanish-speaking patients were less likely than English speaking patients to be in good adherence (51% versus 57%, p<0.001). Race concordance for African American patients was associated with adherence to all their CVD medications (53% vs. 50%, p<0.05). Language concordance was associated with medication adherence for Spanish-speaking patients (51% vs. 45%, p<0.05). CONCLUSION: Increasing opportunities for patient-physician race/ethnicity and language concordance may improve medication adherence for African American and Spanish-speaking patients, though a similar effect was not observed for Asian patients or English-proficient Hispanic patients.

Authors: Traylor AH; Schmittdiel JA; Uratsu CS; Mangione CM; Subramanian U

J Gen Intern Med. 2010 Nov;25(11):1172-7. Epub 2010 Jun 23.

PubMed abstract

The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: the DISTANCE study

OBJECTIVE: To assess the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions. METHODS: Cross-sectional survey of 8638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination. RESULTS: Respondents included 8116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician-patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients. CONCLUSIONS: Reports of suboptimal interactions among patients with LEP were more common among those with language-discordant physicians. PRACTICE IMPLICATIONS: Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician-patient language concordance.

Authors: Schenker Y; Karter AJ; Schillinger D; Warton EM; Adler NE; Moffet HH; Ahmed AT; Fernandez A

Patient Educ Couns. 2010 Nov;81(2):222-8. Epub 2010 Mar 11.

PubMed abstract

Fine mapping of chromosome 15q25.1 lung cancer susceptibility in African-Americans

Several genome-wide association studies identified the chr15q25.1 region, which includes three nicotinic cholinergic receptor genes (CHRNA5-B4) and the cell proliferation gene (PSMA4), for its association with lung cancer risk in Caucasians. A haplotype and its tagging single nucleotide polymorphisms (SNPs) encompassing six genes from IREB2 to CHRNB4 were most strongly associated with lung cancer risk (OR = 1.3; P < 10(-20)). In order to narrow the region of association and identify potential causal variations, we performed a fine-mapping study using 77 SNPs in a 194 kb segment of the 15q25.1 region in a sample of 448 African-American lung cancer cases and 611 controls. Four regions, two SNPs and two distinct haplotypes from sliding window analyses, were associated with lung cancer. CHRNA5 rs17486278 G had OR = 1.28, 95% CI 1.07-1.54 and P = 0.008, whereas CHRNB4 rs7178270 G had OR = 0.78, 95% CI 0.66-0.94 and P = 0.008 for lung cancer risk. Lung cancer associations remained significant after pack-year adjustment. Rs7178270 decreased lung cancer risk in women but not in men; gender interaction P = 0.009. For two SNPs (rs7168796 A/G and rs7164594 A/G) upstream of PSMA4, lung cancer risks for people with haplotypes GG and AA were reduced compared with those with AG (OR = 0.56, 95% CI 0.38-0.82; P = 0.003 and OR = 0.73, 95% CI 0.59-0.90, P = 0.004, respectively). A four-SNP haplotype spanning CHRNA5 (rs11637635 C, rs17408276 T, rs16969968 G) and CHRNA3 (rs578776 G) was associated with increased lung cancer risk (P = 0.002). The identified regions contain SNPs predicted to affect gene regulation. There are multiple lung cancer risk loci in the 15q25.1 region in African-Americans.

Authors: Hansen HM; Quesenberry CP; Wiencke JK; et al.

Hum Mol Genet. 2010 Sep 15;19(18):3652-61. Epub 2010 Jun 29.

PubMed abstract

Disparities in the risk of gestational diabetes by race-ethnicity and country of birth

Little information exists on the association between maternal country of birth and risk of gestational diabetes (GDM). We examined within each race-ethnicity group whether the risk of GDM differs between women born inside and outside the US. The study was a cohort study of 216 089 women who delivered an infant between 1995 and 2004 with plasma glucose data from the screening 50-g glucose challenge test and the diagnostic 100-g, 3-h oral glucose tolerance test. The age-adjusted prevalence of GDM varied by race-ethnicity and was lowest for non-Hispanic white (4.1%) and highest among Asian Indians (11.1%). In multivariable models, being born outside of the US was associated with an increased risk of GDM among black, Asian Indian, Filipina, Pacific Islanders, Chinese, Mexicans and non-Hispanic white women, whereas, Japanese and Korean foreign-born women had a decreased risk of GDM. Clinicians should be aware that among certain race-ethnicity groups women born outside the US may be at increased risk of GDM and may warrant special preventive and culturally sensitive care.

Authors: Hedderson MM; Darbinian JA; Ferrara A

Paediatr Perinat Epidemiol. 2010 Sep;24(5):441-8.

PubMed abstract

Gender differences in treatment of severe carotid stenosis after transient ischemic attack

BACKGROUND AND PURPOSE: Gender differences in carotid endarterectomy (CEA) rates after transient ischemic attack are not well studied, although some reports suggest that eligible men are more likely to have CEA than women after stroke. METHODS: We retrospectively identified all patients diagnosed with transient ischemic attack and >or=70% carotid stenosis on ultrasound in 2003 to 2004 from 19 emergency departments. Medical records were abstracted for clinical data; 90-day follow-up events, including stroke, cardiovascular events, or death; CEA within 6 months; and postoperative 30-day outcomes. We assessed gender as a predictor of CEA and its complications adjusting for demographic and clinical variables as well as time to CEA between groups. RESULTS: Of 299 patients identified, 47% were women. Women were older with higher presenting systolic blood pressure and less likely to smoke or to have coronary artery disease or diabetes. Fewer women (36.4%) had CEA than men (53.8%; P=0.004). Reasons for withholding surgical treatment were similar in women and men, and there were no differences in follow-up stroke, cardiovascular event, postoperative complications, or death. Time to CEA was also significantly delayed in women. CONCLUSIONS: Women with severe carotid stenosis and recent transient ischemic attack are less likely to undergo CEA than men, and surgeries are more delayed.

Authors: Poisson SN; Johnston SC; Sidney S; Klingman JG; Nguyen-Huynh MN

Stroke. 2010 Sep;41(9):1891-5. Epub 2010 Jul 22.

PubMed abstract

Hypoglycemia is more common among type 2 diabetes patients with limited health literacy: the Diabetes Study of Northern California (DISTANCE)

BACKGROUND: Little is known about the frequency of significant hypoglycemic events in actual practice. Limited health literacy (HL) is common among patients with type 2 diabetes, may impede diabetes self-management, and thus HL could increase the risk of hypoglycemia. OBJECTIVE: To determine the proportion of ambulatory, pharmacologically-treated patients with type 2 diabetes reporting > or =1 significant hypoglycemic events in the prior 12 months, and evaluate whether HL is associated with hypoglycemia. RESEARCH DESIGN: Cross-sectional analysis in an observational cohort, the Diabetes Study of Northern California (DISTANCE). SUBJECTS: The subjects comprised 14,357 adults with pharmacologically-treated, type 2 diabetes who are seen at Kaiser Permanente Northern California (KPNC), a non-profit, integrated health care delivery system. MEASURES: Patient-reported frequency of significant hypoglycemia (losing consciousness or requiring outside assistance); patient-reported health literacy. RESULTS: At least one significant hypoglycemic episode in the prior 12 months was reported by 11% of patients, with the highest risk for those on insulin (59%). Patients commonly reported limited health literacy: 53% reported problems learning about health, 40% needed help reading health materials, and 32% were not confident filling out medical forms by themselves. After adjustment, problems learning (OR 1.4, CI 1.1-1.7), needing help reading (OR 1.3, CI 1.1-1.6), and lack of confidence with forms (OR 1.3, CI 1.1-1.6) were independently associated with significant hypoglycemia. CONCLUSIONS: Significant hypoglycemia was a frequent complication in this cohort of type 2 diabetes patients using anti-hyperglycemic therapies; those reporting limited HL were especially vulnerable. Efforts to reduce hypoglycemia and promote patient safety may require self-management support that is appropriate for those with limited HL, and consider more vigilant surveillance, conservative glycemic targets or avoidance of the most hypoglycemia-inducing medications.

Authors: Sarkar U; Karter AJ; Liu JY; Moffet HH; Adler NE; Schillinger D

J Gen Intern Med. 2010 Sep;25(9):962-8. Epub 2010 May 18.

PubMed abstract

Prevalence of electrocardiographic abnormalities in a middle-aged, biracial population: Coronary Artery Risk Development in Young Adults study

BACKGROUND: Few studies to date have described the prevalence of electrocardiographic (ECG) abnormalities in a biracial middle-aged cohort. METHODS AND RESULTS: Participants underwent measurement of traditional risk factors and 12-lead ECGs coded using both Minnesota Code and Novacode criteria. Among 2585 participants, of whom 57% were women and 44% were black (mean age 45 years), the prevalence of major and minor abnormalities was significantly higher (all P < .001) among black men and women compared to whites. These differences were primarily due to higher QRS voltage and ST/T-wave abnormalities among blacks. There was also a higher prevalence of Q waves (Minnesota Code 1-1, 1-2, 1-3) than described by previous studies. These racial differences remained after multivariate adjustment for traditional cardiovascular (CV) risk factors. CONCLUSIONS: Black men and women have a significantly higher prevalence of ECG abnormalities, independent of traditional cardiovascular risk factors, than whites in a contemporary cohort of middle-aged participants.

Authors: Walsh JA 3rd; Prineas R; Daviglus ML; Ning H; Liu K; Lewis CE; Sidney S; Schreiner PJ; Iribarren C; Lloyd-Jones DM

J Electrocardiol. 2010 Sep-Oct;43(5):385.e1-9. Epub 2010 Apr 5.

PubMed abstract

The predictors of patient-physician race and ethnic concordance: a medical facility fixed-effects approach

OBJECTIVE: To examine the predictors of patient-physician race/ethnicity concordance among diabetes patients in an integrated delivery system. DATA SOURCE: Kaiser Permanente’s Northern California Diabetes Registry of 2005. STUDY DESIGN: Logistic regression predicted concordance for each racial/ethnic group. Availability of a concordant physician, whether a patient chose their physician, and patient language were main explanatory variables. DATA COLLECTION/EXTRACTION METHODS: The study population consisted of 109,745 patients and 1,750 physicians. PRINCIPAL FINDINGS: Patients who chose their physicians were more likely to have a same race/ethnicity physician with OR of 2.2 (95 percent CI 1.74-2.82) for African American patients, 1.71 (95 percent CI 1.44-2.04) for Hispanic patients, 1.11 (95 percent CI 1.04-1.18) for white patients, and 1.38 (95 percent CI 1.23, 1.55) for Asian patients. Availability of a same race/ethnicity physician was also a predictor of concordance for African American patients (OR 2.7; 95 percent CI 2.45-2.98) and marginally significant for Hispanic patients (OR 1.02; 95 percent CI 1.01-1.02), white patients (OR 1.02; 95 percent CI 1.00-1.04), and Asian patients (OR 1.05; 95 percent CI 1.03, 1.07). Limited English language was a strong predictor of concordance for Hispanic patients (OR 4.81; 95 percent CI 4.2-5.51) and Asian patients (OR 9.8; 95 percent CI 7.7, 12.6). CONCLUSION: Patient language, preferences, and the racial composition of the physician workforce predict race/ethnicity concordance.

Authors: Traylor AH; Schmittdiel JA; Uratsu CS; Mangione CM; Subramanian U

Health Serv Res. 2010 Jun;45(3):792-805. Epub 2010 Mar 10.

PubMed abstract

Social disparities in dental insurance and annual dental visits among medically insured patients with diabetes: the Diabetes Study of Northern California (DISTANCE) Survey

INTRODUCTION: People with diabetes are at increased risk of periodontal disease and tooth loss. Healthy People 2010 set a goal that 71% or more of people with diabetes should have an annual dental exam. METHODS: We assessed dental insurance and annual dental visits among dentate respondents from the Diabetes Study of Northern California (DISTANCE) Survey cohort (N = 20,188), an ethnically stratified, random sample of patients with diabetes aged 30 to 75 years receiving medical care from Kaiser Permanente Northern California. We calculated predicted probabilities for an annual dental visit (PPADV) by using regression models that incorporated age, sex, education level, annual household income, and self-reported race/ethnicity, stratified by whether the respondent had dental insurance. RESULTS: Among 12,405 dentate patients, 9,257 (75%) had dental insurance. Annual dental visits were reported by 7,557 (82%) patients with dental insurance and 1,935 (61%) patients without dental insurance. The age-sex adjusted odds ratio for an annual dental visit was 2.66 (95% confidence interval, 2.33-3.03) for patients with dental insurance compared to those without dental insurance. For patients with dental insurance, the PPADV was 71% or more for all except those with the lowest household income. In contrast, for those without dental insurance, the PPADV was less than 71% for all except those with the most education or the highest income. We found some racial/ethnic subgroups were more likely than others to take advantage of dental insurance to have an annual dental visit. CONCLUSION: Patients with diabetes in this managed care population who lacked dental insurance failed to meet the Healthy People 2010 goal for an annual dental visit. An increased effort should be made to promote oral health among people with diabetes.

Authors: Moffet HH; Schillinger D; Weintraub JA; Adler N; Liu JY; Selby JV; Karter AJ

Prev Chronic Dis. 2010 May;7(3):A57. Epub 2010 May 15.

PubMed abstract

Race/ethnicity, social support, and associations with diabetes self-care and clinical outcomes in NHANES

PURPOSE: The purpose of this study was to evaluate how social support and race/ethnicity were associated with diabetes self-care behaviors and clinical outcomes. METHODS: Using the cross-sectional 2005-2006 National Health and Nutrition Examination Survey (NHANES), the authors examined white, black, and Latino respondents who self-reported a diabetes diagnosis (n = 450), estimating the associations of social support on diabetes outcomes. The primary exposure was a social support index (0-5), which assessed the number of sources of support in one’s life. Outcomes were self-care behaviors (controlling weight, exercising, controlling fat/caloric intake, checking feet, and self-monitoring blood glucose) and intermediate clinical outcomes (hemoglobin A1C, diastolic blood pressure, and low-density lipoprotein [LDL]). RESULTS: There were no differences in social support by race/ethnicity. The authors observed several significant race/ethnicity by social support interactions in adjusted models, controlling for age, gender, education, self-reported health, depression, functional disability, insurance status, and insulin use. Among blacks, social support was associated with controlling weight (odds ratio [OR] = 1.55, P = .03), exercising (OR = 1.38, P = .03), controlling fat/calories (OR = 1.84, P = .03), and lower diastolic blood pressure (beta = -3.07, P = .02). Among whites, social support was associated with lower LDL (beta = -9.45, P = .01). No significant effects were noted for Latinos. CONCLUSIONS: The relationship of social support with diabetes management differed by race/ethnicity, with the strongest findings among blacks. Social support may be influential for maintaining self-care behaviors among blacks and controlling lipid levels among whites.

Authors: Rees CA; Karter AJ; Young BA

Diabetes Educ. 2010 May-Jun;36(3):435-45. Epub 2010 Mar 23.

PubMed abstract

Maternal and paternal race/ethnicity are both associated with gestational diabetes

OBJECTIVE: The objective of the study was to examine the rates of gestational diabetes mellitus (GDM) associated with both maternal and paternal race/ethnicity. STUDY DESIGN: This was a retrospective cohort study of all women delivered within a managed care network. Rates of GDM were calculated for maternal, paternal, and combined race/ethnicity. RESULTS: Among the 139,848 women with identified race/ethnicity, Asians had the highest rate (P < .001) of GDM (6.8%) as compared with whites (3.4%), African Americans (3.2%), and Hispanics (4.9%). When examining race/ethnicity controlling for potential confounders, we found that the rates of GDM were higher among Asian (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.4-1.6) and Hispanic (aOR, 1.2; 95% CI, 1.1-1.4) women as well as Asian (aOR, 1.4; 95% CI, 1.3-1.5) and Hispanic (aOR, 1.3; 95% CI, 1.2-1.4) men as compared with their white counterparts. CONCLUSION: We found that rates of GDM are affected by both maternal and paternal race/ethnicity. In both Asians and Hispanics, maternal and paternal race are equally associated with an increase in GDM. These differences may inform further investigation of the pathophysiology of GDM.

Authors: Caughey AB; Cheng YW; Stotland NE; Washington AE; Escobar GJ

Am J Obstet Gynecol. 2010 Jun;202(6):616.e1-5. Epub 2010 Apr 18.

PubMed abstract

Body burdens of brominated flame retardants and other persistent organo-halogenated compounds and their descriptors in US girls

BACKGROUND: Levels of brominated flame retardants are increasing in US populations, yet little data are available on body burdens of these and other persistent hormonally active agents (HAAs) in school-aged children. Exposures to such chemicals may affect a number of health outcomes related to development and reproductive function. OBJECTIVE: Determine the distribution of biomarkers of polybrominated diphenyl ethers (PBDEs), polychlorinated biphenyls (PCBs), and organo-chlorinated pesticides (OCPs), such as DDT/DDE, in children, and their variation by key descriptor variables. METHODS: Ethnically diverse cohorts of girls 6-8 y old at baseline are being followed for growth and pubertal development in a multi-site, longitudinal study. Nearly 600 serum samples from the California and Ohio sites were analyzed for lipids, 35 PCB congeners, 11 PBDE congeners, and 9 OCPs. The biomarker distributions were examined and geometric means compared for selected analytes across categories of age, race, site, body mass index (BMI), parental education, maternal age at delivery, and breast feeding in adjusted models. RESULTS: Six PBDE congeners were detected among greater than 70% of samples, with BDE-47 having the highest concentration (median 42.2, range 4.9-855 ng/g lipid). Girls in California had adjusted geometric mean (GM) PBDE levels significantly higher than girls in Ohio. Furthermore, Blacks had significantly higher adjusted GMs of all six PBDE congeners than Whites, and Hispanics had intermediate values. GMs tended to be lower among more obese girls, while other variables were not strongly associated. In contrast, GMs of the six PCB congeners most frequently detected were significantly lower among Blacks and Hispanics than Whites. PCBs and the three pesticides most frequently detected were also consistently lower among girls with high BMI, who were not breast-fed, whose mothers were younger, or whose care-givers (usually parents) were less educated. Girls in California had higher GMs than in Ohio for the pesticides and most PCB congeners, but the opposite for CB-99 and -118. CONCLUSIONS: Several of these potential HAAs were detected in nearly all of these young girls, some at relatively high levels, with variation by geographic location and other demographic factors that may reflect exposure pathways. The higher PBDE levels in California likely reflect differences in fire regulation and safety codes, with potential policy implications.

Authors: Windham GC; Pinney SM; Sjodin A; Lum R; Jones RS; Needham LL; Biro FM; Hiatt RA; Kushi LH

Environ Res. 2010 Apr;110(3):251-7. Epub 2010 Feb 2.

PubMed abstract

Reports from today’s health care environment on the implementation of screening, diagnosis, and treatment recommendations

Authors: Kim WR; Valdiserri RO; Wright LN; Manos MM; Do ST

J Fam Pract. 2010 Apr;59(4 Suppl):S43-50.

PubMed abstract

Drinking Patterns, Gender and Health I: Attitudes and Health Practices

Despite considerable research, relationships among gender, alcohol consumption, and health remain controversial, due to potential confounding by health-related attitudes and practices associated with drinking, measurement challenges, and marked gender differences in drinking. We examined gender/alcohol consumption differences in health-related attitudes and practices, and evaluated how these factors affected relationships among gender, alcohol consumption, and health status. A stratified random sample of adult health-plan members completed a mail survey, yielding 7884 respondents (2995 male/4889 female). Using MANCOVAs and adjusting for health-related attitudes, values, and practices, we examined gender differences in relationships between alcohol consumption and health. More frequent heavy drinking was associated with worse health-related attitudes and values, worse feelings about visiting the doctor, and worse health-related practices. Relationships between health-related practices and alcohol use differed by gender, and daily or almost daily heavy drinking was associated with significantly lower physical and mental health for women compared to men. Drinking status (lifelong abstainers, former drinkers, and level of regular alcohol consumption) was related to health status and vitality, even after adjusting for health-related attitudes, values, and practices. Relationships did not differ by gender. Former drinkers reported lower physical and mental health status than either lifelong abstainers or current drinkers. Drinking status is independently related to physical health, mental health, and vitality, even after controlling for the health-related attitudes, values, and practices expected to confound these relationships. Among current drinkers, women who engage in very frequent heavy drinking have worse physical and mental health than their male counterparts.

Authors: Polen MR; Green CA; Perrin NA; Anderson BM; Weisner CM

Addict Res Theory. 2010 Apr 01;18(2):122-142.

PubMed abstract

Patient race/ethnicity and patient-physician race/ethnicity concordance in the management of cardiovascular disease risk factors for patients with diabetes

OBJECTIVE Patient-physician race/ethnicity concordance can improve care for minority patients. However, its effect on cardiovascular disease (CVD) care and prevention is unknown. We examined associations of patient race/ethnicity and patient-physician race/ethnicity concordance on CVD risk factor levels and appropriate modification of treatment in response to high risk factor values (treatment intensification) in a large cohort of diabetic patients. RESEARCH DESIGN AND METHODS The study population included 108,555 adult diabetic patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient race/ethnicity on risk factor control and treatment intensification after adjusting for patient and physician-level characteristics. RESULTS African American patients were less likely than whites to have A1C <8.0% (64 vs. 69%, P < 0.0001), LDL cholesterol <100 mg/dl (40 vs. 47%, P < 0.0001), and systolic blood pressure (SBP) <140 mmHg (70 vs. 78%, P < 0.0001). Hispanic patients were less likely than whites to have A1C <8% (62 vs. 69%, P < 0.0001). African American patients were less likely than whites to have A1C treatment intensification (73 vs. 77%, P < 0.0001; odds ratio [OR] 0.8 [95% CI 0.7-0.9]) but more likely to receive treatment intensification for SBP (78 vs. 71%, P < 0.0001; 1.5 [1.3-1.7]). Hispanic patients were more likely to have LDL cholesterol treatment intensification (47 vs. 45%, P < 0.05; 1.1 [1.0-1.2]). Patient-physician race/ethnicity concordance was not significantly associated with risk factor control or treatment intensification. CONCLUSIONS Patient race/ethnicity is associated with risk factor control and treatment intensification, but patient-physician race/ethnicity concordance was not. Further research should investigate other potential drivers of disparities in CVD care.

Authors: Traylor AH; Subramanian U; Uratsu CS; Mangione CM; Selby JV; Schmittdiel JA

Diabetes Care. 2010 Mar;33(3):520-5. Epub 2009 Dec 15.

PubMed abstract

Recurrent headaches in children: an epidemiological survey of two middle schools in inner city Chicago.

OBJECTIVES: The aim of this study was to longitudinally evaluate the epidemiological characteristics of headaches in a school-based, community setting and to determine the impact of headache symptoms on the health of children.METHODS: After institutional review board approval, a prospective cohort study was conducted at two Chicago public schools for a period of 6 months. Members of the research team surveyed both schools weekly for headache and other pain symptoms. The students rated each pain symptom on a 5-point scale from 0 ("not at all") to 4 ("a whole lot"). Demographic information was collected at the time of enrollment, and all participants were asked to complete age-appropriate and validated pediatric surveys to assess the severity of concurrent somatic complaints, anxiety symptoms, functional limitations, and quality of life issues.RESULTS: Of the participating children, 89.5% reported at least one headache during the study period. Females experienced more frequent headaches compared with males (P < 0.05). Children reporting headaches had a significantly increased risk of experiencing other troubling somatic symptoms (P < 0.05). Headache severity showed a moderate correlation with increased feelings of anxiety, functional disability, and a diminished quality of life (P < 0.05).CONCLUSIONS: School-aged children commonly experience headaches. Children experiencing headaches are more likely to report other somatic symptoms, feelings of anxiety, functional limitations, and quality of life impairments.

Authors: Nyame, Yaw A YA; Ambrosy, Andrew P AP; Saps, Miguel M; Adams, Papa N PN; Dhroove, Gati N GN; Suresh, Santhanam S

Pain practice : the official journal of World Institute of Pain. 2011 Feb 01;10(3):214-21. Epub 2010-01-08.

PubMed abstract

Ethnic disparities in accessing treatment for depression and substance use disorders in an integrated health plan

OBJECTIVE: This study examined ethnic differences in accessing treatment for depression and substance use disorders (SUDs) among men and women in a large integrated health plan, and explored factors potentially contributing to health care disparities. METHODS: Participants were 22,543 members ages 20 to 65 who responded to health surveys in 2002 and 2005. Survey questions were linked to provider-assigned diagnoses, electronic medication, psychiatry, and chemical dependency program records. RESULTS: Among women diagnosed with depression, Latinas (p < .01) and Asian-Americans (p < .001) were less likely than Whites to fill an antidepressant prescription. Among men diagnosed with depression, African Americans (p < .01) were less likely than Whites to do so. Among women diagnosed with an SUD, African Americans (p < .05) were less likely than Whites to have one or more chemical dependency program visits. CONCLUSIONS: Results demonstrated ethnic differences in accessing depression and SUD treatment among patients diagnosed with these disorders, which persisted after controlling for education, income, having a regular health care provider and length of health plan enrollment. Findings highlight potential gender differences in ethnic disparities, lower antidepressant utilization among Asian Americans, and the effects of co-occurring disorders in accessing behavioral health care.

Authors: Satre DD; Campbell CI; Gordon NS; Weisner C

Int J Psychiatry Med. 2010;40(1):57-76.

PubMed abstract

Distribution of asymmetric dimethylarginine among 980 healthy, older adults of different ethnicities

BACKGROUND: Endothelium-derived nitric oxide plays a crucial role in the regulation of vascular tone and the development of cardiovascular disease. The endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine (ADMA) has emerged as a novel cardiovascular risk factor. ADMA appears to be an independent predictor for cardiovascular and overall mortality. However, the majority of studies investigating the clinical role of ADMA were performed in European study populations with few individuals of other ethnicities. METHODS: We performed a cross-sectional study of 980 healthy, older (age 60-72 years) individuals of different ethnicities living in the San Francisco Bay area and analyzed ADMA plasma concentrations and their relationship to other cardiovascular risk factors. Plasma ADMA concentrations were measured using a recently developed, highly sensitive ELISA. RESULTS: In our entire sample, we were able to define a reference interval for ADMA plasma concentrations of 0.47 (90% CI 0.46-0.48) mumol/L to 0.85 (0.84-0.89) mumol/L. The mean ADMA concentration was 0.63 (SD 0.11) mumol/L (median 0.61 mumol/L). Mean ADMA concentrations were significantly lower in African Americans (0.60 mumol/L; P < 0.01) and mixed non-Hispanics (0.60 mumol/L; P < 0.05) compared with whites (0.63 mumol/L). ADMA was positively correlated with cystatin-C in both men (rho = 0.29) and women (rho = 0.37), and median plasma ADMA concentrations increased across cystatin-C quintiles. CONCLUSIONS: ADMA varies nearly 2-fold across a healthy sample of older men and women, correlates with age, body mass index, and renal function, and is different across ethnic groups. Additional studies in a wider age range and including larger ethnic subgroups would be useful.

Authors: Sydow K; Fortmann SP; Fair JM; Varady A; Hlatky MA; Go AS; Iribarren C; Tsao PS; ADVANCE Investigators

Clin Chem. 2010 Jan;56(1):111-20. Epub 2009 Nov 5.

PubMed abstract

Physical activity and obesity in African Americans: the Jackson Heart Study

OBJECTIVES: To better understand how obesity and low levels of physical activity (PA) contribute to racial health disparities, we examined the association of PA domains (work, home life, and leisure) with indicators of socioeconomic status and markers of obesity in African Americans. METHODS: These cross sectional analyses of interview and clinical measures from the baseline visit of the Jackson Heart Study of cardiovascular disease (CVD) in African Americans of the Jackson, Mississippi metropolitan statistical area included 3,174 women and 1,830 men aged 21-95 years. The main measures were active living, sport, work, home life, and total PA scores; participation in regular moderate or vigorous intensity leisure physical activity (MVLPA); demographics, body mass index (BMI), waist circumference (WC) and CVD risk factors. RESULTS: The sample was 63% female, 81% high school or college graduates, with 51% aged 45-64 years, and mostly overweight (32%) or obese (53%). Women were less active than men in all domains except home life. Total PA was inversely associated with WC in women and men. The overweight (BMI 25-29.9) group was most active in all domains except work; active living and sport PA and prevalence of MVLPA then declined in a dose response association with increasing BMI. Work PA was associated with the lowest BMI but otherwise with indicators of less favorable socioeconomic status and health. CONCLUSIONS: Observed differences in PA in African Americans by domain and association with obesity biomarkers suggest areas for future study and intervention to reduce health disparities.

Authors: Dubbert PM; Robinson JC; Sung JH; Ainsworth BE; Wyatt SB; Carithers T; Newton R; Rhudy JL; Barbour K; Sternfeld B; Taylor H

Ethn Dis. 2010 Autumn;20(4):383-9.

PubMed abstract

Ethnic differences in anemia among patients with diabetes mellitus: the Diabetes Study of Northern California (DISTANCE)

To examine ethnic differences in hemoglobin testing practices and to test the hypothesis that ethnicity is an independent predictor of anemia among patients with diabetes mellitus. We conducted a panel study to assess the rate of hemoglobin testing during 1999-2001 and the period prevalence and incidence of anemia among 79,985 adults with diabetes mellitus receiving care within Kaiser Permanente of Northern California. Anemia was defined as hemoglobin <13.0 g/dL in men or < 12.0 g/dL in women. Overall, 82.1% of the cohort was tested for anemia at least once during the 3-year study period. Mixed ethnicity patients were most likely to be tested, followed by whites, blacks, Latinos, and Asians (P < 0.0001). Fifteen percent of the cohort had prevalent anemia at baseline, and an additional 22% of those tested developed anemia during the study period. Anemia was more prevalent among blacks and mixed ethnicity persons compared with other racial/ethnic groups. Anemia was also more prevalent among those >/=70 years of age or with estimated glomerular filtration rate <60 ml/min/1.73 m(2). In multivariable models, blacks had higher and Asians had lower odds of prevalent anemia and hazard ratios of incident anemia compared with whites. Within a large, diverse cohort with diabetes, ethnicity was predictive of anemia, even after adjustment for age, level of kidney function, and other potential confounders. Blacks with diabetes are at increased risk of anemia relative to whites. These differences may account for some of the observed ethnic disparities in diabetes complications.

Authors: Ahmed AT; Go AS; Warton EM; Parker MM; Karter AJ

Am J Hematol. 2010 Jan;85(1):57-61.

PubMed abstract

Influence of the social environment on children’s school travel

OBJECTIVES: To analyze the association between parental perceptions of the social environment and walking and biking to school among 10-14-year-olds. METHODS: Surveys were conducted with 432 parents of 10-14-year-olds in the San Francisco Bay Area during 2006 and 2007; the final sample size was 357. The social environment was measured with a 3-item scale assessing child-centered social control. Unadjusted and adjusted differences in rates of active travel to school were compared between families reporting high levels of social control in their neighborhood and those reporting low or neutral levels of social control. Adjusted differences were computed by matching respondents on child and household characteristics and distance to school. RESULTS: Of children whose parents reported high levels of social control, 37% walked or biked to school, compared with 24% of children whose parents reported low or neutral levels. The adjusted difference between the two groups was 10 percentage points (p=0.04). The association was strongest for girls and non-Hispanic whites. CONCLUSIONS: Higher levels of parent-perceived child-centered social control are associated with more walking and biking to school. Increasing physical activity through active travel to school may require intervention programs to address the social environment.

Authors: McDonald NC; Deakin E; Aalborg AE

Prev Med. 2010 Jan;50 Suppl 1:S65-8. Epub 2009 Sep 29.

PubMed abstract

The literacy divide: health literacy and the use of an internet-based patient portal in an integrated health system-results from the diabetes study of northern California (DISTANCE)

Internet-based patient portals are intended to improve access and quality, and will play an increasingly important role in health care, especially for diabetes and other chronic diseases. Diabetes patients with limited health literacy have worse health outcomes, and limited health literacy may be a barrier to effectively utilizing internet-based health access services. We investigated use of an internet-based patient portal among a well characterized population of adults with diabetes. We estimated health literacy using three validated self-report items. We explored the independent association between health literacy and use of the internet-based patient portal, adjusted for age, gender, race/ethnicity, educational attainment, and income. Among 14,102 participants (28% non-Hispanic White, 14% Latino, 21% African-American, 9% Asian, 12% Filipino, and 17% multiracial or other ethnicity), 6099 (62%) reported some limitation in health literacy, and 5671 (40%) respondents completed registration for the patient portal registration. In adjusted analyses, those with limited health literacy had higher odds of never signing on to the patient portal (OR 1.7, 1.4 to 1.9) compared with those who did not report any health literacy limitation. Even among those with internet access, the relationship between health literacy and patient portal use persisted (OR 1.4, 95% CI 1.2 to 1.8). Diabetes patients reporting limited health literacy were less likely to both access and navigate an internet-based patient portal than those with adequate health literacy. Although the internet has potential to greatly expand the capacity and reach of health care systems, current use patterns suggest that, in the absence of participatory design efforts involving those with limited health literacy, those most at risk for poor diabetes health outcomes will fall further behind if health systems increasingly rely on internet-based services.

Authors: Sarkar U; Karter AJ; Liu JY; Adler NE; Nguyen R; Lopez A; Schillinger D

J Health Commun. 2010;15 Suppl 2:183-96.

PubMed abstract

Racial differences in pelvic organ prolapse

OBJECTIVE: To compare the estimated prevalence of, risk factors for, and level of bother associated with subjectively reported and objectively measured pelvic organ prolapse in a racially diverse cohort. METHODS: The Reproductive Risks for Incontinence Study at Kaiser 2 is a population-based cohort study of 2,270 middle-aged and older women. Symptomatic prolapse was self-reported, and bother was assessed on a five-point scale. In 1,137 women, prolapse was measured with the Pelvic Organ Prolapse Quantification (POP-Q) system. Multivariable logistic regression analysis was used to identify the independent association of prolapse and race while controlling for risk factors. RESULTS: The participants’ mean (standard deviation) age was 55 (9) years, and 44% were white, 20% were African American, 18% were Asian American, and 18% were Latina or other race. Seventy-four women (3%) reported symptomatic prolapse. In multivariable analysis, the risk of symptomatic prolapse was higher in white (prevalence ratio 5.35, 95% confidence interval [CI] 1.89-15.12) and Latina (prevalence ratio 4.89, 95% CI 1.64-14.58) compared with African-American women. Race was not associated with report of moderate to severe bother. Degree of prolapse by POP-Q stage was similar across all racial groups; however, the risk of the leading edge of prolapse at or beyond the hymen was higher in white (prevalence ratio 1.40, 95% CI 1.02-1.92) compared with African-American women. CONCLUSION: Compared with African-American women, Latina and white women had four to five times higher risk of symptomatic prolapse, and white women had 1.4-fold higher risk of objective prolapse with leading edge of prolapse at or beyond the hymen. LEVEL OF EVIDENCE: II.

Authors: Whitcomb EL; Rortveit G; Brown JS; Creasman JM; Thom DH; Van Den Eeden SK; Subak LL

Obstet Gynecol. 2009 Dec;114(6):1271-7.

PubMed abstract

Racial disparities in erectile dysfunction among participants in the California Men’s Health Study

INTRODUCTION: The burden of erectile dysfunction (ED) among different racial and ethnic groups is unclear, in part, because prior studies have not included all four major racial and ethnic groups in the same population-based sample. AIM: To determine the prevalence and odds of ED among all four major racial and ethnic groups after adjustment for demographic, medical, socioeconomic, and lifestyle characteristics. METHODS: This cross-sectional study was conducted using data from men, aged 45-69 years, without a diagnosis of prostate cancer (N = 78,445), who completed questionnaires as part of the California Men’s Health Study, a large multiethnic cohort study with detailed demographic, medical and, socioeconomic data. MAIN OUTCOME MEASURE: Erectile dysfunction measured by a previously validated four-level response question. RESULTS: The overall prevalence of ED by age category was 13%, 24%, and 44% for men aged 45-49 years, 50 and 59 years, and 60-69 years, respectively. In a multivariable model, relative to white men, Hispanic (OR 1.05, 95% CI 0.99, 1.12), Asian (OR 1.1, 95% CI 1.02, 1.19), and other men (OR 1.13, 95% CI 1.06, 1.1.21) had increased odds of moderate-severe ED, while black men were less likely to report moderate to severe ED (OR 0.86, 95% CI 0.81, 0.92). Black (OR 0.54, 95% CI 0.48, 0.61) and Asian men (OR 0.91, 95% CI 0.80, 1.04) were less likely to have severe ED after adjustment for age, socioeconomic status, medical co-morbidities, and lifestyle characteristics. CONCLUSION: These data demonstrate that the prevalence of ED among different racial and ethnic groups is likely the result of complex phenomena and depends upon the interplay of socioeconomic, demographic, medical, cultural, and lifestyle characteristics. After accounting for these factors, these data suggest that Asian and black men are less likely to have severe ED relative to white men.

Authors: Smith JF; Caan BJ; Sternfeld B; Haque R; Quesenberry CP Jr; Quinn VP; Shan J; Walsh TJ; Lue TF; Jacobsen SJ; Van Den Eeden SK

J Sex Med. 2009 Dec;6(12):3433-9. Epub 2009 Sep 30.

PubMed abstract

Correlates of prostate-specific antigen testing in a large multiethnic cohort

OBJECTIVE: To examine factors associated with prostate-specific antigen (PSA) testing in the multiethnic California Men’s Health Study. STUDY DESIGN: Cross-Sectional analysis nested within a cohort of male health plan members (n = 55,278). METHODS: We extracted laboratory serum PSA values during the study period from 1998 to 2002. Using selected demographic and healthcare factors, we estimated the proportion of men who underwent PSA testing at least once during the 5-year period. Odds ratios and corresponding 95% confidence intervals were estimated to assess the association between these factors and PSA screening use. RESULTS: African American men had substantially higher PSA screening prevalence than white men (82.6% vs 73.7%). Low PSA screening use was associated with Latino race/ethnicity, lower level of education, residency in the United States for 25 years or less, current smoking, and lack of PSA test discussion with healthcare providers. The strongest positive predictors of PSA testing were African American race/ethnicity (odds ratio, 1.66; 95% confidence interval, 1.50-1.83) and high concern about prostate cancer (odds ratio, 1.53; 95% confidence interval, 1.38-1.69). In contrast, when men did not discuss PSA testing with their physicians, they were 80% less likely to undergo screening. CONCLUSIONS: In this insured population for whom financial barriers are minimized, PSA screening varied by race/ethnicity and by other patient and clinical factors, possibly reflecting inconsistencies in prostate cancer screening guidelines. Despite these differences, healthcare providers have a key role in patients’ likelihood of undergoing PSA screening.

Authors: Haque R; Van Den Eeden SK; Jacobsen SJ; Caan B; Avila CC; Slezak J; Sternfeld B; Loo RK; Quinn VP

Am J Manag Care. 2009 Nov;15(11):793-9.

PubMed abstract

Disparities in outpatient and home health service utilization following stroke: results of a 9-year cohort study in Northern California

OBJECTIVE: To examine whether there are disparities in utilization of outpatient and home care services after stroke. DESIGN: Retrospective cohort study. SETTING: The Kaiser Permanente of Northern California health care system, which provides health care for approximately 3.3 million members. PARTICIPANTS: A total of 11,119 patients hospitalized for a stroke between 1996 and 2003 and followed for 1 year. MAIN OUTCOME MEASURES: Receipt of outpatient rehabilitation (physical therapy, occupational therapy, speech pathology, or physical medicine and rehabilitation/physiatry visits), and/or home health care. RESULTS: There were significant differences in outpatient rehabilitation visits and home health enrollment during the year after acute care discharge for all the parameters under study. Older age and female gender were associated with less outpatient rehabilitation treatment, but these subpopulations were more likely to be enrolled in home health care. Non-whites, patients from urban areas, those with ischemic strokes, and those with longer acute care hospital stays had relatively more outpatient rehabilitation and were also more likely to be enrolled in the home health program. In addition, patients living in geographic areas with a median household income of $80,000 or more had significantly more outpatient rehabilitation visits than did patients living in lower income areas. CONCLUSIONS: Variations in outpatient rehabilitation visits and in home health care exist in this large integrated health system in terms of age, gender, race/ethnicity, residence area, type of stroke, and length of stay in an acute care hospital. The Kaiser Permanente integrated health care system seems to have outpatient stroke rehabilitation and home health programs that are providing care without disparities in relation to non-white populations, but other disparities appear to exist that may be related to socioeconomic factors, referral patterns, family support systems, or other cultural factors that have not been identified.

Authors: Chan L; Wang H; Terdiman J; Hoffman J; Ciol MA; Lattimore BF; Sidney S; Quesenberry C; Lu Q; Sandel ME

PM R. 2009 Nov;1(11):997-1003.

PubMed abstract

Health-related quality of life among long-term rectal cancer survivors with an ostomy: manifestations by sex

PURPOSE: Intestinal stomas can pose significant challenges for long-term (> or = 5 years) rectal cancer (RC) survivors. Specifying common challenges and sociodemographic or clinical differences will further the development of tailored interventions to improve health-related quality of life (HRQOL). PATIENTS AND METHODS: This was a matched cross-sectional study of long-term RC survivors conducted in three Kaiser Permanente regions. The mailed questionnaire included the modified City of Hope Quality of Life-Ostomy (mCOH-QOL-Ostomy) and Medical Outcomes Study 36-Item Short-Form Health Survey, version 2 (SF-36v2). Groups surveyed were permanent ostomates (cases) and those who did not require an ostomy (controls). RC survivors were matched on sex, age, and time since diagnosis. Comparisons between groups used regression analysis with adjustment for age, comorbidity score, history of radiation therapy, income, and work status. RESULTS: Response rate was 54% (491 of 909). Cases and controls had similar demographic characteristics. On the basis of the mCOH-QOL-Ostomy, both male and female cases had significantly worse social well-being compared with controls, while only female cases reported significantly worse overall HRQOL and psychological well-being. For younger females (< age 75 years), ostomy had a greater impact on physical well-being compared with older females. Based on the SF-36v2, statistically significant and meaningful differences between female cases and controls were observed for seven of the eight scales and on the physical and mental component summary scores. CONCLUSION: Men and women report a different profile of challenges, suggesting the need for targeted or sex-specific interventions to improve HRQOL in this population. This may include focus on physical HRQOL for female ostomy survivors younger than age 75.

Authors: Krouse RS; Grant M; Hornbrook MC; et al.

J Clin Oncol. 2009 Oct 1;27(28):4664-70. Epub 2009 Aug 31.

PubMed abstract

Survival differences by race/ethnicity and treatment for localized hepatocellular carcinoma within the United States

Racial differences among hepatocellular carcinoma survival have been reported, but the etiology behind these disparities remains unclear. Using multi-variable logistic regression analysis, our restrospective cohort study investigated the demographic disparities in survival among localized hepatocellular carcinoma in the United States. From 1998 to 2001, 2,776 cases of localized hepatocellular carcinoma were identified. Significant racial/ethnic disparities in overall survival and utilization of therapies were identified. Compared with non-Hispanic white males, black females were 56% less likely to survive 3 years (OR 0.44; 95% CI 0.21-0.93). Treatment-specific models also demonstrated disparities, e.g., compared with non-Hispanic whites, Asians receiving transplantation were 77% more likely to survive 3 years (OR, 1.77; 95% CI 1.28-2.44). There are significant racial/ethnic disparities in 3-year survival among patients with localized hepatocellular carcinoma. These differences are partially explained by demographic differences in utilization of therapy and in stage-specific survival for each therapy.

Authors: Wong RJ; Corley DA

Dig Dis Sci. 2009 Sep;54(9):2031-9. Epub 2009 Jan 1.

PubMed abstract

Race/ethnicity and risk of AIDS and death among HIV-infected patients with access to care

BACKGROUND: Prior studies evaluating racial/ethnic differences in responses to antiretroviral therapy (ART) among HIV-infected patients have not adequately accounted for many potential confounders, and few have included Hispanic patients. OBJECTIVE: To identify racial/ethnic differences in ART adherence, and risk of AIDS and death after ART initiation for HIV patients with similar access to care. DESIGN: Retrospective cohort study. PARTICIPANTS: 4,686 HIV-infected patients (66% White, 20% Black, and 14% Hispanic) initiating ART and who were enrolled in an integrated healthcare system. MEASUREMENTS: Main outcomes evaluated were ART adherence, new AIDS clinical events, and all-cause mortality. The potential confounding effects of demographics, socioeconomic status, ART parameters, HIV disease stage, and other clinical parameters were considered in multivariable models. RESULTS: Adjusted mean adherence levels were higher among White (70.1%; ref) compared with Black (64.2%; P < 0.001) and Hispanic patients (65.2%; P < 0.001). Adjusted hazard ratios (HR) for the risk of new AIDS events (White patients as reference) were 1.3 (P = 0.09) for Black and 0.9 (P = 0.64) for Hispanic patients. The adjusted HR for AIDS comparing Hispanic to Black patients was 0.7 (P = 0.11). Hispanic patients had fewer deaths compared with other racial/ethnic groups, particularly cancer and cardiovascular-related. However, adjusted HRs for death were 1.2 (P = 0.37) and 0.9 (P = 0.62) for Black and Hispanic patients, respectively, compared with White patients and 0.9 (P = 0.63) for Hispanic compared with Black patients. Adjustment for adherence did not change inferences for AIDS or death. CONCLUSIONS: In the setting of similar access to care, we did not observe a disparity for the risk of clinical events for racial/ethnic minorities, despite lower ART adherence.

Authors: Silverberg MJ; Leyden W; Quesenberry CP Jr; Horberg MA

J Gen Intern Med. 2009 Sep;24(9):1065-72. Epub 2009 Jul 16.

PubMed abstract

Health disparities in the Latino population

In this review, the authors provide an approach to the study of health disparities in the US Latino population and evaluate the evidence, using mortality rates for discrete medical conditions and the total US population as a standard for comparison. They examine the demographic structure of the Latino population and how nativity, age, income, and education are related to observed patterns of health and mortality. A key issue discussed is how to interpret the superior mortality indices of Latino immigrants and the subsequent declining health status of later generations. Explanations for differences in mortality include selection, reverse selection, death record inconsistencies, inequalities in health status, transnational migration, social marginality, and adaptation to environmental conditions in the United States. The utility of the public health social inequality framework and the status syndrome for explaining Latino disparities is discussed. The authors examine excess mortality from 8 causes: diabetes, stomach cancer, liver cancer, cervical cancer, human immunodeficiency virus/acquired immunodeficiency syndrome, liver disease, homicide, and work-related injuries. The impact of intergenerational changes in health behavior within the Latino population and the contributory role of suboptimal health care are interpreted in the context of implications for future research, public health programs, and policies.

Authors: Vega WA; Rodriguez MA; Gruskin E

Epidemiol Rev. 2009;31:99-112. Epub 2009 Aug 27.

PubMed abstract

Gender differences in sleep disruption and fatigue on quality of life among persons with ostomies

STUDY OBJECTIVES: The aim of this study is to examine differences in sleep disruption and fatigue of men and women colorectal cancer (CRC) survivors with intestinal ostomies and associated health-related quality of life (HR-QOL). METHODS: Participants in this cross-sectional study of long-term (> 5 years) CRC survivors received care at Kaiser Permanente. Measures included the City of Hope QOL Ostomy questionnaire with narrative comments for ostomy-related ‘greatest challenges.’ The Short Form-36 Version 2 (SF-36v2) health survey provided physical (PCS) and mental composite scale (MCS) scores to examine generic HR-QOL. The ‘sleep disruption’ and ‘fatigue’ items from the ostomy questionnaire (scale from 0 to 10 with higher scores indicating better HR-QOL) were dependent variables, while independent variables included age, ethnicity, education, partnered status, body mass index, and time since surgery. Data were analyzed using chi-square for nominal variables, Student t-tests for continuous variables, and logistic regression with significance set at p < 0.05. RESULTS: On the ostomy-specific measure, women (n = 118) compared to men (n = 168) reported more sleep disruption (p < 0.01), adjusted for age, and greater levels of fatigue (p < 0.01), adjusted for time since surgery. Women's PCS and MCS scores indicated poorer HR-QOL compared to men, and differences were clinically meaningful. Qualitative narrative comments suggested that sleep disruption could stem from ostomy-associated fear of or actual leakage during sleep. CONCLUSION: Although women CRC survivors with ostomies report more sleep disruption and fatigue, which is reflected in their reduced physical and mental health scores on the SF-36v2 compared to men with ostomies, their stated reasons for disrupted sleep are similar to their male counterparts. These findings can provide a foundation for gender-relevant ostomy interventions to improve sleep and HR-QOL in this patient population.

Authors: Baldwin CM; Grant M; Wendel C; Hornbrook MC; Herrinton LJ; McMullen C; Krouse RS

J Clin Sleep Med. 2009 Aug 15;5(4):335-43.

PubMed abstract

Sexual function and aging in racially and ethnically diverse women

OBJECTIVES: To examine factors influencing sexual activity and functioning in racially and ethnically diverse middle-aged and older women. DESIGN: Cross-sectional cohort study. SETTING: Integrated healthcare delivery system. PARTICIPANTS: One thousand nine hundred seventy-seven women aged 45 to 80. MEASUREMENTS: Self-administered questionnaires assessed sexual desire, activity, satisfaction, and problems. RESULTS: Of the 1,977 participants (876 white, 388 African American, 347 Latina, and 351 Asian women), 43% reported at least moderate sexual desire, and 60% had been sexually active in the previous 3 months. Half of sexually active participants (n=969) described their overall sexual satisfaction as moderate to high. Among sexually inactive women, the most common reason for inactivity was lack of interest in sex (39%), followed by lack of a partner (36%), physical problem of partner (23%), and lack of interest by partner (11%); only 9% were inactive because of personal physical problems. In multivariable analysis, African-American women were more likely than white women to report at least moderate desire (odds ratio (OR)=1.65, 95% confidence interval (CI)=1.25-2.17) but less likely to report weekly sexual activity (OR=0.68, 95% CI=0.48-0.96); sexually active Latina women were more likely than white women to report at least moderate sexual satisfaction (OR=1.75, 95% CI=1.20-2.55). CONCLUSION: A substantial proportion of community-dwelling women remain interested and engaged in sexual activity into older age. Lack of a partner capable of or interested in sex may contribute more to sexual inactivity than personal health problems in this population. Racial and ethnic differences in self-reported sexual desire, activity, and satisfaction may influence discussions about sexual difficulties in middle-aged and older women.

Authors: Huang AJ; Subak LL; Thom DH; Van Den Eeden SK; Ragins AI; Kuppermann M; Shen H; Brown JS

J Am Geriatr Soc. 2009 Aug;57(8):1362-8. Epub 2009 Jun 24.

PubMed abstract

Identifying risk factors for racial disparities in diabetes outcomes: the translating research into action for diabetes study

BACKGROUND: Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications. OBJECTIVE: To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites. DESIGN: Case-control study. SUBJECTS: A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans. MEASURES: Cases were patients with poor control of at least 2 of 3 intermediate outcomes (HbA1c > or =8.0%, SBP > or =140 mmHg, LDL cholesterol > or =130 mg/dL) and controls were patients with good control of all 3 (HbA1c <8.0%, SBP <140 mmHg, LDL cholesterol <130 mg/dL). In multivariate analyses, we determined whether each of several potentially mutable risk factors, including depression, poor adherence to medications, low self-efficacy for reducing cardiovascular risk, and poor patient-provider communication, predicted case or control status. RESULTS: Among blacks but not whites, in multivariate analyses depression (odds ratio: 2.28; 95% confidence interval: 1.09-4.75) and having missed medication doses (odds ratio: 1.96; 95% confidence interval: 1.01-3.81) were associated with greater odds of being a case rather than a control. None of the other risk factors were associated for either blacks or whites. CONCLUSIONS: Depression and missing medication doses are more strongly associated with poor diabetes control among blacks than in whites. These 2 risk factors may represent important targets for patient-level interventions to address racial disparities in diabetes outcomes.

Authors: Duru OK; Gerzoff RB; Selby JV; Brown AF; Ackermann RT; Karter AJ; Ross S; Steers N; Herman WH; Waitzfelder B; Mangione CM

Med Care. 2009 Jun;47(6):700-6.

PubMed abstract

CYP1A1/2 haplotypes and lung cancer and assessment of confounding by population stratification

Prior studies of lung cancer and CYP1A1/2 in African-American and Latino populations have shown inconsistent results and have not yet investigated the haplotype block structure of CYP1A1/2 or addressed potential population stratification. To investigate haplotypes in the CYP1A1/2 region and lung cancer in African-Americans and Latinos, we conducted a case-control study (1998-2003). African-Americans (n = 535) and Latinos (n = 412) were frequency matched on age, sex, and self-reported race/ethnicity. We used a custom genotyping panel containing 50 single nucleotide polymorphisms in the CYP1A1/2 region and 184 ancestry informative markers selected to have large allele frequency differences between Africans, Europeans, and Amerindians. Latinos exhibited significant haplotype main effects in two blocks even after adjusting for admixture [odds ratio (OR), 2.02; 95% confidence interval (95% CI), 1.28-3.19 and OR, 0.55; 95% CI, 0.36-0.83], but no main effects were found among African-Americans. Adjustment for admixture revealed substantial confounding by population stratification among Latinos but not African-Americans. Among Latinos and African-Americans, interactions between smoking level and haplotypes were not statistically significant. Evidence of population stratification among Latinos underscores the importance of adjusting for admixture in lung cancer association studies, particularly in Latino populations. These results suggest that a variant occurring within the CYP1A2 region may be conferring an increased risk of lung cancer in Latinos.

Authors: Aldrich MC; Selvin S; Hansen HM; Barcellos LF; Wrensch MR; Sison JD; Kelsey KT; Buffler PA; Quesenberry CP Jr; Seldin MF; Wiencke JK

Cancer Res. 2009 Mar 15;69(6):2340-8. Epub 2009 Mar 10.

PubMed abstract

Black-White differences in hysterectomy prevalence: the CARDIA study

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

Authors: Bower JK; Schreiner PJ; Sternfeld B; Lewis CE

Am J Public Health. 2009 Feb;99(2):300-7. Epub 2008 Dec 4.

PubMed abstract

Cohort Profile: The Diabetes Study of Northern California (DISTANCE)–objectives and design of a survey follow-up study of social health disparities in a managed care population

Authors: Moffet HH; Adler N; Schillinger D; Ahmed AT; Laraia B; Selby JV; Neugebauer R; Liu JY; Parker MM; Warton M; Karter AJ

Int J Epidemiol. 2009 Feb;38(1):38-47. Epub 2008 Mar 7.

PubMed abstract

Prevalence and progression of subclinical atherosclerosis in younger adults with low short-term but high lifetime estimated risk for cardiovascular disease: the coronary artery risk development in young adults study and multi-ethnic study of atherosclerosis

BACKGROUND: We hypothesized that individuals with low 10-year but high lifetime cardiovascular disease risk would have a greater burden of subclinical atherosclerosis than those with low 10-year but low lifetime risk. METHODS AND RESULTS: We included 2988 individuals < or = 50 years of age at examination year 15 from the Coronary Artery Risk Development in Young Adults (CARDIA) study and 1076 individuals < or = 50 of age at study entry from the Multi-Ethnic Study of Atherosclerosis (MESA). The 10-year risk and lifetime risk for cardiovascular disease were estimated for each participant, permitting stratification into 3 groups: low 10-year (<10%)/low lifetime (<39%) risk, low 10-year (<10%)/high lifetime risk (> or = 39%), and high 10-year risk (> or = 10%) or diagnosed diabetes mellitus. Baseline levels and change in levels of subclinical atherosclerosis (coronary artery calcium or carotid intima-media thickness) were compared across risk strata. Among participants with low 10-year risk (91% of all participants) in CARDIA, those with a high lifetime risk compared with low lifetime risk had significantly greater common (0.83 versus 0.80 mm in men; 0.79 versus 0.75 mm in women) and internal (0.85 versus 0.80 mm in men; 0.80 versus 0.76 mm in women) carotid intima-media thickness, higher coronary artery calcium prevalence (16.6% versus 9.8% in men; 7.1% versus 2.3% in women), and significantly greater incidence of coronary artery calcium progression (22.3% versus 15.4% in men; 8.7% versus 5.3% in women). Similar results were observed in MESA. CONCLUSIONS: Individuals with low 10-year but high lifetime risk have a greater subclinical disease burden and greater incidence of atherosclerotic progression compared with individuals with low 10-year and low lifetime risk, even at younger ages.

Authors: Berry JD; Liu K; Folsom AR; Lewis CE; Carr JJ; Polak JF; Shea S; Sidney S; O'Leary DH; Chan C; Lloyd-Jones DM

Circulation. 2009 Jan 27;119(3):382-9. Epub 2009 Jan 12.

PubMed abstract

Racial differences in long-term adherence to oral antidiabetic drug therapy: a longitudinal cohort study

BACKGROUND: Adherence to oral antidiabetic medications is often suboptimal. Adherence differences may contribute to health disparities for black diabetes patients, including higher microvascular event rates, greater complication-related disability, and earlier mortality. METHODS: In this longitudinal retrospective cohort study, we used 10 years of patient-level claims and electronic medical record data (1/1/1992-12/31/2001) to assess differences in short- and long-term adherence to oral antidiabetic medication among 1906 newly diagnosed adults with diabetes (26% black, 74% white) in a managed care setting in which all members have prescription drug coverage. Four main outcome measures included: (1) time from diabetes diagnosis until first prescription of oral antidiabetic medication; (2) primary adherence (time from first prescription to prescription fill); (3) time until discontinuation of oral antidiabetic medication from first prescription; and (4) long-term adherence (amount dispensed versus amount prescribed) over a 24-month follow-up from first oral antidiabetic medication prescription. RESULTS: Black patients were as likely as whites to initiate oral therapy and fill their first prescription, but experienced higher rates of medication discontinuation (HR: 1.8, 95% CI: 1.2, 2.7) and were less adherent over time. These black-white differences increased over the first six months of therapy but stabilized thereafter for patients who initiated on sulfonylureas. Significant black-white differences in adherence levels were constant throughout follow-up for patients initiated on metformin therapy. CONCLUSION: Racial differences in adherence to oral antidiabetic drug therapy persist even with equal access to medication. Early and continued emphasis on adherence from initiation of therapy may reduce persistent racial differences in medication use and clinical outcomes.

Authors: Trinacty CM; Adams AS; Soumerai SB; Zhang F; Meigs JB; Piette JD; Ross-Degnan D

BMC Health Serv Res. 2009 Feb 7;9:24.

PubMed abstract

Birthplace and mortality among insured Latinos: the paradox revisited

OBJECTIVES: We investigated the Latino paradox in a managed care setting and examined the role of birthplace. METHODS: We evaluated 133,155 non-Latino Whites and 5,237 Latinos (36% born in the United States, 34% in Central and South America, 21% in Mexico, and 8% in the Caribbean Islands) who were enrolled in an integrated healthcare delivery system in northern California. Baseline data were from 1964-1973, and the median followup was 34 years. Main outcome measures were cause-specific and all-cause mortality. RESULTS: In fully-adjusted analyses, and compared with non-Latino Whites, the risk of death from circulatory causes was significantly lower among US-born Latinos (hazard ratio [HR] .79, 95% confidence interval [CI] .66-.93), among Central and South America-born Latinos (HR .76, 95% CI .63-.91), and Caribbean-born Latinos (HR .66, 95% CI .47-0.93). Risk of death by malignant neoplasms was significantly lower among US-born Latinos (HR .68, 95% CI .56-.83). Risk of respiratory death was significantly lower among Central and South America-born Latinos (HR .50, 95% CI .32-.80). All-cause mortality risk was significantly decreased in US-born Latinos (HR .79, 95% CI .71-.87), Central and South America-born Latinos (HR .81, 95% CI .73-.90), and Caribbean-born Latinos (HR .76, 95% CI .63-.93) but not in Mexico-born Latinos. CONCLUSIONS: In our managed care setting, the Latino paradox phenomenon varied by birthplace; it was more evident among US-born Latinos. This subgroup experienced lower circulatory, cancer, and all-cause mortality than did non-Latino Whites, despite higher prevalences of current smoking, obesity, and asymptomatic hyperglycemia.

Authors: Iribarren C; Darbinian JA; Fireman BH; Burchard EG

Ethn Dis. 2009 Spring;19(2):185-91.

PubMed abstract

Characterizing the admixed African ancestry of African Americans

BACKGROUND: Accurate, high-throughput genotyping allows the fine characterization of genetic ancestry. Here we applied recently developed statistical and computational techniques to the question of African ancestry in African Americans by using data on more than 450,000 single-nucleotide polymorphisms (SNPs) genotyped in 94 Africans of diverse geographic origins included in the HGDP, as well as 136 African Americans and 38 European Americans participating in the Atherosclerotic Disease Vascular Function and Genetic Epidemiology (ADVANCE) study. To focus on African ancestry, we reduced the data to include only those genotypes in each African American determined statistically to be African in origin. RESULTS: From cluster analysis, we found that all the African Americans are admixed in their African components of ancestry, with the majority contributions being from West and West-Central Africa, and only modest variation in these African-ancestry proportions among individuals. Furthermore, by principal components analysis, we found little evidence of genetic structure within the African component of ancestry in African Americans. CONCLUSIONS: These results are consistent with historic mating patterns among African Americans that are largely uncorrelated to African ancestral origins, and they cast doubt on the general utility of mtDNA or Y-chromosome markers alone to delineate the full African ancestry of African Americans. Our results also indicate that the genetic architecture of African Americans is distinct from that of Africans, and that the greatest source of potential genetic stratification bias in case-control studies of African Americans derives from the proportion of European ancestry.

Authors: Zakharia F; Go AS; Iribarren C; Risch N; Tang H; et al.

Genome Biol. 2009;10(12):R141. Epub 2009 Dec 22.

PubMed abstract

Disparities in stroke rehabilitation: results of a study in an integrated health system in northern California

OBJECTIVE: To determine whether there are disparities in postacute stroke rehabilitation based on type of stroke, race/ethnicity, sex/gender, age, socioeconomic status, geographic region, or service area referral patterns in a large integrated health system with multiple levels of care. DESIGN: Cohort study tracking rehabilitation services for 365 days after acute hospitalization for a first stroke. SETTING: The Northern California Kaiser Permanente Health System (approximately 3.3 million membership population) PARTICIPANTS: A total of 11,119 patients hospitalized for acute stroke from 1996 to 2003. The cohort includes patients discharged from acute care after a stroke. Postacute care rehabilitation services were evaluated according to the level of care ever-received within the 365 days after discharge from acute care, including inpatient rehabilitation hospital (IRH), skilled nursing facility (SNF), home health and outpatient, or no rehabilitation services. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Service delivery. RESULTS: Patients discharged to an IRH had longer lengths of stay in acute care. Patients with hemorrhagic stroke were less likely to be treated in an IRH. Patients whose highest level of rehabilitation was SNF were older and more likely to be women. After adjusting for age and other covariates, women were less likely to go to an IRH than men. Asian and black patients were more likely than white patients to be treated in an IRH or SNF. Also more likely to go to an IRH were patients from higher socioeconomic groups, from urban areas, and from geographic areas close to the regional rehabilitation hospital. CONCLUSIONS: These results suggest variation in care delivery and extent of postacute care based on differences in patient demographics and geographic factors. Results also varied over time. Some minority populations in this cohort appeared to be more likely to receive IRH care, possibly because of disease severity, family support systems, cultural factors, or differences in referral patterns.

Authors: Sandel ME; Wang H; Terdiman J; Hoffman JM; Ciol MA; Sidney S; Quesenberry C; Lu Q; Chan L

PM R. 2009 Jan;1(1):29-40. Epub 2009 Jan 9.

PubMed abstract

Base excision repair genes and risk of lung cancer among San Francisco Bay Area Latinos and African-Americans

Base excision repair (BER) is the primary DNA damage repair mechanism for repairing small base lesions resulting from oxidation and alkylation damage. This study examines the association between 24 single-nucleotide polymorphisms (SNPs) belonging to five BER genes (XRCC1, APEX1, PARP1, MUTYH and OGG1) and lung cancer among Latinos (113 cases and 299 controls) and African-Americans (255 cases and 280 controls). The goal was to evaluate the differences in genetic contribution to lung cancer risk by ethnic groups. Analyses of individual SNPs and haplotypes were performed using unconditional logistic regressions adjusted for age, sex and genetic ancestry. Four SNPs among Latinos and one SNP among African-Americans were significantly (P < 0.05) associated with either risk of all lung cancer or non-small cell lung cancer (NSCLC). However, only the association between XRCC1 Arg399Gln (rs25487) and NSCLC among Latinos (odds ratio associated with every copy of Gln = 1.52; 95% confidence interval: 1.01-2.28) had a false-positive report probability of <0.5. Arg399Gln is a SNP with some functional evidence and has been shown previously to be an important SNP associated with lung cancer, mostly for Asians. Since the analyses were adjusted for genetic ancestry, the observed association between Arg399Gln and NSCLC among Latinos is unlikely to be confounded by population stratification; however, this result needs to be confirmed by additional studies among the Latino population. This study suggests that there are genetic differences in the association between BER pathway and lung cancer between Latinos and African-Americans.

Authors: Chang JS; Wrensch MR; Hansen HM; Sison JD; Aldrich MC; Quesenberry CP Jr; Seldin MF; Kelsey KT; Wiencke JK

Carcinogenesis. 2009 Jan;30(1):78-87. Epub 2008 Nov 24.

PubMed abstract

Generational status and duration of residence predict diabetes prevalence among Latinos: the California Men’s Health Study

BACKGROUND: Diabetes disproportionately affects Latinos. However, examining Latinos as one group obscures important intra-group differences. This study examined how generational status, duration of US residence, and language preference are associated with diabetes prevalence and to what extent these explain the higher prevalence among Latinos. METHODS: We determined nativity, duration of US residence, language preference, and diabetes prevalence among 11 817 Latino, 6109 black, and 52 184 white participants in the California Men’s Health Study. We combined generational status and residence duration into a single migration status variable with levels: > or = third generation; second generation; and immigrant living in the US for > 25, 16-25, 11-15, or < or = 10 years. Language preference was defined as language in which the participant took the survey. Logistic regression models were specified to assess the associations of dependent variables with prevalent diabetes. RESULTS: Diabetes prevalence was 22%, 23%, and 11% among Latinos, blacks, and whites, respectively. In age-adjusted models, we observed a gradient of risk of diabetes by migration status among Latinos. Further adjustment for socioeconomic status, obesity and health behaviors only partially attenuated this gradient. Language preference was a weak predictor of prevalent diabetes in some models and not significant in others. In multivariate models, we found that odds of diabetes were higher among US-born Latinos than US-born blacks. CONCLUSION: Generational status and residence duration were associated with diabetes prevalence among middle-aged Latino men in California. As the Latino population grows, the burden of diabetes-associated disease is likely to increase and demands public health attention.

Authors: Ahmed AT; Quinn VP; Caan B; Sternfeld B; Haque R; Van den Eeden SK

BMC Public Health. 2009 Oct 19;9:392.

PubMed abstract

Chronic kidney disease in United States Hispanics: a growing public health problem

Hispanics are the fastest growing minority group in the United States. The incidence of end-stage renal disease (ESRD) in Hispanics is higher than non-Hispanic Whites and Hispanics with chronic kidney disease (CKD) are at increased risk for kidney failure. Likely contributing factors to this burden of disease include diabetes and metabolic syndrome, both are common among Hispanics. Access to health care, quality of care, and barriers due to language, health literacy and acculturation may also play a role. Despite the importance of this public health problem, only limited data exist about Hispanics with CKD. We review the epidemiology of CKD in US Hispanics, identify the factors that may be responsible for this growing health problem, and suggest gaps in our understanding which are suitable for future investigation.

Authors: Lora CM; Daviglus ML; Kusek JW; Porter A; Ricardo AC; Go AS; Lash JP

Ethn Dis. 2009 Autumn;19(4):466-72.

PubMed abstract

Racial differences in self-reported infertility and risk factors for infertility in a cohort of black and white women: the CARDIA Women’s Study

OBJECTIVE: To determine racial differences in self-reported infertility and in risk factors for infertility in a cohort of black and white women. DESIGN: A cross-sectional analysis of data from the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) Study, a prospective, epidemiologic investigation of the determinants and evolution of cardiovascular risk factors among black and white young adults and from the ancillary CARDIA Women’s Study (CWS). SETTING: Population-based sample from four US communities (Birmingham, AL; Chicago, IL; Minneapolis, MN; Oakland, CA). PATIENT(S): Women aged 33-44 years who had complete data (n = 764). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Self-report of ever having unprotected sexual intercourse for at least 12 months without becoming pregnant. RESULT(S): Among nonsurgically sterile women, blacks had a twofold increased odds (95% confidence interval [CI] 1.3-3.1) of infertility compared with whites after adjustment for socioeconomic position (education and ability to pay for basics), correlates of pregnancy intent (marital status and hormonal contraceptive use), and risk factors for infertility (age, smoking, T, fibroid presence, and ovarian volume). The corresponding odds ratio among all women was 1.5 (95% CI 1.0-2.2). Difficulty paying for basics and ovarian volume were associated with infertility among black but not white women. CONCLUSION(S): In this population-based sample, black women were more likely to have experienced infertility. This disparity is not explained by common risk factors for infertility, such as smoking and obesity, and among nonsurgically sterile women, it is not explained by gynecologic risk factors such as fibroids and ovarian volume.

Authors: Wellons MF; Lewis CE; Schwartz SM; Gunderson EP; Schreiner PJ; Sternfeld B; Richman J; Sites CK; Siscovick DS

Fertil Steril. 2008 Nov;90(5):1640-8. Epub 2008 Mar 5.

PubMed abstract

Comparison of statistical methods for estimating genetic admixture in a lung cancer study of African Americans and Latinos

A variety of methods are available for estimating genetic admixture proportions in populations; however, few investigators have conducted detailed comparisons using empirical data. The authors characterized admixture proportions among self-identified African Americans (n = 535) and Latinos (n = 412) living in the San Francisco Bay Area who participated in a lung cancer case-control study (1998-2003). Individual estimates of genetic ancestry based on 184 informative markers were obtained from a Bayesian approach and 2 maximum likelihood approaches and were compared using descriptive statistics, Pearson correlation coefficients, and Bland-Altman plots. Case-control differences in individual admixture proportions were assessed using 2-sample t tests and logistic regression analysis. Results indicated that Bayesian and frequentist approaches to estimating admixture provide similar estimates and inferences. No difference was observed in admixture proportions between African-American cases and controls, but Latino cases and controls significantly differed according to Amerindian and European genetic ancestry. Differences in admixture proportions between Latino cases and controls were not unexpected, since cases were more likely to have been born in the United States. Genetic admixture proportions provide a quantitative measure of ancestry differences among Latinos that can be used in analyses of genetic risk factors.

Authors: Aldrich MC; Quesenberry CP; Wiencke JK; et al.

Am J Epidemiol. 2008 Nov 1;168(9):1035-46. Epub 2008 Sep 12.

PubMed abstract

Nucleotide excision repair genes and risk of lung cancer among San Francisco Bay Area Latinos and African Americans

Few studies on the association between nucleotide excision repair (NER) variants and lung cancer risk have included Latinos and African Americans. We examine variants in 6 NER genes (ERCC2, ERCC4, ERCC5, LIG1, RAD23B and XPC) in association with primary lung cancer risk among 113 Latino and 255 African American subjects newly diagnosed with primary lung cancer from 1998 to 2003 in the San Francisco Bay Area and 579 healthy controls (299 Latinos and 280 African Americans). Individual single nucleotide polymorphism and haplotype analyses, multifactor dimensionality reduction (MDR) and principal components analysis (PCA) were performed to assess the association between 6 genes in the NER pathway and lung cancer risk. Among Latinos, ERCC2 haplotype CGA (rs238406, rs11878644, rs6966) was associated with reduced lung cancer risk [odds ratio (OR) of 0.65 and 95% confidence interval (CI): 0.44-0.97], especially among nonsmokers (OR = 0.29; 95% CI: 0.12-0.67). From MDR analysis, in Latinos, smoking and 3 SNPs (ERCC2 rs171140, ERCC5 rs17655 and LIG1 rs20581) together had a prediction accuracy of 67.4% (p = 0.001) for lung cancer. Among African Americans, His/His genotype of ERCC5 His1104Asp (rs17655) was associated with increased lung cancer risk (OR = 1.78; 95% CI: 1.09-2.91), and LIG1 haplotype GGGAA (rs20581, rs156641, rs3730931, rs20579 and rs439132) was associated with reduced lung cancer risk (OR = 0.61; 95% CI: 0.42-0.88). Our study suggests different elements of the NER pathway may be important in the different ethnic groups resulting either from different linkage relationship, genetic backgrounds and/or exposure histories.

Authors: Chang JS; Wrensch MR; Hansen HM; Sison JD; Aldrich MC; Quesenberry CP Jr; Seldin MF; Kelsey KT; Kittles RA; Silva G; Wiencke JK

Int J Cancer. 2008 Nov 1;123(9):2095-104.

PubMed abstract

Comparison of baseline dietary intake of Hispanic and matched non-Hispanic white breast cancer survivors enrolled in the Women’s Healthy Eating and Living study

OBJECTIVE: To assess the reported baseline dietary intake of Hispanic and non-Hispanic white breast cancer survivors in the Women’s Healthy Eating and Living study, a randomized plant-based dietary intervention clinical trial. DESIGN: Dietary data from 4 days repeated 24-hour recalls within 3 weeks included daily total intake of energy, protein, carbohydrates, cholesterol, total fat, monounsaturated fat, saturated fat, polyunsaturated fat, fruit/vegetable servings, carotenoids, alcohol, caffeine, and percentage of energy from protein, carbohydrates, alcohol, and fats. SUBJECTS: One hundred sixty-five Hispanic breast cancer survivors age-matched to 165 non-Hispanic white breast cancer survivors diagnosed with Stage I, II, or IIIA primary operable breast cancer. STATISTICAL ANALYSES: Two-sample t tests and Wilcoxon rank sum tests to compare dietary intake, and logistic and ordinal logistic regression analyses to examine the association between ethnicity, alcohol, and lycopene consumption, while controlling for place of birth, education, body mass index, and time since diagnosis. RESULTS: Hispanics were more likely to be foreign-born (P<0.001), less educated (P<0.0001) and to consume higher amounts of lycopene (P=0.029), while non-Hispanic whites were more likely to consume alcohol (P=0.001). However, no differences were observed in the average amounts of alcohol consumed or total percents of energy from alcohol. Both groups consumed more than five servings of fruits and vegetables daily. Being Hispanic remained a significant predictor of lower alcohol use (P=0.004) and higher lycopene consumption (P=0.005) after controlling for place of birth, education, body mass index, and time since diagnosis. CONCLUSIONS: There are more similarities than differences in the dietary intake of Hispanic and non-Hispanic white breast cancer survivors in the Women's Healthy Eating and Living study. Further analysis is needed to determine if higher lycopene consumption shown among the Hispanic participants will translate to greater protection against breast cancer recurrence or increased survival.

Authors: Hernandez-Valero MA; Thomson CA; Hernandez M; Tran T; Detry MA; Theriault RL; Hajek RA; Pierce JP; Flatt SW; Caan BJ; Jones LA

J Am Diet Assoc. 2008 Aug;108(8):1323-9.

PubMed abstract

Racial differences in treatment of early-stage prostate cancer

OBJECTIVES: To determine whether differences existed in prostate cancer treatment received by white and African American men at a health maintenance organization where access to medical care is theoretically equal for all members and, if so, to determine the reasons for these differences. METHODS: We used information from the Kaiser Permanente Northwest Tumor Registry to identify all men diagnosed with local- or regional-stage prostate cancer between 1980 and 2000. We compared the likelihood of treatment with curative intent (TCI) between the two races, adjusting for age, tumor grade, stage, and the presence of comorbid conditions. We reviewed medical records of all 79 African American men and a sample of 158 white men (matched for age, stage, grade, and year of diagnosis) to determine the reasons that men did or did not receive TCI. RESULTS: Seventy-one percent of African American men and 82% of white men were treated with curative intent (P = 0.01). African American men were not more likely than white men to refuse TCI when it was offered (10.6% versus 8.1%, respectively; P = 0.6). However, urologists offered TCI less often to African American men than to white men (85% versus 91%, respectively; P = 0.02), and this difference could not be explained by differences in age, tumor grade, stage, or presence of comorbid conditions. CONCLUSIONS: African American men were less likely to receive TCI than white men. Because all of the men were insured, economic factors did not cause this difference. Furthermore, the cause did not seem to be differences in age, tumor grade, stage, or comorbid conditions.

Authors: Richert-Boe KE; Weinmann S; Shapiro JA; Rybicki BA; Enger SM; Van Den Eeden SK; Weiss NS

Urology. 2008 Jun;71(6):1172-6. Epub 2008 Feb 15.

PubMed abstract

Racial and ethnic variations in hepatocellular carcinoma incidence within the United States

BACKGROUND: The increasing incidence of hepatocellular carcinoma coupled with this cancer’s high mortality is a public health problem. Delineating high-risk populations and cancer patterns can provide valuable information. This is necessary to broaden screening and surveillance guidelines related to early detection and prevention. METHODS: By using data collected by the Surveillance, Epidemiology, and End Results program, a population-based cancer registry in the United States, our retrospective cohort study evaluated sex-specific, race/ethnicity-specific, and age-specific variations in hepatocellular carcinoma incidence from 1992 to 2004. RESULTS: With men and women combined, the incidence of hepatocellular carcinoma among Asians was the highest, nearly double that of white Hispanics (11.0 vs 6.8 per 100,000/y), and more than 4 times higher than that of Caucasians (11.0 vs 2.6 per 100,000/y). Although male subjects demonstrated a doubling of cancer rates every 10 years from 30 to 50 years of age, female subjects reached male-comparable rates of cancer 10 to 15 years later and peaked at significantly lower values for all race and ethnic groups. CONCLUSION: Marked differences in the incidence rates of hepatocellular carcinoma by sex, ethnicity, and age of diagnosis likely represent variations in risk factor distributions (eg, viral hepatitis) and possibly in host genetics or other environmental factors. An individualized approach tailored to specific risk profiles may more effectively identify treatable tumors than more general guidelines.

Authors: Wong R; Corley DA

Am J Med. 2008 Jun;121(6):525-31.

PubMed abstract

Ethnic differences in C-reactive protein concentrations

BACKGROUND: Limited data exist regarding the ethnic differences in C-reactive protein (CRP) concentrations, an inflammatory marker associated with risk of cardiovascular disease (CVD). We hypothesized that known CVD risk factors, including anthropometric characteristics, would explain much of the observed ethnic variation in CRP. METHODS: We performed a cross-sectional analysis of 3154 women, without known CVD and not receiving hormone therapy, enrolled in the Study of Women’s Health Across the Nation (SWAN), a multiethnic prospective study of pre- and perimenopausal women. RESULTS: The study population was 47.4% white, 27.7% African-American, 8.5% Hispanic, 7.7% Chinese, and 8.6% Japanese; mean age was 46.2 years. African-American women had the highest median CRP concentrations (3.2 mg/L), followed by Hispanic (2.3 mg/L), white (1.5 mg/L), Chinese (0.7 mg/L), and Japanese (0.5 mg/L) women (all pairwise P < 0.001 compared with white women). Body mass index (BMI) markedly attenuated the association between ethnicity and CRP. After adjusting for age, socioeconomic status, BMI, and other risk factors, African-American ethnicity was associated with CRP concentrations >3 mg/L (odds ratio 1.37, 95% CI 1.07-1.75), whereas Chinese and Japanese ethnicities were inversely related (0.58, 0.35-0.95, and 0.43, 0.26-0.72, respectively). CONCLUSIONS: Modifiable risk factors, particularly BMI, account for much but not all of the ethnic differences in CRP concentrations. Further study is needed of these ethnic differences and their implications for the use of CRP in CVD risk prediction.

Authors: Kelley-Hedgepeth A; Lloyd-Jones DM; Colvin A; Matthews KA; Johnston J; Sowers MR; Sternfeld B; Pasternak RC; Chae CU; SWAN Investigators

Clin Chem. 2008 Jun;54(6):1027-37. Epub 2008 Apr 10.

PubMed abstract

Cardiac autonomic control and the effects of age, race, and sex: the CARDIA study

BACKGROUND: Stratification variables of age, race, and sex figure prominently in the assessment of cardiovascular disease risk. Similarly, cardiac autonomic regulation, measured by RR interval variability (RRV), is associated with risk. The relationship among these variables is unclear. METHODS: We examined the cross-sectional relationship between RRV and age, race, and sex in 757 subjects from the NHLBI-funded Coronary Artery Disease in Young Adults (CARDIA) Study. RESULTS: Age was a significant determinant of RRV, despite the narrow range (33-47): participants aged 33-39 years had had greater levels of HF power, LF power, and standard deviation (SD) of RR intervals than did those aged 40-47 years. There was no age effect for the LF/HF ratio. Compared to whites, blacks had lower levels of LF power, SD, and lower LF/HF. Blacks and whites did not differ in HF power. Finally, compared to men, women had lower levels of LF power, SD, and LF/HF but did not differ in HF power. CONCLUSIONS: Data from the CARDIA study suggest that in adults in the 33-47 year age range, indices of RRV were greater in younger compared to older subjects, in men compared to women and in whites compared to blacks. These findings are broadly consistent with those of other large studies examining relationships between RRV and age, sex, and race. However, patterns of associations between RRV and these stratification variables are not entirely consistent with an underlying autonomic physiology linked to cardioprotection.

Authors: Sloan RP; Huang MH; McCreath H; Sidney S; Liu K; Dale Williams O; Seeman T

Auton Neurosci. 2008 May 30;139(1-2):78-85. Epub 2008 Mar 4.

PubMed abstract

Use of recovery biomarkers to calibrate nutrient consumption self-reports in the Women’s Health Initiative

Underreporting of energy consumption by self-report is well-recognized, but previous studies using recovery biomarkers have not been sufficiently large to establish whether participant characteristics predict misreporting. In 2004-2005, 544 participants in the Women’s Health Initiative Dietary Modification Trial completed a doubly labeled water protocol (energy biomarker), 24-hour urine collection (protein biomarker), and self-reports of diet (assessed by food frequency questionnaire (FFQ)), exercise, and lifestyle habits; 111 women repeated all procedures after 6 months. Using linear regression, the authors estimated associations of participant characteristics with misreporting, defined as the extent to which the log ratio (self-reported FFQ/nutritional biomarker) was less than zero. Intervention women in the trial underreported energy intake by 32% (vs. 27% in the comparison arm) and protein intake by 15% (vs. 10%). Younger women had more underreporting of energy (p = 0.02) and protein (p = 0.001), while increasing body mass index predicted increased underreporting of energy and overreporting of percentage of energy derived from protein (p = 0.001 and p = 0.004, respectively). Blacks and Hispanics underreported more than did Caucasians. Correlations of initial measures with repeat measures (n = 111) were 0.72, 0.70, 0.46, and 0.64 for biomarker energy, FFQ energy, biomarker protein, and FFQ protein, respectively. Recovery biomarker data were used in regression equations to calibrate self-reports; the potential application of these equations to disease risk modeling is presented. The authors confirm the existence of systematic bias in dietary self-reports and provide methods of correcting for measurement error.

Authors: Neuhouser ML; Caan B; Prentice RL; et al.

Am J Epidemiol. 2008 May 15;167(10):1247-59. Epub 2008 Mar 15.

PubMed abstract

Medication adherence and racial differences in A1C control

​OBJECTIVE: The purpose of this study was to examine medication adherence and other self-management practices as potential determinants of higher glycemic risk among black relative to white patients.RESEARCH DESIGN AND METHODS: We used a retrospective, longitudinal repeated-measures design to model the contribution of medication adherence to black-white differences in A1C among type 2 diabetic patients at a large multispecialty group practice. We identified 1,806 adult (aged >/=18 at diagnosis) patients (467 black and 1,339 white) with newly initiated oral hypoglycemic therapy between 1 December 1994 and 31 December 2000. Race was identified using an electronic medical record and patient self-report. Baseline was defined as the 13 months preceding and included the month of therapy initiation. All patients were required to have at least 12 months of follow-up.RESULTS: At initiation of therapy, black patients had higher average A1C values compared with whites (9.8 vs. 8.9, a difference of 0.88; P < 0.0001). Blacks had lower average medication adherence during the first year of therapy (72 vs. 78%; P < 0.0001). Although more frequent medication refills were associated with lower average A1C values, adjustment for adherence did not eliminate the black-white gap.CONCLUSIONS: We found persistent racial differences in A1C that were not explained by differences in medication adherence. Our findings suggest that targeting medication adherence alone is unlikely to reduce disparities in glycemic control in this setting. Further research is needed to explore possible genetic and environmental determinants of higher A1C among blacks at diagnosis, which may represent a critical period for more intensive intervention..

Authors: Adams AS; Trinacty CM; Zhang F; Kleinman K; Grant RW; Meigs JB; Soumerai SB; Ross-Degnan D

​​Diabetes Care. 2008 May;31(5):916-21. doi: 10.2337/dc07-1924. Epub 2008 Jan 30.

PubMed abstract

Perception of neighborhood problems, health behaviors, and diabetes outcomes among adults with diabetes in managed care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE: Recent data suggest that residential environment may influence health behaviors and outcomes. We assessed whether perception of neighborhood problems was associated with diabetes behaviors and outcomes. RESEARCH DESIGN AND METHODS: This cross-sectional analysis included 7,830 diabetic adults enrolled in Translating Research Into Action for Diabetes, a study of diabetes care and outcomes in managed care settings. Perception of neighborhood problems was measured using a summary score of participants’ ratings of crime, trash, litter, lighting at night, and access to exercise facilities, transportation, and supermarkets. Outcomes included health behaviors and clinical outcomes. Hierarchical regression models were used to account for clustering of patients within neighborhoods and to adjust for objective neighborhood socioeconomic status (percentage living in poverty) and potential individual-level confounders (age, sex, race/ethnicity, education, income, comorbidity index, and duration of diabetes). RESULTS: After adjustment, residents of neighborhoods in the lowest tertile (most perceived problems) reported higher rates of current smoking (15 vs. 11%) than those in the highest tertile and had slightly lower participation in any weekly physical activity (95 vs. 96%). In addition, their blood pressure control was worse (25 vs. 31% <130/80 mmHg), and their Short Form 12 scores were slightly lower (44 vs. 46 units for emotional well-being and 43 vs. 44 units for physical well-being); all P < 0.01. CONCLUSIONS: Neighborhood problems were most strongly associated with more smoking and higher blood pressure, both of which have significant implications for cardiovascular risk. Potential mechanisms that explain these associations should be further explored in longitudinal studies.

Authors: Gary TL; Safford MM; Gerzoff RB; Ettner SL; Karter AJ; Beckles GL; Brown AF

Diabetes Care. 2008 Feb;31(2):273-8. Epub 2007 Nov 13.

PubMed abstract

Race/ethnicity and economic differences in cost-related medication underuse among insured adults with diabetes: the Translating Research Into Action for Diabetes Study

OBJECTIVE: To examine racial/ethnic and economic variation in cost-related medication underuse among insured adults with diabetes. RESEARCH DESIGN AND METHODS: We surveyed 5,086 participants from the multicenter Translating Research Into Action for Diabetes Study. Respondents reported whether they used less medication because of cost in the past 12 months. We examined unadjusted and adjusted rates of cost-related medication underuse, using hierarchical regression, to determine whether race/ethnicity differences still existed after accounting for economic, health, and other demographic variables. RESULTS: Participants were 48% white, 14% African American, 14% Latino, 15% Asian/Pacific Islander, and 8% other. Overall, 14% reported cost-related medication underuse. Unadjusted rates were highest for Latinos (23%) and African Americans (17%) compared with whites (13%), Asian/Pacific Islanders (11%), and others (15%). In multivariate analyses, race/ethnicity significantly predicted cost-related medication underuse (P = 0.048). However, adjusted rates were only slightly higher for Latinos (14%) than whites (10%) (P = 0.026) and were not significantly different for African Americans (11%), Asian/Pacific Islanders (7%), and others (11%). Income and out-of-pocket drug costs showed the greatest differences in adjusted rates of cost-related medication underuse (15 vs. 5% for participants with income $50,000 and 24 vs. 7% for participants with out-of-pocket costs >$150 per month vs.

Authors: Tseng CW; Karter AJ; Mangione CM; et al.

Diabetes Care. 2008 Feb;31(2):261-6. Epub 2007 Nov 13.

PubMed abstract

Educational disparities in rates of smoking among diabetic adults: the translating research into action for diabetes study

OBJECTIVES: We assessed educational disparities in smoking rates among adults with diabetes in managed care settings. METHODS: We used a cross-sectional, survey-based (2002-2003) observational study among 6538 diabetic patients older than 25 years across multiple managed care health plans and states. For smoking at each level of self-reported educational attainment, predicted probabilities were estimated by means of hierarchical logistic regression models with random intercepts for health plan, adjusted for potential confounders. RESULTS: Overall, 15% the participants reported current smoking. An educational gradient in smoking was observed that varied significantly (P<.003) across age groups, with the educational gradient being strong in those aged 25 to 44 years, modest in those aged 45 to 64 years, and nonexistent in those aged 65 years or older. Of particular note, the prevalence of smoking observed in adults aged 25-44 years with less than a high school education was 50% (95% confidence interval: 36% to 63%). CONCLUSIONS: Approximately half of poorly educated young adults with diabetes smoke, magnifying the health risk associated with early-onset diabetes. Targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes are needed.

Authors: Karter AJ; Ettner SL; et al.

Am J Public Health. 2008 Feb;98(2):365-70. Epub 2007 Jun 28.

PubMed abstract

Effect of race/ethnicity on the efficacy of warfarin: potential implications for prevention of stroke in patients with atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia seen in clinical practice. It affects approximately 6% of persons over 65 years of age and is independently associated with a 4- to 5-fold higher risk of ischaemic stroke and a 2-fold higher risk of death. Randomized controlled trials have shown that treatment with adjusted-dose oral vitamin K antagonists (primarily warfarin with a target international normalized ratio [INR] of 2.0-3.0) reduces the relative risk of ischaemic stroke by two-thirds (an approximately 3% reduction in annual absolute risk), but is associated with a 0.2% excess annual absolute risk of intracranial haemorrhage (ICH). However, in ‘real world’ studies, the risk reductions in ischaemic stroke with warfarin have been significantly lower (25-50% relative risk reduction) than in selected trial samples. Moreover, more than 90% of patients enrolled in the sentinel trials were White/European. This raises the question of whether the beneficial results of warfarin can be extrapolated to persons of colour. Important differences in stroke risk profile and responsiveness to warfarin exist across racial/ethnic groups, such that one cannot assume a priori that there is a net benefit of warfarin therapy for AF patients of all racial/ethnic groups.Among patients with ischaemic stroke, AF is more likely to be implicated as the cause of stroke in the White population than in other racial/ethnic groups. Furthermore, AF may be a stronger predictor of ischaemic stroke among the White population than in Black or Hispanic/Latino populations. Approximately one-third of strokes in AF patients are noncardioembolic. Warfarin has been shown to be ineffective in preventing recurrent noncardioembolic strokes. Many persons of colour with AF have other risk factors that predispose them to noncardioembolic stroke, which may partially explain why warfarin has been reported to be less efficacious in preventing strokes in non-White patients with AF, even after adjustment for co-morbidities and anticoagulation monitoring. Notably, the background incidence of ICH is higher in Black, Hispanic and Asian patients than in White patients. Any greater than expected increases in bleeding secondary to anticoagulation may potentially offset any benefit gained from cardioembolic stroke reduction, although this has not been fully resolved.Finally, there are racial/ethnic differences in the prevalence of certain polymorphisms in genes that influence warfarin pharmacokinetics and pharmacodynamics (e.g. cytochrome P450 2C9 and vitamin K epoxide reductase). The Asian population generally appear to require the lowest daily dose of warfarin to maintain a given INR target, with the White population requiring an intermediate daily dose and the Black population requiring the highest daily dose. These differences must be taken into account when administering warfarin in order to minimize the risk of under- or over-anticoagulation.In summary, warfarin is highly effective in preventing ischaemic strokes in White patients with AF at a modestly higher risk of ICH. Whether the same net clinical benefit extends to persons of colour is unproven. Given the rapidly changing demographic nationally and internationally, additional research is needed to resolve this important question.

Authors: Shen AY; Chen W; Yao JF; Brar SS; Wang X; Go AS

CNS Drugs. 2008;22(10):815-25.

PubMed abstract

Prevalence and correlates of substance use among South African primary care clinic patients

We aimed to assess prevalence and correlates of hazardous use of tobacco, alcohol and other drugs in a primary care population in Cape Town, South Africa. Stratified random sampling was used to select 14 of the 49 clinics in the public health sector in Cape Town, and every ‘nth’ patient, with those ages 18-25 oversampled (N = 2,618). Data were collected from December 2003 through 2004, using the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test. Hazardous use of tobacco was most common, followed by alcohol and then other drugs. Hazardous tobacco use was associated with the 18-25 years age group, no religious involvement, high school completion, and higher stress. Hazardous alcohol use was associated with male gender, younger men, no religious involvement, employment, some high school education, and higher stress. Hazardous use of other drugs was associated with Colored (mixed) race (particularly among men), no religious involvement, employment, and stress. For all substances, women, particularly Black women, had the lowest rates of hazardous use. Although the study is cross-sectional, it does identify groups that may be at high risk of substance misuse and for whom intervention is urgent. Because prevalence of substance use is high in this population, routine screening should be introduced in primary care clinics.

Authors: Ward CL; Mertens JR; Flisher AJ; Bresick GF; Sterling SA; Little F; Weisner CM

Subst Use Misuse. 2008;43(10):1395-410.

PubMed abstract

Population stratification in a case-control study of brain arteriovenous malformation in Latinos

BACKGROUND: Genetic association studies conducted in admixed populations may be confounded by population stratification resulting in spurious associations. The purpose of this pilot study was to determine the presence and effect of population stratification in a case-control study of brain arteriovenous malformation (BAVM). METHODS: We tested 83 ancestry informative markers in BAVM cases and healthy controls of self-reported Latino race/ethnicity (n = 294). Individual ancestry estimates (IAE) were obtained using the Structure program, assuming 3 underlying subpopulations. Summary chi(2) tests comparing genotype frequency of ancestry informative markers were used to detect stratification and IAE were included as covariates in logistic regression analysis to account for differences in genetic background. RESULTS: Admixture estimates for Latinos (overall 47% native American, 45% European and 8% African ancestry) revealed heterogeneity between individuals within ancestral groups. The summary chi(2) test was significant (p = 0.005), suggesting ancestral differences between cases and controls. Furthermore, genetic ancestry was associated with frequency differences in a promoter variant in the IL-6 gene (IL-6 -174G>C). On average, subjects with the IL6 -174 GG genotype had 6% greater Native American ancestry (p = 0.023). Age- and sex-adjusted risk of BAVM associated with the IL-6 -174 GG genotype was 1.85 (95% CI 0.99-3.48, p = 0.055), and further adjustments for IAE yielded an OR of 1.96 (95% CI 1.03-3.72, p = 0.039). CONCLUSION: The IL-6 -174G>C polymorphism was associated with increased risk of BAVM among Latinos after accounting for differences in ancestral background. These results suggest subtle, negative confounding and illustrate the importance of addressing population stratification in case-control studies conducted in admixed populations.

Authors: Kim H; Hysi PG; Pawlikowska L; Choudhry S; Gonzalez Burchard E; Kwok PY; Sidney S; McCulloch CE; Young WL

Neuroepidemiology. 2008;31(4):224-8. Epub 2008 Oct 7.

PubMed abstract

Race/ethnicity and validity of self-reported pneumococcal vaccination

BACKGROUND: National and state surveys show large disparities in pneumococcal vaccination status among Whites, Blacks and Latinos aged >/= 65. The purpose of this study is to determine whether there is any difference in the validity of self-report for pneumococcal vaccination by race/ethnicity that might contribute to the substantial disparities observed in population-level coverage estimates. METHODS: Self-reported vaccination status was compared with medical record documentation for samples of White, Black, and Latino members of a large health plan to examine whether differences in validity of self-report contribute to observed disparities. RESULTS: Sensitivity was significantly lower for Blacks (0.849, 95% CI 0.818-0.876) and Latinos (0.869, 95% CI 0.847-0.889) than for Whites (0.931 95% CI 0.918-0.942). Specificity was somewhat higher for Blacks than for Latinos and Whites, but the differences were not statistically significant. Coverage for Whites, Blacks and Latinos, respectively, was 84.3%, 73.5%, and 82.3% based on self-report, but 74.8%, 71.9%, and 84.2% based on medical records. CONCLUSION: The results of this study suggest that differential self-report error, i.e., summative effect of over-reporting and under-reporting within a race-ethnic group, may contribute to the size and direction of race-ethnic disparities in pneumococcal vaccination observed in surveys.

Authors: Gordon NP; Wortley PM; Singleton JA; Lin TY; Bardenheier BH

BMC Public Health. 2008 Jul 3;8:227.

PubMed abstract

Racial differences in the use of respiratory medications in premature infants after discharge from the neonatal intensive care unit

OBJECTIVE: To determine the effect of race and ethnicity on the use of oral beta-agonists, inhaled beta-agonists, and inhaled corticosteroids to treat respiratory symptoms in former premature infants after controlling for medical conditions, socioeconomic status, and site of outpatient care. STUDY DESIGN: Using a population cohort of infants born at a gestational age or = 34 weeks at 5 Northern California Kaiser Permanente hospitals between 1998 and 2001 (n = 1436), we constructed multivariable models to determine predictive factors for the receipt of respiratory medications during the first year after discharge. RESULTS: After controlling for confounding factors, black infants were more likely to receive oral beta-agonists compared with white infants (OR 4.30, 95% CI 2.33-7.94), and Hispanic infants were less likely to receive inhaled beta-agonists (OR 0.62, 95% CI 0.39-0.99) or inhaled corticosteroids (OR 0.28, 95% CI 0.12-0.67). These findings were not explained by more outpatient visits for respiratory symptoms in black or Hispanic infants, because the observed racial differences persisted when children of similar respiratory symptoms were examined. CONCLUSIONS: Even in a high-risk population of insured infants, substantial racial differences persist in the use of respiratory medications that could not be explained by differences in respiratory symptoms.

Authors: Lorch SA; Wade KC; Bakewell-Sachs S; Medoff-Cooper B; Escobar GJ; Silber JH

J Pediatr. 2007 Dec;151(6):604-10, 610.e1. Epub 2007 Aug 24.

PubMed abstract

Patient sex and quality of ED care for patients with myocardial infarction

OBJECTIVE: The aim of the study was to assess the quality of care between male and female emergency department (ED) patients with acute myocardial infarction (AMI). METHODS: A 2-year retrospective cohort study of 2215 patients with AMI presenting immediately to 5 EDs from July 1, 2000, through June 30, 2002 was conducted. Data on patient characteristics, clinical presentation, and ED processes of care were obtained from chart and electrocardiogram reviews. Multivariable regression models were used to assess the independent association between sex and the ED administration of aspirin, beta-blockers, and reperfusion therapy to eligible patients with AMI. RESULTS: There were 849 women and 1366 men in the study. Female patients were older than male patients (74.3 years for women vs 66.8 years for men, P < .001). Among ideal patients, women were less likely than men to receive aspirin (76.3% of women vs 81.3% of men, P < .01), beta-blockers (51.7% of women vs 61.4% of men, P < .01), and reperfusion therapy (64.0% of women vs 72.8% of men, P < .05). However, after adjustment for age, there was no longer a significant relationship between sex and the use of aspirin (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.95-1.03), beta-blockers (OR, 0.94; 95% CI, 0.82-1.04), or reperfusion therapy (OR, 1.01; 95% CI, 0.89-1.09). In models adjusting for additional demographic, clinical, and hospital characteristics, there remained no association between sex and the processes of care. CONCLUSION: Women with AMI treated in the ED have a lower likelihood of receiving aspirin, beta-blocker, and reperfusion therapy. However, this association appears to be explained by the age difference between men and women with AMI. Although there are no apparent sex disparities in care, ED AMI management remains suboptimal for both sexes.

Authors: Vinson DR; Go AS; Rumsfeld JS; et al.

Am J Emerg Med. 2007 Nov;25(9):996-1003.

PubMed abstract

Racial discrimination & health: pathways & evidence

This review provides an overview of the existing empirical research of the multiple ways by which discrimination can affect health. Institutional mechanisms of discrimination such as restricting marginalized groups to live in undesirable residential areas can have deleterious health consequences by limiting socio-economic status (SES) and creating health-damaging conditions in residential environments. Discrimination can also adversely affect health through restricting access to desirable services such as medical care and creating elevated exposure to traditional stressors such as unemployment and financial strain. Central to racism is an ideology of inferiority that can adversely affect non-dominant groups because some members of marginalized populations will accept as true the dominant society’s ideology of their group’s inferiority. Limited empirical research indicates that internalized racism is inversely related to health. In addition, the existence of these negative stereotypes can lead dominant group members to consciously and unconsciously discriminate against the stigmatized. An overview of the growing body of research examining the ways in which psychosocial stress generated by subjective experiences of discrimination can affect health is also provided. We review the evidence from the United States and other societies that suggest that the subjective experience of discrimination can adversely affect health and health enhancing behaviours. Advancing our understanding of the relationship between discrimination and health requires improved assessment of the phenomenon of discrimination and increased attention to identifying the psychosocial and biological pathways that may link exposure to discrimination to health status.

Authors: Ahmed AT; Mohammed SA; Williams DR

Indian J Med Res. 2007 Oct;126(4):318-27.

PubMed abstract

Effect of race on asthma management and outcomes in a large, integrated managed care organization

BACKGROUND: Morbidity from asthma disproportionately affects black people. Whether this excess morbidity is fully explained by differences in asthma severity, access to care, or socioeconomic status (SES) is unknown. METHODS: We assessed whether there were racial disparities in asthma management and outcomes in a managed care organization that provides uniform access to health care and then determined to what degree these disparities were explained by differences in SES, asthma severity, and asthma management. We prospectively studied 678 patients from a large, integrated health care delivery system. Patients who had been hospitalized for asthma were interviewed after discharge to ascertain information about asthma history, health status, and SES. Small-area socioeconomic data were ascertained by means of geocoding and linkage to the US Census 2000. Patients were followed up for subsequent emergency department (ED) visits or hospitalizations (median follow-up, 1.9 years). RESULTS: Black race was associated with a higher risk of ED visits (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.39-2.66) and hospitalizations (HR, 1.89; 95% CI, 1.30-2.76). This finding persisted after adjusting for SES and differences in asthma therapy (adjusted HR for ED visits, 1.73; 95% CI, 1.07-2.81; and adjusted HR for hospitalizations, 2.01; 95% CI, 1.33-3.02). CONCLUSIONS: Even in a health care setting that provides uniform access to care, black race was associated with worse asthma outcomes, including a greater risk of ED visits and hospitalizations. This association was not explained by differences in SES, asthma severity, or asthma therapy. These findings suggest that genetic differences may underlie these racial disparities.

Authors: Erickson SE; Iribarren C; Tolstykh IV; Blanc PD; Eisner MD

Arch Intern Med. 2007 Sep 24;167(17):1846-52.

PubMed abstract

Ethnic differences in coronary artery calcium in a healthy cohort aged 60 to 69 years

Measurement of coronary artery calcium (CAC) has been proposed as a screening tool, but CAC levels may differ according to race and gender. Racial/ethnic and gender distributions of CAC were examined in a randomly selected cohort of 60- to 69-year-old healthy subjects. Demographic, race/ethnicity (R/E), and clinical characteristics and assessment of CAC were collected. There were 723 white/European, 105 African-American, 73 Hispanic, and 67 East Asian subjects (597 men, 369 women) included in this analysis. Men had a significantly higher prevalence of any CAC (score>10) than women (76% vs 41%; p<0.0001). For men, the unadjusted odds of having any CAC was 2.2 (95% confidence interval [CI] 1.3 to 3.8) for whites compared with African-Americans. For women, CAC scores were not significantly different across ethnic groups. After adjustment for coronary risk factors, African-American and East Asian R/E remained associated with a lower prevalence of CAC in men (adjusted odds ratios [ORs] 0.33 and 0.47, respectively), as well as older age (OR 1.2, 95% CI 1.1 to 1.3), known hyperlipidemia (OR 1.7, 95% CI 1.1 to 2.7), and history of hypertension (OR 2.2, 95% CI 1.4 to 3.3). In women, Asian R/E (OR 2.5, 95% CI 1.1 to 5.7), history of smoking (adjusted OR 2.8, 95% CI 1.3 to 6.1), and known hyperlipidemia (adjusted OR 2.0, 95% CI 1.3 to 3.1) were associated with a higher prevalence of CAC independent of other risk factors. In conclusion, our data indicate that the presence of CAC varied significantly across selected race/ethnic groups independent of traditional cardiovascular risk factors.

Authors: Fair JM; Kiazand A; Varady A; Mahbouba M; Norton L; Rubin GD; Iribarren C; Go AS; Hlatky MA; Fortmann SP

Am J Cardiol. 2007 Sep 15;100(6):981-5. Epub 2007 Jul 2.

PubMed abstract

Racial/Ethnic differences in longitudinal risk of intracranial hemorrhage in brain arteriovenous malformation patients

BACKGROUND AND PURPOSE: Race/ethnicity is associated with overall incidence of intracranial hemorrhage (ICH), but its impact in patients with brain arteriovenous malformation is unknown. We evaluated whether race/ethnicity was a risk factor for ICH in the natural course in a large, multiethnic cohort of patients with brain arteriovenous malformation followed longitudinally. METHODS: Data were collected prospectively for patients with brain arteriovenous malformation evaluated at the University of California, San Francisco (n=436) and retrospectively through databases and chart review in the 20 hospitals of the Kaiser Permanente Medical Care Program (n=1028). Multivariate Cox regression was performed to assess the influence of race/ethnicity on subsequent ICH, adjusting for risk factors. Cases were censored at first treatment, loss to follow-up, or death. RESULTS: Average follow up was 4.7+/-8.0 years for Kaiser Permanente Medical Care Program patients and 2.8+/-7.3 years for University of California, San Francisco patients with no difference in time to ICH between cohorts (log rank P=0.57). The annualized 5-year ICH rate was 2.1% (3.7% for ruptured at presentation; 1.4% for unruptured). Initial ICH presentation (hazard ratio: 3.0, 95% CI: 1.9 to 4.9, P<0.001) and Hispanic race/ethnicity (hazard ratio: 1.9, 95% CI: 1.1 to 3.3, P=0.02) were independent predictors of ICH, adjusting for age, gender, cohort, and a cohort-age interaction. The ICH risk for Hispanics versus whites increased to 3.1 (95% CI: 1.3 to 7.4, P=0.013) after further adjusting for arteriovenous malformation size and deep venous drainage in a subset of cases with complete data. Similar trends were observed for blacks (hazard ratio: 2.1, 95% CI: 0.9 to 4.8, P=0.09) and Asians (hazard ratio: 2.4, 95% CI: 0.8 to 7.1, P=0.11), although nonsignificant. CONCLUSIONS: This study reports the first description of race/ethnic differences in brain arteriovenous malformation, with Hispanics at an increased risk of subsequent ICH compared with whites.

Authors: Kim H; McCulloch CE; UCSF BAVM Study Project; et al.

Stroke. 2007 Sep;38(9):2430-7. Epub 2007 Aug 2.

PubMed abstract

Mammographic density in a multiethnic cohort

OBJECTIVES: To compare mammographic density among premenopausal and early perimenopausal women from four racial/ethnic groups and to examine density and acculturation among Japanese and Chinese women. DESIGN: The study included 391 white, 60 African American, 171 Japanese, and 179 Chinese participants in the Study of Women’s Health Across the Nation, a multisite study of US women transitioning through menopause. Mammograms done when women were premenopausal or early perimenopausal were assessed for area of dense breast tissue and the percent of the breast occupied by dense tissue (percent density). Information on race/ethnicity, acculturation, and other factors was obtained from standardized instruments. Multiple linear regression modeling was used to examine the association between race/ethnicity or acculturation and density measures. RESULTS: Age-adjusted mean percent density was highest for Chinese (52%) and lowest for African American (34%) women. After additional adjustment for body mass index, menopause status, age at first birth, breast-feeding duration, waist circumference, and smoking, African Americans had the highest mean percent density (51%) and Japanese women had the lowest (39%). In contrast, the area of dense tissue was highest for African Americans and similar for white, Japanese, and Chinese women. Less acculturated Chinese and Japanese women tended to have a larger area of density and a higher percent density. CONCLUSIONS: Neither the age-adjusted nor fully adjusted results for percent density or area of dense tissue reflected current differences in breast cancer incidence rates among similarly aged African American, Japanese, Chinese, and white women. In addition, mammographic density was higher in less acculturated Asian women.

Authors: Habel LA; Quesenberry C; Sternfeld B; et al.

Menopause. 2007 Sep-Oct;14(5):891-9.

PubMed abstract

Minimum incidence of primary cervical dystonia in a multiethnic health care population

BACKGROUND: The two existing estimates of the incidence of primary cervical dystonia were based on observations in relatively ethnically homogeneous populations of European descent. OBJECTIVE: To estimate the minimum incidence of primary cervical dystonia in the multiethnic membership of a health maintenance organization in Northern California. METHODS: Using a combination of electronic medical records followed by medical chart reviews, we identified incident cases of cervical dystonia first diagnosed between 1997 and 1999. RESULTS: We identified 66 incident cases of cervical dystonia from 8.2 million person-years of observation. The minimum estimate of the incidence of cervical dystonia in this population is 0.80 per 100,000 person-years. Ethnicity-specific incidence rates were calculated for individuals over age 30. Incidence was higher in white individuals (1.23 per 100,000 person-years) than in persons of other races (0.15 per 100,000 person-years, p < 0.0001). The minimum estimated incidence was 2.5 times higher in women than in men (1.14 vs 0.45 per 100,000 person-years, p = 0.0005). The average age at diagnosis was higher in women (56 years) than in men (45 years, p = 0.0004). There was no significant difference in reported symptom duration prior to diagnosis between women and men (3.9 vs 5.3 years). CONCLUSION: The estimated incidence of diagnosed cervical dystonia among white individuals in this Northern Californian population is similar to previous estimates in more ethnically homogeneous populations of largely European descent. The incidence in other races, including Hispanic, Asian, and black appears to be significantly lower. The incidence is also higher in women than in men.

Authors: Marras C; Van Den Eeden SK; Fross RD; Benedict-Albers KS; Klingman J; Leimpeter AD; Nelson LM; Risch N; Karter AJ; Bernstein AL; Tanner CM

Neurology. 2007 Aug 14;69(7):676-80.

PubMed abstract

Race and risk of schizophrenia in a US birth cohort: another example of health disparity?

BACKGROUND: Immigrant groups in Western Europe have markedly increased rates of schizophrenia. The highest rates are found in ethnic groups that are predominantly black. Separating minority race/ethnicity from immigration in Western Europe is difficult; in the US, these issues can be examined separately. Here we compared rates of schizophrenia between whites and African Americans and evaluated whether the association was mediated by socioeconomic status (SES) of family of origin in a US birth cohort. METHODS: Study subjects were offspring of women enrolled during pregnancy at Alameda County Kaiser Permanente Medical Care Plan clinics (1959-66) in the Child Health and Development Study. For schizophrenia spectrum disorders, 12 094 of the 19 044 live births were followed over 1981-97. The analysis is restricted to cohort members whose mothers identified as African American or white at intake. Stratified proportional hazards regression was the method of analysis; the robustness of findings to missing data bias was assessed using multiple imputation. RESULTS: African Americans were about 3-fold more likely than whites to be diagnosed with schizophrenia [Rate Ratio (RR) = 3.27; 95% confidence interval (CI): 1.71-6.27]. After adjusting for indicators of family SES at birth, the RR was about 2-fold (RR = 1.92; 95% CI: 0.86-4.28). Using multiple imputation in the model including family SES indicators, the RR for race and schizophrenia was strengthened in comparison with the estimate obtained without imputation. CONCLUSION: The data indicate substantially elevated rates of schizophrenia among African Americans in comparison with whites in this birth cohort. The association may have been partly but not wholly mediated by an effect of race on family SES.

Authors: Bresnahan M; Begg MD; Brown A; Schaefer C; Sohler N; Insel B; Vella L; Susser E

Int J Epidemiol. 2007 Aug;36(4):751-8. Epub 2007 Apr 17.

PubMed abstract

Tailoring of outpatient substance abuse treatment to women, 1995-2005

BACKGROUND: Tailoring substance abuse treatment to women often leads to better outcomes. Previous evidence, however, suggests limited availability of such options. OBJECTIVES: This investigation sought to depict recent changes in outpatient substance abuse treatment (OSAT) tailoring to women and to identify unit and contextual factors associated with these practices. RESEARCH DESIGN: Data were from 2 waves of a national OSAT unit survey (N = 618 in 1995, N = 566 in 2005). Comparisons of weighted means between waves indicate which practices changed over time. Multiple logistic regressions with generalized estimating equations test associations between unit and contextual attributes and tailoring to women. MEASURES: Tailoring to women was measured as availability of prenatal care, child care, single sex therapy, and same sex therapists, and the percentage of staff trained to meet female clients’ needs. RESULTS: Two measures of tailoring to women declined significantly between 1995 and 2005: availability of single sex therapy (from 66% to 44% of units) and percent of staff trained to work with women (from 42% to 32% of units). No aspect of tailoring to women became more common. Proportion of female clients, total number of clients, methadone status, and private and government managed care were associated with higher odds of tailoring to women. For-profit facilities, which became more prevalent during the study period, had lower odds than other units of tailoring treatment to women. CONCLUSIONS: Some key aspects of OSAT tailoring to women decreased significantly in the last decade. Managed care contracts may offer 1 mechanism for counteracting these trends.

Authors: Campbell CI; Wells R; Alexander JA; Jiang L; Nahra TA; Lemak CH

Med Care. 2007 Aug;45(8):775-80.

PubMed abstract

Risk factors for mortality among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE: We sought to examine demographic, socioeconomic, and biological predictors of all-cause, cardiovascular, and noncardiovascular mortality in patients with diabetes. RESEARCH DESIGN AND METHODS: Survey, medical record, and administrative data were obtained from 8,733 participants in the Translating Research Into Action for Diabetes Study, a multicenter, prospective, observational study of diabetes care in managed care. Data on deaths (n = 791) and cause of death were obtained from the National Death Index after 4 years. Predictors examined included age, sex, race, education, income, duration, and treatment of diabetes, BMI, smoking, microvascular and macrovascular complications, and comorbidities. RESULTS: Predictors of adjusted all-cause mortality included older age (hazard ratio [HR] 1.04 [95% CI 1.03-1.05]), male sex (1.57 [1.35-1.83]), lower income (< $15,000 vs. > $75,000, HR 1.82 [1.30-2.54]; $15,000-$40,000 vs. > $75,000, HR 1.58 [1.15-2.17]), longer duration of diabetes (> or = 9 years vs. < 9 years, HR 1.20 [1.02-1.41]), lower BMI (< 26 vs. 26-30 kg/m2, HR 1.43 [1.13-1.69]), smoking (1.44 [1.20-1.74]), nephropathy (1.46 [1.23-2.73]), macrovascular disease (1.46 [1.23-1.74]), and greater Charlson index (> or = 2-3 vs. < 1, HR 2.01 [1.04-3.90]; > or = 3 vs. < 1, HR 4.38 [2.26-8.47]). The predictors of cardiovascular and noncardiovascular mortality were different. Macrovascular disease predicted cardiovascular but not noncardiovascular mortality. CONCLUSIONS: Among people with diabetes and access to medical care, older age, male sex, smoking, and renal disease are important predictors of mortality. Even within an insured population, socioeconomic circumstance is an important independent predictor of health.

Authors: McEwen LN; Kim C; Karter AJ; Haan MN; Ghosh D; Lantz PM; Mangione CM; Thompson TJ; Herman WH

Diabetes Care. 2007 Jul;30(7):1736-41. Epub 2007 Apr 27.

PubMed abstract

Cross-sectional analysis of specific complementary and alternative medicine (CAM) use by racial/ethnic group and menopausal status: the Study of Women’s Health Across the Nation (SWAN)

OBJECTIVE: To examine the relationships of race/ethnicity, menopausal status, health characteristics, and symptoms with use of 21 types of complementary and alternative medicine (CAM) in midlife women. DESIGN: Cross-sectional, multiple logistic regression analyses of 2,118 women completing the sixth annual visit in the Study of Women’s Health Across the Nation, a multisite, multiethnic, longitudinal study. RESULTS: More than half of women used some type of CAM. Use of most types of CAM differed significantly by race/ethnicity, except the use of ginkgo biloba and glucosamine. Significantly more African Americans at most sites and Chinese women used ginseng. Use of most types of CAM did not differ significantly by menopausal status or vasomotor symptoms, except the use of soy supplements, which was significantly greater among women who reported vasomotor symptoms. Women reporting somatic symptoms were significantly more likely to use glucosamine. Women reporting psychological symptoms were significantly more likely to use ginkgo biloba and soy supplements. The number of comorbidities, moderate or high socioeconomic status, number of healthy behaviors, symptom sensitivity, age, and dietary genistein intake were significantly positively associated with use of several types of CAM. CONCLUSIONS: The use of most types of CAM is not related to menopausal status or symptom reporting but to sociodemographic factors, comorbidities, and health behaviors. Given the large proportion of midlife women who use CAM and the potential for interactions with prescribed medications, healthcare practitioners should inquire about CAM use and be aware of which factors influence the use of different types of CAM.

Authors: Gold EB; Bair Y; Zhang G; Utts J; Greendale GA; Upchurch D; Chyu L; Sternfeld B; Adler S

Menopause. 2007 Jul-Aug;14(4):612-23.

PubMed abstract

Genetic ancestry, population sub-structure, and cardiovascular disease-related traits among African-American participants in the CARDIA Study

African-American populations are genetically admixed. Studies performed among unrelated individuals from ethnically admixed populations may be both vulnerable to confounding by population stratification, but offer an opportunity for efficiently mapping complex traits through admixture linkage disequilibrium. By typing 42 ancestry-informative markers and estimating genetic ancestry, we assessed genetic admixture and heterogeneity among African-American participants in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort. We also assessed associations between individual genetic ancestry and several quantitative and binary traits related to cardiovascular risk. We found evidence of population sub-structure and excess inter-marker linkage disequilibrium, consistent with recent admixture. The estimated group admixture proportions were 78.1% African and 22.9% European, but differed according to geographic region. In multiple regression models, African ancestry was significantly associated with decreased total cholesterol, decreased LDL-cholesterol, and decreased triglycerides, and also with increased risk of insulin resistance. These observed associations between African ancestry and several lipid traits are consistent with the general tendency of individuals of African descent to have healthier lipid profiles compared to European-Americans. There was no association between genetic ancestry and hypertension, BMI, waist circumference, CRP level, or coronary artery calcification. These results demonstrate the potential for confounding of genetic associations with some cardiovascular disease-related traits in large studies involving US African-Americans.

Authors: Reiner AP; Carlson CS; Ziv E; Iribarren C; Jaquish CE; Nickerson DA

Hum Genet. 2007 Jun;121(5):565-75. Epub 2007 Mar 14.

PubMed abstract

Diet and lifestyle factors associated with premenstrual symptoms in a racially diverse community sample: Study of Women’s Health Across the Nation (SWAN)

AIMS: We sought to determine if the frequency of reported physical or emotional premenstrual symptoms (PMSx) was associated with (1) dietary intake of phytoestrogens, fiber, fat, or calcium, (2) consumption of alcohol or caffeine, (3) active or passive smoke exposure or lack of physical exercise, and (4) race/ethnicity or socioeconomic status. METHODS: A cross-sectional analysis was conducted of PMSx and demographic and lifestyle factors reported at baseline in the multiethnic sample of 3302 midlife women in the Study of Women’s Health Across the Nation (SWAN). Stepwise multiple logistic regression analyses were performed for the overall sample and for each racial/ethnic group for each of five PMSx groupings. RESULTS: Most dietary factors were not related to PMSx. Fat intake was negatively associated with craving and bloating (adjusted odds ratio [AOR] = 0.56, p = 0.024), and fiber intake was positively associated with breast pain (AOR = 1.39, p = 0.037). Alcohol intake was negatively associated with anxiety and mood changes (AOR = 0.63, p = 0.045) and headaches (AOR = 0.50, p = 0.009). Current smoking (AOR = 1.60, p = 0.028) and passive smoke exposure (AOR = 1.56, p = 0.050) were positively associated with cramps and back pain. Symptom reporting differed significantly by race/ethnicity. PMSx were also associated with comorbidities, early perimenopausal status, depressive symptoms, and symptom sensitivity. CONCLUSION: We found little evidence to support a role for diet in PMSx reporting. However, alcohol intake was positively associated with premenstrual anxiety and mood changes, and active and passive smoke exposure was associated with a number of PMSx. Ethnic differences in symptom reporting and associations of comorbidities, early perimenopausal status, depressive symptoms, and symptom sensitivity with reported PMSx were also observed.

Authors: Gold EB; Sternfeld B; Zhang G; et al.

J Womens Health (Larchmt). 2007 Jun;16(5):641-56.

PubMed abstract

Abdominal obesity, ethnicity and gastro-oesophageal reflux symptoms

OBJECTIVE: To evaluate the associations between abdominal obesity and gastro-oesophageal reflux disease (GORD), and their interactions with ethnicity and gender. DESIGN: A cross-sectional study. Participants completed detailed symptom questionnaires and underwent a standardised examination, including anthropometric measurements. SETTING: A large integrated healthcare system. PATIENTS: 80 110 members of the Kaiser Permanente multiphasic health check-up cohort. MAIN OUTCOME MEASURES: Gastro-oesophageal reflux-type symptoms. RESULTS: Recent reflux-type symptoms were present in 11% of the population. The multivariate OR for symptoms with an abdominal diameter (adjusted for body mass index (BMI)) of >/=26 vs <16.3 cm was 1.85 (95% CI 1.55 to 2.21) for the white population, 0.95 (95% CI 0.61 to 1.48) for the black population and 0.64 (95% CI 0.18 to 2.30) for Asians. The mean abdominal diameter was greater in men (22.0 cm, 95% CI 21.9 to 22.0) than in women (20.1 cm, 95% CI 20.0 to 20.1, p<0.01), but the risk of symptoms for any given diameter did not differ markedly by gender. The association between increasing BMI and symptoms was also much stronger among the white population than among the black population. The association between BMI and reflux-type symptoms was partially mediated through abdominal diameter. CONCLUSIONS: There was a consistent association between abdominal diameter (independent of BMI) and reflux-type symptoms in the white population, but no consistent associations in the black population or Asians. The BMI association was also strongest among the white population. These findings, combined with the increased prevalence of abdominal obesity in male subjects, suggest that an increased obesity may disproportionately increase GORD-type symptoms in the white population and in male subjects.

Authors: Corley DA; Kubo A; Zhao W

Gut. 2007 Jun;56(6):756-62. Epub 2006 Oct 17.

PubMed abstract

Metabolic syndrome and cognitive decline in elderly Latinos: findings from the Sacramento Area Latino Study of Aging study

OBJECTIVES: To investigate the effect of metabolic syndrome on cognitive function in an elderly Latino population and to determine whether inflammation modifies this association. DESIGN: A longitudinal cohort study. SETTING: Sacramento area and the surrounding California counties from 1998 to 1999. PARTICIPANTS: One thousand six hundred twenty-four Latinos aged 60 and older who participated in the Sacramento Area Latino Study of Aging. MEASUREMENTS: Baseline metabolic syndrome was calculated using the Third Adult Treatment Panel of the National Cholesterol Education Program. Cognitive function was measured using the Modified Mini-Mental State Examination (3MS) and the Delayed Word-List Recall (DelRec), a verbal memory test. The effect of metabolic syndrome on cognitive change scores was examined using random effects models; in addition, the effect of the individual components of the syndrome on cognitive change was examined. RESULTS: Of the 1,624 participants, 718 (44%) had metabolic syndrome at baseline. Those with metabolic syndrome had worse 3-year change scores on 3MS (P=.04) and DelRec (P=.03). Multivariate adjustment attenuated the results for DelRec but not for 3MS. This association was especially pronounced in participants with a high serum level of inflammation, resulting in an average 3MS score 0.64 points lower per year (P=.03) for those with metabolic syndrome. Individual components of metabolic syndrome were not associated with cognitive decline except for elevated glucose on the DelRec (P=.02) and high blood pressure on 3MS (P=.05). CONCLUSION: Metabolic syndrome and inflammation may both contribute to cognitive decline in older people of diverse backgrounds. The results also suggest that, in elderly Latinos, the composite measure of metabolic syndrome is a greater risk for cognitive decline than its individual components.

Authors: Yaffe K; Haan M; Blackwell T; Cherkasova E; Whitmer RA; West N

J Am Geriatr Soc. 2007 May;55(5):758-62.

PubMed abstract

Educational disparities in health behaviors among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study

BACKGROUND: Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors. METHODS: This observational study was based on a cohort of 8,763 survey respondents drawn from ~180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment (‘education’) and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans. RESULTS: Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25-44, modest for those ages 45-64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings. CONCLUSION: The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

Authors: Karter AJ; Ettner SL; et al.

BMC Public Health. 2007 Oct 29;7:308.

PubMed abstract

The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE: We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care. RESEARCH DESIGN AND METHODS: Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry. RESULTS: Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with <10% of black participants enrolled in provider groups in the highest-intensity quintile for physician feedback and <10% of both black and Asian/Pacific Islander participants enrolled in groups in the highest-intensity quintile for diabetes registry use. Although disparities in care were confirmed, particularly for black relative to white subjects, we did not find a consistent pattern of disparity attenuation with increasing implementation intensity for either processes of care or medication management of intermediate outcomes. CONCLUSIONS: For the most part, high-intensity implementation of a diabetes registry, physician feedback, or physician reminders, 3 clinical care strategies similar to those used in many health care settings, are not associated with attenuation of known disparities of diabetes care in managed care.

Authors: Duru OK; Karter AJ; TRIAD Study Group; et al.

Med Care. 2006 Dec;44(12):1121-8.

PubMed abstract

Urinary incontinence and pelvic floor dysfunction in Asian-American women

OBJECTIVE: The objective of the study was to describe the prevalence, risk factors, and impact of urinary incontinence and other pelvic floor disorders among Asian-American women. STUDY DESIGN: This was a population-based cohort study of older women randomly selected from age and race strata. RESULTS: Weekly urinary incontinence was reported by 65 of 345 Asian women (18%), with stress and urge incontinence being approximately equally common. In multivariate analysis, higher body mass index (greater than 25 kg/m2) was associated with both stress incontinence (odds ratio 4.90, 95% confidence interval 1.76 to 13.68) and urge incontinence (odds ratio 2.49, 95% confidence interval 1.01 to 6.16) in Asians. Hysterectomy was a significant risk factor for stress incontinence (odds ratio 2.79, 95% confidence interval 1.03 to 7.54). Only 34% of Asian women with weekly urinary incontinence reported ever having sought treatment. Pelvic floor exercises were the most common form of treatment, being used by 29% of Asian women with weekly incontinence. Asians were less likely then white women to report anal incontinence (21% versus 29%, P = .007), although this difference became nonsignificant after adjusting for differences in risk factors. CONCLUSION: Asian women share some risk factors for stress and urge urinary incontinence with white women. Urinary incontinence is associated with anal incontinence among Asian women.

Authors: Huang AJ; Thom DH; Kanaya AM; Wassel-Fyr CL; Van Den Eeden SK; Ragins AI; Subak LL; Brown JS

Am J Obstet Gynecol. 2006 Nov;195(5):1331-7. Epub 2006 Apr 27.

PubMed abstract

Quality-of-life impact and treatment of urinary incontinence in ethnically diverse older women

OBJECTIVE: To identify the factors associated with greater quality-of-life impact, treatment seeking, and use of treatments for urinary incontinence in ethnically diverse older women. METHODS: Cross-sectional analysis of a population-based cohort of 2109 middle-aged and older women who were randomly selected from age and race/ethnicity strata. Data were collected by self-report questionnaires and in-person interviews. Multivariable logistic regression was used to identify predictors of high quality-of-life impact (Incontinence Impact Questionnaire [IIQ] score > or =75th percentile), treatment seeking, and use of treatments for incontinence. RESULTS: More than one fourth (n = 603) of the study participants (including 96 black [16%], 123 Latina [20%], 65 Asian [11%], and 309 white [51%] women) reported weekly incontinence. After clinical severity and other factors were adjusted for, women were more likely to experience high quality-of-life impact if they had nighttime incontinence (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.3-4.9), coital incontinence (OR, 1.9; 95% CI, 1.1-3.3), or comorbid fecal incontinence (OR, 2.2; 95% CI, 1.2-4.2). Predictors of treatment seeking included older age (OR, 1.6 per 10 years; 95% CI, 1.2-2.0); higher IIQ score (OR, 4.6 for highest IIQ quartile vs lowest IIQ quartile; 95% CI, 2.5-8.4), and higher household income (OR, 2.6 for income > or = US dollars 100 000/y vs < US dollars 20 000/y; 95% CI, 1.0-2.7). CONCLUSIONS: Clinicians seeking to evaluate the impact of incontinence on women's lives should assess not only the clinical severity of their symptoms but also the specific context in which symptoms occur. The prevalence of treatment seeking for incontinence is low across all ethnic groups, even when women have clinically severe symptoms and access to a health provider.

Authors: Huang AJ; Brown JS; Kanaya AM; Creasman JM; Ragins AI; Van Den Eeden SK; Thom DH

Arch Intern Med. 2006 Oct 9;166(18):2000-6.

PubMed abstract

Risks for end-stage renal disease, cardiovascular events, and death in Hispanic versus non-Hispanic white adults with chronic kidney disease

Rates of ESRD are rising faster in Hispanic than non-Hispanic white individuals, but reasons for this are unclear. Whether rates of cardiovascular events and mortality differ among Hispanic and non-Hispanic white patients with chronic kidney disease (CKD) also is not well understood. Therefore, this study examined the associations between Hispanic ethnicity and risks for ESRD, cardiovascular events, and death in patients with CKD. A total of 39,550 patients with stages 3 to 4 CKD from Kaiser Permanente of Northern California were included. Hispanic ethnicity was obtained from self-report supplemented by surname matching. GFR was estimated from the abbreviated Modification of Diet in Renal Disease equation, and clinical outcomes, patient characteristics, and longitudinal medication use were ascertained from health plan databases and state mortality files. After adjustment for sociodemographic characteristics, Hispanic ethnicity was associated with an increased risk for ESRD (hazard ratio [HR] 1.93; 95% confidence interval [CI] 1.72 to 2.17) when compared with non-Hispanic white patients, which was attenuated after controlling for diabetes and insulin use (HR 1.50; 95% CI 1.33 to 1.69). After further adjustment for potential confounders, Hispanic ethnicity remained independently associated with an increased risk for ESRD (HR 1.33; 95% CI 1.17 to 1.52) as well as a lower risk for cardiovascular events (HR 0.82; 95% CI 0.76 to 0.88) and death (HR 0.72; 95% CI 0.66 to 0.79). Among a large cohort of patients with CKD, Hispanic ethnicity was associated with lower rates of death and cardiovascular events and a higher rate of progression to ESRD. The higher prevalence of diabetes among Hispanic patients only partially explained the increased risk for ESRD. Further studies are required to elucidate the cause(s) of ethnic disparities in CKD-associated outcomes.

Authors: Peralta CA; Shlipak MG; Fan D; Ordonez J; Lash JP; Chertow GM; Go AS

J Am Soc Nephrol. 2006 Oct;17(10):2892-9. Epub 2006 Sep 7.

PubMed abstract

Disparities in HbA1c levels between African-American and non-Hispanic white adults with diabetes: a meta-analysis

OBJECTIVE: Among individuals with diabetes, a comparison of HbA(1c) (A1C) levels between African Americans and non-Hispanic whites was evaluated. Data sources included PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health, the Cochrane Library, the Combined Health Information Database, and the Education Resources Information Center. RESEARCH DESIGN AND METHODS: We executed a search for articles published between 1993 and 2005. Data on sample size, age, sex, A1C, geographical location, and study design were extracted. Cross-sectional data and baseline data from clinical trials and cohort studies for African Americans and non-Hispanic whites with diabetes were included. Diabetic subjects aged <18 years and those with pre-diabetes or gestational diabetes were excluded. We conducted a meta-analysis to estimate the difference in the mean values of A1C for African Americans and non-Hispanic whites. RESULTS: A total of 391 studies were reviewed, of which 78 contained A1C data. Eleven had data on A1C for African Americans and non-Hispanic whites and met selection criteria. A meta-analysis revealed the standard effect to be 0.31 (95% CI 0.39-0.25). This standard effect correlates to an A1C difference between groups of approximately 0.65%, indicating a higher A1C across studies for African Americans. Grouping studies by study type (cross-sectional or cohort), method of data collection for A1C (chart review or blood draw), and insurance status (managed care or nonmanaged care) showed similar results. CONCLUSIONS: The higher A1C observed in this meta-analysis among African Americans compared with non-Hispanic whites may contribute to disparity in diabetes morbidity and mortality in this population.

Authors: Kirk JK; D'Agostino RB Jr; Bell RA; Passmore LV; Bonds DE; Karter AJ; Narayan KM

Diabetes Care. 2006 Sep;29(9):2130-6.

PubMed abstract

Objectively measured sleep characteristics among early-middle-aged adults: the CARDIA study

Despite mounting evidence that sleep duration is a risk factor across diverse health and functional domains, little is known about the distribution and determinants of sleep. In 2003-2004, the authors used wrist activity monitoring and sleep logs to measure time in bed, sleep latency (time required to fall asleep), sleep duration, and sleep efficiency (percentage of time in bed spent sleeping) over 3 days for 669 participants at one of the four sites of the Coronary Artery Risk Development in Young Adults (CARDIA) study (Chicago, Illinois). Participants were aged 38-50 years, 58% were women, and 44% were Black. For the entire sample, mean time in bed was 7.5 (standard deviation (SD), 1.2) hours, mean sleep latency was 21.9 (SD, 29.0) minutes, mean sleep duration was 6.1 (SD, 1.2) hours, and mean sleep efficiency was 80.9 (SD, 11.3)%. All four parameters varied by race-sex group. Average sleep duration was 6.7 hours for White women, 6.1 hours for White men, 5.9 hours for Black women, and 5.1 hours for Black men. Race-sex differences (p < 0.001) remained after adjustment for socioeconomic, employment, household, and lifestyle factors and for apnea risk. Income was independently associated with sleep latency and efficiency. Sleep duration and quality, which have consequences for health, are strongly associated with race, sex, and socioeconomic status.

Authors: Lauderdale DS; Knutson KL; Yan LL; Rathouz PJ; Hulley SB; Sidney S; Liu K

Am J Epidemiol. 2006 Jul 1;164(1):5-16. Epub 2006 Jun 1.

PubMed abstract

Progress in pediatric asthma surveillance II: geospatial patterns of asthma in Alameda County, California

INTRODUCTION: As with many diseases, the epidemic of asthma among children over the past few decades has been shaped by a social and environmental context that is becoming progressively more evident. Commonly used methods for asthma surveillance, however, are based on national rather than local data. The purpose of this study was to develop high-resolution asthma surveillance techniques responsive to the needs of health care professionals and local child health and social justice advocates. METHODS: We assembled a working data set of health care use records from 2001 from public and private sources covering 1.7 million person-months among children younger than 18 years in Alameda County, California. Health care use was categorized by type and analyzed by census tract demographic information. Images of the geographic distribution of health service events were created using density estimation mapping with overlapping 0.5-mile (805-m) radius spatial buffers, and statistical significance (two-tailed P & .05) was estimated using a Monte Carlo simulation algorithm. RESULTS: High-poverty communities had higher rates of emergency department visits due to asthma than low-poverty communities but had lower rates for indicators of quality primary asthma care. Geospatial analysis enabled visualization of this phenomenon; it further detected areas with elevated emergency department visit rates and potentially related environmental hazards in and around communities of concern. Areas of the county not previously considered to be deeply burdened by asthma were identified as having high emergency department visit rates. CONCLUSION: The assembly and high-resolution geospatial analysis of health care use data contributed to a more detailed depiction of pediatric asthma disparities than was previously available to community members, public health professionals, and clinicians. Information generated using these techniques facilitated discussion among stakeholders of the environmental and social contexts of asthma and health disparities in general. Proceedings of group evaluations suggested that the material aided in the translation of data describing spatial variations in health event risk to address specific community experiences and concerns.

Authors: Roberts EM; English PB; Wong M; Wolff C; Valdez S; Van den Eeden SK; Ray GT

Prev Chronic Dis. 2006 Jul;3(3):A92. Epub 2006 Jun 15.

PubMed abstract

Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes

OBJECTIVES: We sought to determine whether literacy mediates the relationship between education and glycemic control among diabetes patients. METHODS: We measured educational attainment, literacy using the Short Test of Functional Health Literacy in Adults (s-TOFHLA), and glycemic control (HbA1c) in 395 diabetes patients at a U.S. public hospital. We performed path analysis to compare two competing models to explain glycemic control. The direct effects model estimated how education was related to HbA1c; the mediational model estimated the strength of the direct relationship when the additional pathway from education to literacy to HbA1c was added. RESULTS: Both the model with a direct effect of education on HbA1c and the model with literacy as a mediator were supported by good fit to observed data. The mediational model, however, was a significant improvement, with the additional path from literacy to HbA1c reducing the discrepancy from observed data (p < 0.01). After including this path, the direct relationship between education and HbA1c fell to a non-significant threshold. CONCLUSIONS: In a low-income population with diabetes, literacy mediated the relationship between education and glycemic control. This finding has important implications for both education and health policy.

Authors: Schillinger D; Barton LR; Karter AJ; Wang F; Adler N

Public Health Rep. 2006 May-Jun;121(3):245-54.

PubMed abstract

Adolescents entering chemical dependency treatment in private managed care: ethnic differences in treatment initiation and retention

PURPOSE: There has been little research on adolescents of different ethnicities in chemical dependency (CD) treatment, despite a focus on ethnic disparities in health care in recent years. In particular, little is known about ethnic differences in utilization of adolescent CD services. METHODS: We examined treatment initiation and treatment retention in a sample of African American, Native American, Latino, Asian American, and Caucasian adolescents entering CD treatment in a private, managed care health plan (n = 419). Our conceptual framework included ethnicity as the main factor as well as measures of external pressure and internal motivation/readiness for treatment, family environment, psychiatric co-morbidities, and severity of alcohol and drug problems. Logistic and Poisson regression were used to examine differences. RESULTS: The study found ethnic differences in treatment initiation and treatment retention. Native American adolescents had lower odds of returning after intake to initiate treatment compared with Caucasians (odds ratio [OR] .35, p = .009), and African American youth spent less time in treatment than Caucasians (RR: .49, p < .001). CONCLUSIONS: Study findings indicate differences in treatment initiation for Native Americans and in treatment retention for African Americans. Intake and orientation sessions offer an opportunity to intervene with Native American youth. Given their high psychiatric co-morbidity, they may also benefit from the availability of psychiatric services. Even after adjusting for severity, we found shorter treatment retention for African American adolescents and suggest that organizational factors, such as cultural competency, may play an important role.

Authors: Campbell CI; Weisner C; Sterling S

J Adolesc Health. 2006 Apr;38(4):343-50.

PubMed abstract

Epidemiology and adverse cardiovascular risk profile of diagnosed polycystic ovary syndrome

CONTEXT: Polycystic ovary syndrome (PCOS) is associated with menstrual and reproductive abnormalities, insulin resistance, and obesity. OBJECTIVE: The objective of this study was to determine the prevalence of diagnosed PCOS and its association with cardiovascular risk factors. SETTING: The study is set in an integrated health care delivery system in northern California. PATIENTS: A total of 11,035 women with PCOS were identified by one or more outpatient diagnoses of PCOS using health plan databases. An age-matched sample of women without PCOS was also selected. OUTCOME MEASURES: Prevalence of PCOS and targeted cardiovascular risk factors [hypertension, dyslipidemia, diabetes mellitus, and body mass index (BMI)] were measured. RESULTS: During 2002-2004, the prevalence of diagnosed PCOS among female members aged 25-34 yr was 2.6% (95% confidence interval 1.6-1.7%). Women with diagnosed PCOS were more likely than those without PCOS to be obese [BMI > or = 30 mg/m(2); odds ratio (OR) 4.21, 3.96-4.47]. Furthermore, PCOS was associated with diabetes (OR 2.45, confidence interval 2.16-2.79), hypertension (OR 1.41, 1.31-1.51) and known dyslipidemia (OR 1.53, 1.39-1.68), even after adjusting for BMI and known confounders. Among women with PCOS, compared with whites, Blacks and Hispanics were more likely and Asians less likely to be obese; Asians and Hispanics were more likely to have diabetes; and Blacks were more likely and Hispanics less likely to have hypertension. CONCLUSIONS: Within a large, community-based population receiving health care, diagnosed PCOS was highly prevalent and associated with a much higher frequency of cardiovascular risk factors that varied by race/ethnicity. Our prevalence estimates likely underestimate the true prevalence of PCOS. Further studies are needed to explore racial/ethnic differences and the extent to which PCOS contributes to future cardiovascular risk.

Authors: Lo JC; Feigenbaum SL; Yang J; Pressman AR; Selby JV; Go AS

J Clin Endocrinol Metab. 2006 Apr;91(4):1357-63. Epub 2006 Jan 24.

PubMed abstract

Does the association between serum endostatin, an endogenous anti-angiogenic protein, and acute myocardial infarction differ by race?

Endostatin, an endogenous anti-angiogenic protein, has been linked to reduced atherosclerosis in animal models. We conducted a nested case-control study to ascertain whether decreased circulating endostatin might be associated with increased odds of acute myocardial infarction (AMI) and whether this association varied by sex or race. Cases were 211 subjects who subsequently developed AMI, and controls were 173 subjects free of cardiovascular disease matched on age, sex, race and follow-up time. In conditional logistic regression adjusting for traditional risk factors, the odds ratio of AMI per 1 SD increment in endostatin was 0.85 (95% confidence interval, 0.73-1.00). This association varied by race (but not by sex) such that a statistically significant inverse relation was found among Asians and white individuals and a significant positive relation among black individuals. Further research is needed to replicate these findings and to elucidate potential mechanisms for these race/ethnic differences.

Authors: Iribarren C; Herrinton LJ; Darbinian JA; Tamarkin L; Malinowski D; Vogelman JH; Orentreich N; Baer D

Vasc Med. 2006 Feb;11(1):13-20.

PubMed abstract

Differences in prevalence of urinary incontinence by race/ethnicity

PURPOSE: We compared the prevalence of urinary incontinence by type among white, black, Hispanic and Asian-American women. MATERIALS AND METHODS: The RRISK is a population based cohort study of 2,109 randomly selected middle-aged and older women. Incontinence and other variables were assessed by self-report questionnaires and in person interviews. Labor and delivery and surgical data were abstracted from medical records archived since 1946. Logistic regression was used to estimate the OR with 95% CIs for incontinence while adjusting for covariates. RESULTS: The age adjusted prevalence of weekly incontinence was highest among Hispanic women, followed by white, black and Asian-American women (36%, 30%, 25% and 19%, respectively, p <0.001). Type of incontinence also differed among groups, with weekly stress incontinence prevalence being 18%, 15%, 8% and 8% (p <0.001), and weekly urge incontinence prevalence being 10%, 9%, 14% and 7% (p <0.001). After adjustment for age, parity, hysterectomy, estrogen use, body mass, menopausal status and diabetes, the risk of stress incontinence remained significantly lower in black (adjusted OR 0.36, 95% CI 0.23-0.57) and Asian-American (adjusted OR 0.54, 95% CI 0.34-0.86) women compared to white women. In contrast, the risk of urge incontinence was similar in black (adjusted OR 1.19, 95% CI 0.79-1.81) and Asian-American (adjusted OR 0.86, 95% CI 0.52-1.43) women compared to white women. CONCLUSIONS: Significant differences in the adjusted risk of stress incontinence among Hispanic, white, black and Asian-American women suggest the presence of additional, as yet unrecognized, risk or protective factors for stress incontinence.

Authors: Thom DH; Van Den Eeden SK; Ragins AI; Wassel-Fyr C; Vittinghof E; Subak LL; Brown JS

J Urol. 2006 Jan;175(1):259-64.

PubMed abstract

History of depression, race, and cardiovascular risk in CARDIA

Though previous data indicate a positive association between depression and coronary heart disease, the mechanisms mediating these associations remain unclear. These prospective analyses assessed the association between history of Center for Epidemiologic Studies Depression Scale depression and possible mediators of cardiovascular risk at Year 15 of follow-up in African Americans (AA) and Caucasians (C) in the Coronary Artery Risk Development in Young Adults Study. Physiological assessments included plasma levels of low-density-lipoprotein cholestrol (LDL), high-density-lipoprotein cholestrol (HDL), total cholesterol, triglycerides and fasting glucose, diabetes and blood pressure. Behavioral risk factors included alcohol consumption, smoking, physical activity, and body mass index (BMI). AA’s showed significant associations between history of depression and diabetes that did not exist in Cs and AA women had significantly more episodes of depression than any other group. However, associations of depression with smoking, BMI, and physical activity were consistent across groups in the expected direction. HDL-cholesterol was positively and LDL-cholesterol inversely associated with depression in Cs, which was unexpected. These data indicate that in this still healthy cohort, there are already associations between depression and factors that predispose to cardiovascular risk.

Authors: Knox S; Barnes A; Kiefe C; Lewis CE; Iribarren C; Matthews KA; Wong ND; Whooley M

Int J Behav Med. 2006;13(1):44-50.

PubMed abstract

Socioeconomic status, race, and diurnal cortisol decline in the Coronary Artery Risk Development in Young Adults (CARDIA) Study

OBJECTIVES: The objectives of this study were to assess whether socioeconomic status (SES) is associated with dysregulation of the cortisol diurnal rhythm and whether this association is independent of race and occurs equally in whites and blacks; and to determine if an association between SES and cortisol can be explained (is mediated) by behavioral, social, and emotional differences across the SES gradient. METHODS: Seven hundred eighty-one subjects from a multisite sample representing both whites and blacks provided six saliva cortisol samples over the course of the day: at awakening, 45 minutes, 2.5 hours, 8 hours, and 12 hours after awakening, and at bedtime. RESULTS: Both lower SES (education and income) and being black were associated with higher evening levels of cortisol. These relationships were independent of one another and SES associations with cortisol were similar across racial categories. The evidence was consistent with poorer health practices (primarily smoking), higher levels of depressive symptoms, poorer social networks and supports, and feelings of helplessness (low mastery) mediating the link between SES and cortisol. However, we found no evidence for psychosocial or behavioral mediation of the association between race and cortisol response. CONCLUSIONS: Lower SES was associated in a graded fashion with flatter diurnal rhythms as a result of less of a decline during the evening. This association occurred independent of race and the data were consistent with mediation by health practices, emotional and social factors. Blacks also showed a flatter rhythm at the end of the day. This association was independent of SES and could not be explained by behavioral, social, or emotional mediators.

Authors: Cohen S; Schwartz JE; Epel E; Kirschbaum C; Sidney S; Seeman T

Psychosom Med. 2006 Jan-Feb;68(1):41-50.

PubMed abstract

Availability of services for women in outpatient substance abuse treatment: 1995-2000

Women entering substance abuse treatment have more severe substance abuse problems and more medical and psychiatric comorbidities than men. Research shows that specialized women’s services are associated with better retention and outcomes but relatively little is known about their availability nationwide. This study examined the adoption and implementation of reproductive and female-sensitive social services in a national sample of outpatient substance abuse treatment (OSAT) organizations in 1995 (N = 617) and 2000 (N = 571) by several organizational factors. Overall, reproductive and social services for women have not been widely adopted, although some services did increase over the study period, particularly social services. There was no evidence of large-scale decreases in service availability over the study period, although child care did decline. Nonprofit and public ownership (relative to for-profit) were associated with greater service provision. Managed care units had greater service adoption compared to nonmanaged care units, and this increased over time. Public units and hospital-affiliated units had greater service implementation than other units. However, OSAT units did not always implement the services they adopted, suggesting access to some services may be restricted.

Authors: Campbell CI; Alexander JA

J Behav Health Serv Res. 2006 Jan;33(1):1-19.

PubMed abstract

Differential mortality and transplantation rates among Asians and Pacific Islanders with ESRD

Few studies in patients with ESRD have examined outcomes in Asian or Pacific Islander subgroups compared with white individuals. The objective of this study was to assess ethnic disparities in mortality and kidney transplantation among a multiethnic cohort of incident dialysis patients. A total of 24,963 patients who initiated dialysis within the TransPacific Renal Network (Network 17) between April 1, 1995, and September 30, 2001, were studied to ascertain death and kidney transplantation through September 30, 2002. Overall, 12,902 deaths and 2258 kidney transplantations were observed during 59,075 person-years of follow-up. Mortality on dialysis among Asians and Pacific Islanders (except Chamorros) was lower than that of white individuals after controlling for differences in sociodemographic characteristics, comorbid conditions, and other risk factors for death (adjusted hazard ratio [95% confidence interval] versus white individuals: Japanese 0.64 [0.57 to 0.72], Chinese 0.64 [0.52 to 0.78], Filipino 0.64 [0.57 to 0.72], Native Hawaiian 0.84 [0.72 to 0.96], Samoan 0.62 [0.48 to 0.82], and Chamorro 0.96 [0.84 to 1.20]). In contrast, Asians and Pacific Islanders were much less likely to undergo kidney transplantation (adjusted rate ratio [95% confidence interval] versus white individuals: Japanese 0.34 [0.24 to 0.46], Chinese 0.54 [0.30 to 0.88], Filipino 0.32 [0.26 to 0.47], Native Hawaiian 0.17 [0.10 to 0.30], Samoan 0.17 [0.07 to 0.38], and Chamorro 0.04 [0.01 to 0.14]). Despite wide variations in primary cause of ESRD, clinical characteristics, and body size at dialysis initiation, Asians and Pacific Islanders experience better survival but substantially lower transplantation rates compared with white individuals. Strategies that are aimed at improving access to transplantation in Asian and Pacific Islander communities may further enhance survival among Asians and Pacific Islanders with ESRD.

Authors: Hall YN; Sugihara JG; Go AS; Chertow GM

J Am Soc Nephrol. 2005 Dec;16(12):3711-20. Epub 2005 Oct 19.

PubMed abstract

Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE: To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings. RESEARCH DESIGN AND METHODS: We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA(1c) [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control). RESULTS: Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP. CONCLUSIONS: In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.

Authors: Brown AF; Gregg EW; Stevens MR; Karter AJ; Weinberger M; Safford MM; Gary TL; Caputo DA; Waitzfelder B; Kim C; Beckles GL

Diabetes Care. 2005 Dec;28(12):2864-70.

PubMed abstract

The conundrum of increased burden of end-stage renal disease in Asians

BACKGROUND: Few cohort studies have examined the risk of end-stage renal disease (ESRD) among Asians compared with whites and blacks. METHODS: To compare the incidence of ESRD in Asians, whites, and blacks in Northern California, we examined sociodemographic and clinical data on 299,168 adults who underwent a screening health checkup at Kaiser Permanente between 1964 and 1985. Incident cases of ESRD were ascertained by matching patient identifiers with the nationally comprehensive United States Renal Data System ESRD registry. RESULTS: Overall, 1346 cases of ESRD occurred during 7,837,310 person-years of follow-up. The age-adjusted rate of ESRD (per 100,000 person-years) was 14.0 [95% confidence interval (CI) 10.5-18.5] among Asians, 7.9 (95% CI 6.5-9.5) among whites, and 43.4 (95% CI 36.6-51.4)] among blacks. Controlling for age, gender, educational attainment, diabetes, prior myocardial infarction, serum creatinine, systolic and diastolic blood pressure, proteinuria, hematuria, cigarette smoking, serum total cholesterol, and body mass index increased the risk of ESRD in Asians relative to whites from 1.69 to 2.08 (95% CI 1.61-2.67). By contrast, adjustment for the same covariates decreased the risk of ESRD in blacks relative to whites from 5.30 to 3.28 (95% CI 2.91-3.69). CONCLUSION: Factors contributing to the excess ESRD risk in Asians relative to whites extend beyond usually considered sociodemographic and comorbidity disparities. Strategies aimed at examining novel risk factors for kidney disease and efforts to increase awareness of kidney disease among Asians may reduce ESRD incidence in this high-risk group.

Authors: Hall YN; Hsu CY; Iribarren C; Darbinian J; McCulloch CE; Go AS

Kidney Int. 2005 Nov;68(5):2310-6.

PubMed abstract

Sex and racial/ethnic disparities in outcomes after acute myocardial infarction: a cohort study among members of a large integrated health care delivery system in northern California

BACKGROUND: Previous studies have documented sex and racial/ethnic disparities in outcomes after acute myocardial infarction (AMI), but the explanation of these disparities remains limited. In a setting that controls for access to medical care, we evaluated whether sex and racial/ethnic disparities in prognosis after AMI persist after consideration of socioeconomic background, personal medical history, and medical management. METHODS: We conducted a prospective cohort study of the members (20,263 men and 10,061 women) of an integrated health care delivery system in northern California who had experienced an AMI between January 1, 1995, and December 31, 2002, and were followed up for a median of 3.5 years (maximum, 8 years). Main outcome measures included AMI recurrence and all-cause mortality. RESULTS: In age-adjusted analyses relative to white men, black men (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.26-1.65), black women (HR, 1.47; 95% CI, 1.26-1.72), and Asian women (HR, 1.37; 95% CI, 1.13-1.65) were at increased risk of AMI recurrence. However, multivariate adjustment for sociodemographic background, comorbidities, medication use, angiography, and revascularization procedures effectively removed the excess risk of AMI recurrence in these 3 groups. Similarly, the increased age-adjusted risk of all-cause mortality seen in black men (HR, 1.55; 95% CI, 1.37-1.75) and black women (HR, 1.45; 95% CI, 1.27-1.66) was greatly attenuated in black men and reversed in black women after full multivariate adjustment. CONCLUSION: In a population with equal access to medical care, comprehensive consideration of social, personal, and medical factors could explain sex and racial/ethnic disparities in prognosis after AMI.

Authors: Iribarren C; Tolstykh I; Somkin CP; Ackerson LM; Brown TT; Scheffler R; Syme L; Kawachi I

Arch Intern Med. 2005 Oct 10;165(18):2105-13.

PubMed abstract

Gender differences in the risk of ischemic stroke and peripheral embolism in atrial fibrillation: the AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) study

BACKGROUND: Previous studies provide conflicting results about whether women are at higher risk than men for thromboembolism in the setting of atrial fibrillation (AF). We examined data from a large contemporary cohort of AF patients to address this question. METHODS AND RESULTS: We prospectively studied 13,559 adults with AF and recorded data on patients’ clinical characteristics and the occurrence of incident hospitalizations for ischemic stroke, peripheral embolism, and major hemorrhagic events through searching validated computerized databases and medical record review. We compared event rates by patient sex using multivariable log-linear regression, adjusting for clinical risk factors for stroke, and stratifying by warfarin use. We identified 394 ischemic stroke and peripheral embolic events during 15,494 person-years of follow-up off warfarin. After multivariable analysis, women had higher annual rates of thromboembolism off warfarin than did men (3.5% versus 1.8%; adjusted rate ratio [RR], 1.6; 95% CI, 1.3 to 1.9). There was no significant difference by sex in 30-day mortality after thromboembolism (23% for both). Warfarin use was associated with significantly lower adjusted thromboembolism rates for both women and men (RR, 0.4; 95% CI, 0.3 to 0.5; and RR, 0.6; 95% CI, 0.5 to 0.8, respectively), with similar annual rates of major hemorrhage (1.0% and 1.1%, respectively). CONCLUSIONS: Women are at higher risk than men for AF-related thromboembolism off warfarin. Warfarin therapy appears be as effective in women, if not more so, than in men, with similar rates of major hemorrhage. Female sex is an independent risk factor for thromboembolism and should influence the decision to use anticoagulant therapy in persons with AF.

Authors: Fang MC; Singer DE; Chang Y; Hylek EM; Henault LE; Jensvold NG; Go AS

Circulation. 2005 Sep 20;112(12):1687-91. Epub 2005 Sep 12.

PubMed abstract

Incomplete screening flexible sigmoidoscopy associated with female sex, age, and increased risk of colorectal cancer

BACKGROUND: Several previous studies have found that females and older individuals are at greater risk of having incomplete flexible sigmoidoscopy. However, no prior study has reported the subsequent risk of colorectal cancer (CRC) following incomplete sigmoidoscopy. METHODS: Using data from 55 791 individuals screened as part of the Colon Cancer Prevention (CoCaP) programme of Kaiser Permanente of Northern California, we evaluated the likelihood of having an inadequate (<40 cm) examination by age and sex, and estimated the risk of distal CRC according to depth of sigmoidoscope insertion at the baseline screening examination. Multivariate estimation of risks was performed using Poisson regression. RESULTS: Older individuals were at a much greater risk of having an inadequate examination (relative risk (RR) for age 80+ years compared with 50-59 years 2.6 (95% confidence interval (CI) 2.3-3.0)), as were females (RR 2.3 (95% CI 2.2-2.5)); these associations were attenuated but remained strong if Poisson models were further adjusted for examination limitations (pain, stool, and angulation). There was an approximate threefold increase in the risk of distal CRC if the baseline sigmoidoscopy did not reach a depth of at least 40 cm; a smaller increase in risk was observed for examinations that reached 40-59 cm. CONCLUSIONS: Older individuals and women are at an increased risk of having inadequate sigmoidoscopy. Because inadequate sigmoidoscopy results in an increased risk of subsequent CRC, physicians should consider steps to maximise the depth of insertion of the sigmoidoscope or, failing this, should consider an alternative screening test.

Authors: Doria-Rose VP; Newcomb PA; Levin TR

Gut. 2005 Sep;54(9):1273-8. Epub 2005 May 4.

PubMed abstract

Health services for women in outpatient substance abuse treatment

OBJECTIVE: To evaluate how a sample of outpatient substance abuse treatment units respond to organizational and environmental influences by adopting and implementing treatment services for women. DATA SOURCES: The National Drug Abuse Treatment System Survey from 1995 and 2000, a national survey of outpatient substance abuse treatment units. STUDY DESIGN: Health services for women are the dependent variables. The predictors include organizational and environmental factors that represent resource dependence and institutional pressures for the treatment unit. Logistic regression and Heckman selection models were used to test hypotheses. DATA COLLECTION: Program directors and clinical supervisors at each treatment unit were interviewed by telephone in 1995 and 2000. PRINCIPAL FINDINGS: Units that depended on specific funding for women’s programs and that depended on government funds were more likely to adopt, but not necessarily implement, women’s services. Methadone units and units that train more staff to work with women were more likely to adopt as well as implement women’s services. Private not-for-profit units were more likely to adopt some services, while for-profit units were less so. However, in general, neither for-profit nor not-for-profit units significantly implemented services. There was evidence that the odds of adopting services were greater in 2000 than 1995 for two services, but were otherwise stable. CONCLUSIONS: There is considerable variation in the adoption and implementation of women’s services. In addition, not all adopted services were significantly implemented, which could reflect limited organizational resources and/or conflicting expectations. This also suggests that referral mechanisms to these services, and therefore access, may not be adequate. Government funds and specific funds for women’s programs are important resources for the provision of these services. Women’s services appear more available in methadone units, suggesting that regulation has been influential and that the recent methadone accreditation system should be evaluated. Staff training may be one strategy to encourage implementation of these services. For the most part, the adoption of services for women did not change between 1995 and 2000.

Authors: Campbell CI; Alexander JA

Health Serv Res. 2005 Jun;40(3):781-810.

PubMed abstract

Socioeconomic status and health: is parasympathetic nervous system activity an intervening mechanism?

BACKGROUND: The link between socioeconomic status (SES) and health is widely recognized but the pathophysiologic mechanisms are not well understood. We tested the hypothesis that parasympathetic nervous system (PNS) regulation is one such mechanism. METHODS: In a cross-sectional study, electrocardiogram-derived RR interval variability (RRV), a non-invasive index of cardiac PNS regulation, and SES, measured as educational attainment and income, were collected in 756 subjects in the CARDIA study of heart disease in young adults. RESULTS: Relative to those with less than a high school education, those with high school to college and post-college education had 26% (beta = 0.233) and 43% (beta = 0.355) greater low frequency (LF) RRV, respectively, adjusted for age, sex, and race. For high frequency (HF) RRV, race interacted with income: relative to low income whites, intermediate and high income whites had 133 and 191% greater HF power, respectively, while intermediate and high income blacks had 32 and 44% greater HF RRV, respectively, relative to low income blacks. CONCLUSIONS: Numerous studies demonstrate that psychosocial stressors reduce cardiac parasympathetic regulation and that SES disparities are associated with increasing social stress proportional to the degree of disparity. Data from the current study suggest that PNS regulation may be a mechanism linking the stressful effects of low SES to increased morbidity and mortality.

Authors: Sloan RP; Huang MH; Sidney S; Liu K; Williams OD; Seeman T

Int J Epidemiol. 2005 Apr;34(2):309-15. Epub 2005 Jan 19.

PubMed abstract

Causes and demographic, medical, lifestyle and psychosocial predictors of premature mortality: the CARDIA study

We examined the 16-year mortality experience among participants in the baseline examination (1985-86) of the Coronary Artery Risk Development in Young Adults (CARDIA) Study, a U.S. cohort of 5115 urban adults initially 18-30 years old and balanced by sex and race (black and whites) in the USA. We observed 127 deaths (annual mortality of 0.15%). Compared to white women, the rate ratio (95% confidence interval) of all-cause mortality was 9.3 (4.4, 19.4) among black men, 5.3 (2.5, 11.4) among white men and 2.7 (1.2, 6.1) among black women. The predominant causes of death, which also differed greatly by sex-race, were AIDS (28% of deaths), homicide (16%), unintentional injury (10%), suicide (7%), cancer (7%) and coronary disease (7%). The significant baseline predictors of all-cause mortality in multivariate analysis were male sex, black race, diabetes, self-reported liver and kidney disease, current cigarette smoking and low social support. Two other factors, self-reported thyroid disease and high hostility, were significant predictors in analyses adjusted for age, sex and race. In conclusion, we found striking differences in the rates and underlying cause of death across sex-race groups and several independent predictors of young adult mortality that have major implications for preventive medicine and social policies.

Authors: Iribarren C; Jacobs DR; Kiefe CI; Lewis CE; Matthews KA; Roseman JM; Hulley SB

Soc Sci Med. 2005 Feb;60(3):471-82.

PubMed abstract

Disparities and survival among breast cancer patients

BACKGROUND: Although rates of survival for women with breast cancer have improved, the survival disparity between African American and white women in the United States has increased. PURPOSE: To determine whether this survival disparity persists in an insured population with access to medical care. METHODS: In this retrospective cohort study, we extracted data from the tumor registries of six nonprofit, integrated health care delivery systems affiliated with the Cancer Research Network and assessed the survival of African American (n = 2276) and white (n = 18 879) female enrollees who were diagnosed with invasive breast cancer from January 1, 1993, through December 31, 1998. Cox proportional hazards regression was used to estimate the death rate among African American women relative to that of white women after adjustment for potential explanatory factors including stage at diagnosis, tumor characteristics, and treatment. RESULTS: Five-year survival was lower for African American women (73.8%) than for white women (81.6%). African American women were less likely to have tumor characteristics with good prognosis. Controlling for age at diagnosis, stage, grade, tumor size, and estrogen and progesterone receptor status, the adjusted hazard rate ratio for African American women was 1.34 (95% confidence interval = 1.22 to 1.46). Similar risks were found among women ages 20-49 and 50 and older. Controlling for treatment slightly lowered the hazard rate ratio to 1.31 (95% confidence interval = 1.20 to 1.43). CONCLUSIONS: Among women with invasive breast cancer, being insured and having access to medical care does not eliminate the survival disparity for African American women.

Authors: Field TS; Hornbrook MC; Yao J; et al.

J Natl Cancer Inst Monogr. 2005;(35):88-95.

PubMed abstract

Race and ethnicity: comparing medical records to self-reports

Understanding and eliminating health disparities requires accurate data on race/ethnicity. To assess the quality of race/ethnicity data, we compared medical record classifications to self-report of a study of prophylactic mastectomy. A total of 788 women had race/ethnicity from both sources; 69.9% were 55 years of age or older, 38.3% were at least college graduates, and 67.8% were married or living with someone. There were 817 race/thnicity classifications for the 788 women, of which 758 (92.3%) were identical in the medical record and self-report. Sensitivity and positive predictive value were high (86.7%-97.2%) for whites, Asians, and blacks and moderate (64.0% and 68.1%) for Latinas. However, only one of 18 Native Americans was correctly identified in her medical record. Our results indicate that even if the overall accuracy of medical record classifications for race/ethnicity is high, such a finding may obscure substantial inaccuracies in the recording for racial/ethnic minorities, especially Latinas and Native Americans.

Authors: West CN; Fletcher SW; Emmons KM; et al.

J Natl Cancer Inst Monogr. 2005;(35):72-4.

PubMed abstract

Changes in the health status of women during and after pregnancy

OBJECTIVE: To characterize the changes in health status experienced by a multi-ethnic cohort of women during and after pregnancy. DESIGN: Observational cohort. SETTING/PARTICIPANTS: Pregnant women from 1 of 6 sites in the San Francisco area (N=1,809). MEASUREMENTS AND MAIN RESULTS: Women who agreed to participate were asked to complete a series of telephone surveys that ascertained health status as well as demographic and medical factors. Substantial changes in health status occurred over the course of pregnancy. For example, physical function declined, from a mean score of 95.2 prior to pregnancy to 58.1 during the third trimester (0-100 scale, where 100 represents better health), and improved during the postpartum period (mean score, 90.7). The prevalence of depressive symptoms rose from 11.7% prior to pregnancy to 25.2% during the third trimester, and then declined to 14.2% during the postpartum period. Insufficient money for food or housing and lack of exercise were associated with poor health status before, during, and after pregnancy. CONCLUSIONS: Women experience substantial changes in health status during and after pregnancy. These data should guide the expectations of women, their health care providers, and public policy.

Authors: Haas JS; Jackson RA; Fuentes-Afflick E; Stewart AL; Dean ML; Brawarsky P; Escobar GJ

J Gen Intern Med. 2005 Jan;20(1):45-51.

PubMed abstract

Prepregnancy health status and the risk of preterm delivery

BACKGROUND: Despite extensive evaluation, our understanding of risk factors for premature delivery is incomplete. OBJECTIVE: To examine whether a woman’s health status and risk factors before pregnancy are associated with a woman’s risk of preterm delivery, independent of risk factors that occur during pregnancy. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort of pregnant women in the San Francisco Bay area who delivered a singleton infant (n = 1619). MAIN OUTCOME MEASURE: Preterm delivery (37 weeks’ gestational age). RESULTS: Sociodemographic characteristics alone explained 13.0% of the risk of preterm delivery, whereas risk factors that occurred before pregnancy explained 39.8% and risk factors that occurred during pregnancy explained 47.1%. After we adjusted for sociodemographic characteristics, prepregnancy risk factors, and pregnancy risk factors, women who reported poor physical function during the month before conception were nearly twice as likely to experience a preterm delivery (odds ratio, 1.97; 95% confidence interval, 1.18-3.30) as women with better physical function. CONCLUSION: A broader focus on the health of women prior to pregnancy may improve rates of preterm delivery.

Authors: Haas JS; Fuentes-Afflick E; Stewart AL; Jackson RA; Dean ML; Brawarsky P; Escobar GJ

Arch Pediatr Adolesc Med. 2005 Jan;159(1):58-63.

PubMed abstract

Substance misuse: what place for women-only treatment programs?

Authors: Weisner C

Addiction. 2005 Jan;100(1):7-8.

PubMed abstract

Risk of hemorrhagic stroke in Asian American ethnic groups

The sparseness of prospective data about hemorrhagic stroke (HS) risk among Asian American ethnic groups led to the investigation of 128,934 persons with self-classified ethnicity at health examinations in 1978-1985. Subsequently, 431 persons were hospitalized for HS; 31% for subarachnoid hemorrhage (SAH) and 69% for intracerebral hemorrhage (ICH). Ethnic predictors of HS were studied by Cox proportional hazard models with 7 covariates. With whites as reference, the adjusted relative risk (95% CI) of all Asians for HS was 1.6 (1.1-2.3, p = 0.01), due substantially to increased risks of SAH in Japanese people and ICH in Filipinos. These data mandate emphasis upon preventive measures in these groups.

Authors: Klatsky AL; Friedman GD; Sidney S; Kipp H; Kubo A; Armstrong MA

Neuroepidemiology. 2005;25(1):26-31. Epub 2005 Apr 25.

PubMed abstract

Inconsistencies between self-reported ethnicity and ethnicity recorded in a health maintenance organization

PURPOSE: Information on patient ethnicity in hospital admissions databases is often used in epidemiologic and health services research. However, the extent of consistency of these data with self-reported ethnicity is not well studied, particularly for specific Asian subgroups. We examined agreement between ethnicity in records of a sample of members of five Northern California Kaiser Permanente medical centers with self-reported ethnicity. METHODS: Subjects were 3168 cases and 2413 controls aged 45 years and older from a study of fractures. Ethnicity recorded in the Kaiser admissions database (primarily inpatient) was compared with self-reported ethnicity from the study interviews. RESULTS: Among study subjects with available Kaiser ethnicity, sensitivities and positive predictive values of the Kaiser classification were high among blacks (0.95 for both measures) and whites (0.98 and 0.94, respectively), slightly lower among Asians (0.88 and 0.95, respectively), and considerably lower among Hispanics (0.55 and 0.81, respectively) and American Indians (0.47 and 0.50, respectively). Among Asian subgroups, the proportion classified as Asian was high among Chinese (0.94) and Japanese (0.99) but lower among Filipinos (0.79) and other Asians (0.74). Among the 228 (4%) subjects who self-identified with multiple ethnicities, 13 of 18 white + Hispanic subjects were classified as being white, and of the 77 subjects identifying as part American Indian, only one was classified as being American Indian in the Kaiser database. CONCLUSIONS: Given the importance of ethnicity information, medical facilities should be encouraged to adopt policies toward collecting high quality data.

Authors: Gomez SL; Kelsey JL; Glaser SL; Lee MM; Sidney S

Ann Epidemiol. 2005 Jan;15(1):71-9.

PubMed abstract

Health problems and hospitalizations among Asian-American ethnic groups

OBJECTIVES: To study health status and hospitalization risk among Asian Americans. DESIGN: Cross-sectional analyses and cohort study. SETTING: Comprehensive prepaid health care program in Northern California. PATIENTS: Adult Asian Americans (N=13,592), self-classified at health examinations as 6050 (44.5%) Chinese, 1707 (12.6%) Japanese, 4232 (31.1%) Filipinos, 714 (5.3%) South Asians, and 889 (6.5%) Other Asians. INTERVENTIONS: None except data analysis. OUTCOME MEASURES: With Chinese and Whites (n=72,019) as referents, comparison of symptom composites by logistic regression and hospitalization risk by Cox proportional hazards models. RESULTS: Compared to Chinese, Filipinos, South Asians, and other Asians more frequently reported coronary, respiratory, gastrointestinal, and emotional problems. Chinese and Japanese generally had the lowest hospitalization risk. Compared to Chinese, hospitalization risk was higher (P<.05) among Filipinos for circulatory (men or women), respiratory (men), and digestive (women) conditions (relative risks [RR] range from 1.5 to 1.7) and among South Asian men for cardiovascular conditions (RR=2.2). While Asian groups generally had similar or lower hospitalization risk than Whites, risks were higher for asthma (Filipino and South Asian men, RRs >3.0), peptic ulcer (Chinese men, Filipino men and women, other Asian women [RRs 1.9-5.6]), and coronary disease (South Asian men (RR=2.3) and Filipino women (RR=1.5). CONCLUSIONS: Variations in risk of hospitalization and frequency of reported health problems point out differences in health problems and health needs among subgroups of Asian Americans. This diversity shows the need to study Asian ethnic groups separately.

Authors: Klatsky AL; Tekawa I

Ethn Dis. 2005 Autumn;15(4):753-60.

PubMed abstract

Sex differences in quality of health care related to ischemic heart disease prevention in patients with diabetes: the translating research into action for Diabetes (TRIAD) study, 2000-2001

Authors: Ferrara A; Williamson DF; Karter AJ; Thompson TJ; Kim C; Diabetes (TRIAD) Study Group

Diabetes Care. 2004 Dec;27(12):2974-6.

PubMed abstract

Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries: the CARDIA Study

OBJECTIVES: We examined the effects of self-reported experiences of racial discrimination on Black-White differences in preterm (less than 37 weeks gestation) and low-birthweight (less than 2500 g) deliveries. METHODS: Using logistic regression models, we analyzed data on 352 births among women enrolled in the Coronary Artery Risk Development in Young Adults Study. RESULTS: Among Black women, 50% of those with preterm deliveries and 61% of those with low-birthweight infants reported having experienced racial discrimination in at least 3 situations; among White women, the corresponding percentages were 5% and 0%. The unadjusted odds ratio for preterm delivery among Black versus White women was 2.54 (95% confidence interval [CI]=1.33, 4.85), but this value decreased to 1.88 (95% CI=0.85, 4.12) after adjustment for experiences of racial discrimination and to 1.11 (95% CI=0.51, 2.41) after additional adjustment for alcohol and tobacco use, depression, education, and income. The corresponding odds ratios for low birthweight were 4.24 (95% CI=1.31, 13.67), 2.11 (95% CI=0.75, 5.93), and 2.43 (95% CI=0.79, 7.42). CONCLUSIONS: Self-reported experiences of racial discrimination were associated with preterm and low-birthweight deliveries, and such experiences may contribute to Black-White disparities in perinatal outcomes.

Authors: Mustillo S; Krieger N; Gunderson EP; Sidney S; McCreath H; Kiefe CI

Am J Public Health. 2004 Dec;94(12):2125-31.

PubMed abstract

Immigration and acculturation in relation to health and health-related risk factors among specific Asian subgroups in a health maintenance organization

OBJECTIVES: We sought to determine how risk factors for disease vary among Asian subgroups. METHODS: Using data from a case-control study conducted at Northern California Kaiser Medical Centers (from 1996 to 2001), we compared prevalence of selected risk factors among Asian subgroups and evaluated the associations of these risk factors with sociodemographic factors. RESULTS: Chinese and Japanese patients had a lower body mass index (kg/m(2)) than did other Asians. In all subgroups, being born in the United States was associated with having a body mass index greater than 25 kg/m(2). Compared with other Asians, more Japanese and multiple-race Asians smoked, and more Filipino and multiple-race Asian smokers started smoking at 18 years or younger. Filipinos and multiple-race Asians also were more likely to report diabetes. CONCLUSIONS: These data support the importance of efforts to distinguish among Asian subgroups in public health practice and research.

Authors: Gomez SL; Kelsey JL; Glaser SL; Lee MM; Sidney S

Am J Public Health. 2004 Nov;94(11):1977-84.

PubMed abstract

Gender and risk of adverse outcomes in heart failure

Congestive heart failure (CHF) is the leading cause of hospitalization in the elderly, and these patients are at high risk for subsequent hospitalization. Whether gender affects the risk of rehospitalization in patients who have CHF is less well understood. We studied a random sample of 1,700 adults who had been hospitalized with CHF (from July 1, 1999 to June 30, 2000) and identified all readmissions through June 30, 2001. We used proportional hazards regression to evaluate whether gender affects the risk of all-cause and CHF-specific rehospitalization, after adjusting for differences in demographic characteristics, health-related behaviors, co-morbid conditions, left ventricular systolic function status, and use of CHF therapies. Among 1,591 adults who had confirmed CHF, 752 were women (47.3%). Women were older than men (73 vs 71 years, p <0.001) and more likely to have preserved systolic function (55.3% vs 40.9%, p <0.001), hypertension (83.1% vs 75.2%, p <0.001), and prior renal insufficiency (46.8% vs 34.6%, p <0.001). No significant differences existed between women and men with respect to crude rates of any readmission (144.7 vs 134.6 per 100 person-years, p = 0.36) or CHF-specific readmission (39.9 vs 37.4 per 100 person-years, p = 0.65). After adjusting for potential confounders, there was no significant difference between women and men with respect to risk of any readmission (adjusted hazard ratio 0.88, 95% confidence interval 0.76 to 1.02) or readmission for CHF (adjusted hazard ratio 0.89, 95% confidence interval 0.71 to 1.11). Among a contemporary, diverse population of patients who had CHF, rates of readmission overall and for CHF remained high, but gender was not independently associated with a differential risk of readmission.

Authors: Lee WY; Capra AM; Jensvold NG; Gurwitz JH; Go AS; Epidemiology POaCoHFES

Am J Cardiol. 2004 Nov 1;94(9):1147-52.

PubMed abstract

Marked multi-ethnic variation of esophageal and gastric cardia carcinomas within the United States

OBJECTIVE: No prior studies have contrasted esophageal and gastric cardia carcinoma incidence rates among multiple ethnicities. We evaluated whether these adjacent cancers differ; such detailed demographic analyses would inform risk factor, screening, and intervention studies. METHODS: We contrasted incidence rates and temporal trends from the Surveillance, Epidemiology, and End Results (SEER) cancer registry data between 1992 and 1998 for five groups: non-Hispanic whites (Caucasians), white Hispanics (Hispanics), blacks, Asians/Pacific Islanders (Asians/PI), and Native Americans (NA). RESULTS: Caucasian males’ esophageal adenocarcinoma rate (4.2 per 100,000 population/yr) was double that of Hispanics and four-fold higher than those of blacks, Asians/PI, and NA (p < 0.01). Female rates were much lower than male rates for all ethnicities. Similar to esophageal adenocarcinoma, cardia adenocarcinoma rates were highest in Caucasian males (3.4 per 100,000 population/yr); however, the ethnic differences were much less and female rates were comparable for all almost all ethnicities (range 0.6-0.7 per 100,000 population/yr) except NA. Esophageal adenocarcinoma incidence rates increased significantly only in Caucasians (males 5.6%/yr, females 9%/yr; p < 0.05) and cardia cancer rates did not increase for any ethnicity during this period. In contrast, esophageal squamous cell carcinoma incidence rates were highest in blacks (8.8 per 100,000 population/yr) and Asians/PI (3.9 per 100,000 population/yr) and rates were stable or declined for all ethnicities between 1992 and 1998. CONCLUSIONS: Esophageal and cardia carcinoma incidence rates vary much more markedly by ethnicity and gender than previously reported and the two sites differ from each other. Current putative risk factors do not adequately explain these large differences. These data have implications for risk factor, screening, and intervention studies.

Authors: Kubo A; Corley DA

Am J Gastroenterol. 2004 Apr;99(4):582-8.

PubMed abstract

Factors associated with colorectal cancer screening in a population-based study: the impact of gender, health care source, and time

INTRODUCTION: The effectiveness of colorectal cancer screening in reducing incident colorectal cancer and the risk of death has been shown. Despite campaigns to promote the benefits of and use of colorectal cancer screening, most people are not participating in screening. In this paper, we examine factors associated with screening behavior over time, by health care provider, and by gender and report associations between screening and development of colorectal cancer after adjusting for diet and lifestyle factors. METHODS: Data from two population-based case-control studies of colorectal cancer were used to examine risk associations with nonparticipation in colorectal cancer screening. Study participants were identified for the first study between 1991 and 1994 (N = 1,346 cases and 1,544 controls) and for the second between 1997 and 2001 (N = 952 cases and 1,205 controls) and were asked to complete a detailed in-person interviewer-administered diet and lifestyle questionnaire. The control population is used to examine changes in screening behavior and associations with screening over time. RESULTS: Significantly, fewer people reported fecal occult blood test (FOBT) in 1997-2001 than in 1991-1994 (62.5% in 1991-1994 vs. 47.2% in 1997-2001); a slight nonsignificant increase in sigmoidoscopy screening was reported for these periods among controls (33.9% vs. 36.6%). In the control population, during these periods, there was a statistically significant increase in the number of people who reported having had a sigmoidoscopy for screening rather than for problems (72.6% in 1997-2001 vs. 63.8% in 1991-1994). There were differences in factors associated with screening behavior by time, by sex, and by health care provider, although having a family history of colorectal cancer, having more education, and being male was associated with more screening in all settings. After adjusting for diet and lifestyle factors, we observed that non-sigmoidoscopy screening significantly influenced risk of incident cancer (rectal OR: 2.9; 95% CI, 2.3-3.7; distal tumor OR: 1.8; 95% CI, 1.4-2.3); proximal tumor: 1.4; 95% CI, 1.1-1.8). Nonuse of FOBT also was associated significantly with tumors in the rectal (OR: 1.6; 95% CI, 1.3-1.9) and distal (OR: 1.4; 95% CI, 1.1-1.8) sites. SUMMARY: These data reinforce the importance of screening to reduce risk of colorectal cancer development. However, flexible sigmoidoscopy screening is increasing only modestly over time, and primarily in settings where a significant investment in screening has been made. FOBT screening, which is effective for rectal cancer prevention, is actually decreasing.

Authors: Slattery ML; Kinney AY; Levin TR

Prev Med. 2004 Mar;38(3):276-83.

PubMed abstract

Racial variation in the prevalence of atrial fibrillation among patients with heart failure: the Epidemiology, Practice, Outcomes, and Costs of Heart Failure (EPOCH) study

OBJECTIVES: This study was designed to determine the association between race and atrial fibrillation (AF) among patients with heart failure (HF). BACKGROUND: Atrial fibrillation is known to complicate HF, but whether its prevalence varies by race, and the reasons why, are not well understood. METHODS: We identified adults hospitalized with confirmed HF within a large integrated healthcare delivery system. We obtained information on demographics, comorbidity, vital signs, medications, and left ventricular systolic function status. ‘Atrial fibrillation’ was defined as AF or atrial flutter documented by electrocardiogram or prior physician-assigned diagnoses. We evaluated the independent relationship between race and AF using multivariable logistic regression. RESULTS: Among 1,373 HF patients (223 African Americans, 1,150 Caucasians), the prevalence of AF was 36.9% (95% confidence interval [CI] 34.3% to 39.5%). Compared with Caucasians, African Americans were younger (mean age 67 vs. 74 years, p < 0.001) and more likely to have hypertension (86.6% vs. 77.7%, p < 0.01) and prior diagnosed HF (79.4% vs. 70.7%, p < 0.01). African Americans had less prior diagnosed coronary disease, revascularization, hypothyroidism, or valve replacement. Atrial fibrillation was much less prevalent in African Americans (19.7%) than Caucasians (38.3%, p < 0.001). After adjustment for risk factors for AF and other potential confounders, African Americans had 49% lower odds of AF (adjusted odds ratio 0.51, 95% CI 0.35 to 0.76). CONCLUSIONS: In a contemporary HF cohort, AF was significantly less common among African Americans than among Caucasians. This variation was not explained by differences in traditional risk factors for AF, HF etiology and severity, and treatment.

Authors: Ruo B; Capra AM; Jensvold NG; Go AS

J Am Coll Cardiol. 2004 Feb 4;43(3):429-35.

PubMed abstract

Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature

Authors: Brown AF; Ettner SL; Piette J; Weinberger M; Gregg E; Shapiro MF; Karter AJ; Safford M; Waitzfelder B; Prata PA; Beckles GL

Epidemiol Rev. 2004;26:63-77.

PubMed abstract

Health behaviors and quality of care among Latinos with diabetes in managed care

OBJECTIVES: We evaluated whether ethnicity and language are associated with diabetes care for Latinos in managed care. METHODS: Using data from 4685 individuals in the Translating Research Into Action for Diabetes (TRIAD) Study, a multicenter study of diabetes care in managed care, we constructed multivariate regression models to compare health behaviors, processes of care, and intermediate outcomes for Whites and English- and Spanish-speaking Latinos. RESULTS: Latinos had lower rates of self-monitoring of blood glucose and worse glycemic control than did Whites, higher rates of foot self-care and dilated-eye examinations, and comparable rates of other processes and intermediate outcomes of care. CONCLUSIONS: Although self-management and quality of care are comparable for Latinos and Whites with diabetes, important ethnic disparities persist in the managed care settings studied.

Authors: Brown AF; Gerzoff RB; Karter AJ; Gregg E; Safford M; Waitzfelder B; Beckles GL; Brusuelas R; Mangione CM; TRIAD Study Group

Am J Public Health. 2003 Oct;93(10):1694-8.

PubMed abstract

Race and ethnicity: vital constructs for diabetes research

Authors: Karter AJ

Diabetes Care. 2003 Jul;26(7):2189-93.

PubMed abstract

Incidence of Parkinson’s disease: variation by age, gender, and race/ethnicity

The goal of this study was to estimate the incidence of Parkinson’s disease by age, gender, and ethnicity. Newly diagnosed Parkinson’s disease cases in 1994-1995 were identified among members of the Kaiser Permanente Medical Care Program of Northern California, a large health maintenance organization. Each case met modified standardized criteria/Hughes diagnostic criteria as applied by a movement disorder specialist. Incidence rates per 100,000 person-years were calculated using the Kaiser Permanente membership information as the denominator and adjusted for age and/or gender using the direct method of standardization. A total of 588 newly diagnosed (incident) cases of Parkinson’s disease were identified, which gave an overall annualized age- and gender-adjusted incidence rate of 13.4 per 100,000 (95% confidence interval (CI): 11.4, 15.5). The incidence rapidly increased over the age of 60 years, with only 4% of the cases being under the age of 50 years. The rate for men (19.0 per 100,000, 95% CI: 16.1, 21.8) was 91% higher than that for women (9.9 per 100,000, 95% CI: 7.6, 12.2). The age- and gender-adjusted rate per 100,000 was highest among Hispanics (16.6, 95% CI: 12.0, 21.3), followed by non-Hispanic Whites (13.6, 95% CI: 11.5, 15.7), Asians (11.3, 95% CI: 7.2, 15.3), and Blacks (10.2, 95% CI: 6.4, 14.0). These data suggest that the incidence of Parkinson’s disease varies by race/ethnicity.

Authors: Van Den Eeden SK; Tanner CM; Bernstein AL; Fross RD; Leimpeter A; Bloch DA; Nelson LM

Am J Epidemiol. 2003 Jun 1;157(11):1015-22.

PubMed abstract

Metabolic predictors of 5-year change in weight and waist circumference in a triethnic population: the insulin resistance atherosclerosis study

Insulin resistance, insulin secretion, and glucose tolerance may predict weight change. A total of 1,194 adults aged 39-69 years at baseline (46% with normal glucose tolerance according to World Health Organization criteria, 23% with impaired glucose tolerance, and 31% with type 2 diabetes mellitus who were not taking insulin) were evaluated at baseline (1992-1994) and after 5 years. Baseline insulin sensitivity (S(I)) was measured by means of a 12-sample, insulin-enhanced, frequently sampled intravenous glucose tolerance test. Insulin secretion was assessed in terms of acute insulin response and disposition index, both obtained from the frequently sampled intravenous glucose tolerance test. At follow-up, 25% of subjects had lost more than 2.27 kg (>5 pounds), 38% weighed within 2.27 kg of their baseline weight, and 37% had gained more than 2.27 kg. In separate models, greater weight loss occurred among those with type 2 diabetes than among those with either impaired glucose tolerance or normal glucose tolerance (p < 0.001); baseline acute insulin response and disposition index were positively associated and baseline fasting insulin level was inversely associated with 5-year weight change (p < 0.05 for each; data were adjusted for baseline body mass index and demographic and behavior change variables). Upon simultaneous inclusion of metabolic variables within glucose tolerance status groups, none was a significant predictor of weight loss. Apart from glucose tolerance status itself, measures of insulin metabolism appear to have little effect on weight change over 5 years.

Authors: Mayer-Davis EJ; Kirkner GJ; Karter AJ; Zaccaro DJ

Am J Epidemiol. 2003 Apr 1;157(7):592-601.

PubMed abstract

Changes in food sources of dietary fat in response to an intensive low-fat dietary intervention: early results from the Women’s Health Initiative

OBJECTIVE: To evaluate changes in food sources of dietary fat made by participants in the Women’s Health Initiative Low-Fat Dietary Modification Trial. DESIGN: This study compares sources of dietary fat intake, estimated by a food frequency questionnaire, between intervention and control participants at baseline, 1 year (year 1) and 2 years (year 2) after randomization. The outcome measure was intake of fat in grams per day. Results are given on consumption of fat from six food groups and the intervention effect, defined as mean change in the intervention group minus the change in controls, controlling for baseline fat intake. PARTICIPANTS: 5,004 intervention and 7,426 control postmenopausal women in 40 clinical centers across the United States. RESULTS: At baseline, the major sources of fat were added fats, such as butter, oils, and salad dressings (25%); meats (21%); and desserts (13%). From baseline to year 1, the intervention group reduced fat by 24.3 g/day compared with the control group. Reductions came primarily from added fats (9.1 g/day), meats (4.6 g/day), and desserts (3.9 g/day). White people reduced added fats more than other race/ethnicity groups did, white and Hispanic people were more likely to reduce fat intake from milk and cheese compared with other groups, and Hispanics reduced fat from mixed dishes more than did other race/ethnicity groups (P<.05 for all). APPLICATIONS/CONCLUSIONS: These data indicate that women in the Women's Health Initiative dietary change intervention made substantial changes in food choices. These results can facilitate future low-fat interventions, and also offer clinical applications, by identifying foods that may be refractory to change.

Authors: Patterson RE; Kristal A; Rodabough R; Caan B; Lillington L; Mossavar-Rahmani Y; Simon MS; Snetselaar L; Van Horn L

J Am Diet Assoc. 2003 Apr;103(4):454-60.

PubMed abstract

The importance of race and ethnic background in biomedical research and clinical practice

Authors: Burchard EG; Ziv E; Coyle N; Gomez SL; Tang H; Karter AJ; Mountain JL; Perez-Stable EJ; Sheppard D; Risch N

N Engl J Med. 2003 Mar 20;348(12):1170-5.

PubMed abstract

Commentary: Race, genetics, and disease–in search of a middle ground

Authors: Karter AJ

Int J Epidemiol. 2003 Feb;32(1):26-8.

PubMed abstract

Marked regional variation in adenocarcinomas of the esophagus and the gastric cardia in the United States

BACKGROUND: Adenocarcinomas of the esophagus and the gastric cardia recently have experienced rapidly increasing incidence rates. Although these sites frequently are combined, they may have different risk factors. METHODS: The authors compared regional incidence rates of esophageal adenocarcinoma, gastric cardia adenocarcinoma, and esophageal squamous cell carcinoma within the U.S. Surveillance, Epidemiology, and End Results (SEER) cancer registry for the years 1973-1998. RESULTS: Regional incidence rates varied considerably. The Seattle-Puget Sound registry’s recent average esophageal adenocarcinoma rates were over twice as high as those of the Utah registry (5.3 vs. 2.4 per 100,000 persons per year; P < 0.01); gastric cardia rates also differed (4.0 vs. 2.8 per 100,000 persons per year; P < 0.01). The incidence rate increase also varied markedly between regions. Since 1974, white male esophageal adenocarcinoma rates increased by 800% in Seattle compared with an increase of only 300% in Utah. In contrast, white male cardia adenocarcinoma rates increased by only 16% in Seattle (from 3.1 per 100,000 persons per year in 1974 to 3.6 per 100,000 persons per year in 1998) compared with 300% in Utah (from 0.7 to 2.2 per 100,000 persons per year). Both types of adenocarcinoma were more common in males and in the white population in all regions, but recent esophageal adenocarcinoma rates for black males in Connecticut were significantly higher than the U.S. black male average (3.1 vs. 0.8 per 100,000 persons per year; P < 0.01) and equaled the rates for the white population in some areas. Esophageal adenocarcinoma rates continued rising for white males through 1998, whereas cardia adenocarcinoma rates stabilized after 1988. CONCLUSIONS: There are substantial regional, temporal, and ethnic differences between esophageal adenocarcinoma incidence rates and gastric cardia adenocarcinoma incidence rates within a single cancer registry system. Thus, these malignancies may differ in important ways and should not be combined routinely in research studies. Individual-level studies are needed to explain these substantial regional and ethnic differences.

Authors: Kubo A; Corley DA

Cancer. 2002 Nov 15;95(10):2096-102.

PubMed abstract

Differences in resting metabolic rate between white and African-American young adults

OBJECTIVE: A reported lower resting metabolic rate (RMR) in African-American women than in white women could explain the higher prevalence of obesity in the former group. Little information is available on RMR in African-American men. RESEARCH METHODS AND PROCEDURES: We assessed RMR by indirect calorimetry and body composition by DXA in 395 adults ages 28 to 40 years (100 African-American men, 95 white men, 94 African-American women, and 106 white women), recruited from participants in the Coronary Artery Risk Development in Young Adults (CARDIA), Birmingham, Alabama, and Oakland, California, field centers. RESULTS: Using linear models, fat-free mass, fat mass, visceral fat, and age were significantly related to RMR, but the usual level of physical activity was not. After adjustment for these variables, mean RMR was significantly higher in whites (1665.07 +/- 10.78 kcal/d) than in African Americans (1585.05 +/- 11.02 kcal/d) by 80 +/- 16 kcal/d (p < 0.0001). The ethnic x gender interaction was not significant (p = 0.9512), indicating that the difference in RMR between African-American and white subjects was similar for men and women. DISCUSSION: RMR is approximately 5% higher in white than in African-American participants in CARDIA. The difference was the same for men and women and for lean and obese individuals. The prevalence of obesity is not higher in African-American men than in white men. Because of these reasons, we believe that RMR differences are unlikely to be a primary explanation for why African-American women are more prone to obesity than white women.

Authors: Sharp TA; Bell ML; Grunwald GK; Schmitz KH; Sidney S; Lewis CE; Tolan K; Hill JO

Obes Res. 2002 Aug;10(8):726-32.

PubMed abstract

Factor analysis of metabolic syndrome using directly measured insulin sensitivity: The Insulin Resistance Atherosclerosis Study

Factor analysis, a multivariate correlation technique, has been used to provide insight into the underlying structure of metabolic syndrome, which is characterized by physiological complexity and strong statistical intercorrelation among its key variables. The majority of previous factor analyses, however, have used only surrogate measures of insulin sensitivity. In addition, few have included members of multiple ethnic groups, and only one has presented results separately for subjects with impaired glucose tolerance. The objective of this study was to investigate, using factor analysis, the clustering of physiologic variables using data from 1,087 nondiabetic participants in the Insulin Resistance Atherosclerosis Study (IRAS). This study includes information on the directly measured insulin sensitivity index (S(I)) from intravenous glucose tolerance testing among African-American, Hispanic, and non-Hispanic white subjects aged 40-69 years at various stages of glucose tolerance. Principal factor analysis identified two factors that explained 28 and 9% of the variance in the dataset, respectively. These factors were interpreted as 1) a ‘ metabolic’ factor, with positive loadings of BMI, waist, fasting and 2-h glucose, and triglyceride and inverse loadings of log(S(I)+1) and HDL; and 2) a ‘blood pressure’ factor, with positive loadings of systolic and diastolic blood pressure. The results were unchanged when surrogate measures of insulin resistance were used in place of log(S(I)+1). In addition, the results were similar within strata of sex, glucose tolerance status, and ethnicity. In conclusion, factor analysis identified two underlying factors among a group of metabolic syndrome variables in this dataset. Analyses using surrogate measures of insulin resistance suggested that these variables provide adequate information to explore the underlying intercorrelational structure of metabolic syndrome. Additional clarification of the physiologic characteristics of metabolic syndrome is required as individuals with this condition are increasingly being considered candidates for behavioral and pharmacologic intervention.

Authors: Hanley AJ; Karter AJ; Festa A; D'Agostino R Jr; Wagenknecht LE; Savage P; Tracy RP; Saad MF; Haffner S; Insulin resistance atherosclerosis study

Diabetes. 2002 Aug;51(8):2642-7.

PubMed abstract

Ethnic variation in bone density in premenopausal and early perimenopausal women: effects of anthropometric and lifestyle factors

Bone mineral density (BMD) and fracture rates vary among women of differing ethnicities. Most reports suggest that BMD is highest in African-Americans, lowest in Asians, and intermediate in Caucasians, yet Asians have lower fracture rates than Caucasians. To assess the contributions of anthropometric and lifestyle characteristics to ethnic differences in BMD, we assessed lumbar spine and femoral neck BMD by dual-energy x-ray absorptiometry in 2277 (for the lumbar spine) and 2330 (for the femoral neck) premenopausal or early perimenopausal women (mean age, 46.2 yr) participating in the Study of Women’s Health Across the Nation. Forty-nine percent of the women were Caucasian, 28% were African-American, 12% were Japanese, and 11% were Chinese. BMDs were compared among ethnic groups before and after adjustment for covariates. Before adjustment, lumbar spine and femoral neck BMDs were highest in African-American women, next highest in Caucasian women, and lowest in Chinese and Japanese women. Unadjusted lumbar spine and femoral neck BMDs were 7-12% and 14-24% higher, respectively, in African-American women than in Caucasians, Japanese, or Chinese women. After adjustment, lumbar spine and femoral neck BMD remained highest in African-American women, and there were no significant differences between the remaining groups. When BMD was assessed in a subset of women weighing less than 70 kg and then adjusted for covariates, lumbar spine BMD became similar in African-American, Chinese, and Japanese women and was lowest in Caucasian women. Adjustment for bone size increased values for Chinese women to levels equal to or above those of Caucasian and Japanese women. Among women of comparable weights, there are no differences in lumbar spine BMD among African-American, Chinese, and Japanese women, all of whom have higher BMDs than Caucasians. Femoral neck BMD is highest in African-Americans and similar in Chinese, Japanese, and Caucasians. These findings may explain why Caucasian women have higher fracture rates than African-Americans and Asians.

Authors: Finkelstein JS; Lee ML; Sowers M; Ettinger B; Neer RM; Kelsey JL; Cauley JA; Huang MH; Greendale GA

J Clin Endocrinol Metab. 2002 Jul;87(7):3057-67.

PubMed abstract

Daily aspirin use and prostate cancer risk in a large, multiracial cohort in the US

OBJECTIVE: To examine the relationship between daily aspirin use and risk of prostate cancer in a large, racially diverse cohort of men followed for up to 32 years. METHODS: The study population included 90,100 male subscribers to the Kaiser Permanente Medical Care Program who had received one or more multiphasic health checkups between 1964 and 1973. This general health checkup included a self-completed questionnaire that requested men to record if they took more than six aspirin almost every day during the previous year. Subjects were followed for the development of prostate cancer using the local tumor registry. Cox regression was used to estimate relative risks (RR) and 95% confidence intervals (CI). RESULTS: A total of 2,574 men developed prostate cancer. Of these, 1617 had local stage disease and 719 had either regional or distant disease at diagnosis. A total of 2466 men (2.7%) reported taking more than six aspirin almost every day during the past year at one or more health checkups. After adjusting for birth year, education, race, and the number of health checkups. the relative risk of prostate cancer associated with this amount of aspirin use was 0.76 (95% CI 0.60-0.98). Relative risks did not differ by race and were similar for both local stage and regional or distant stage prostate cancer. CONCLUSION: Results from our large, multiracial cohort study support a modest inverse relationship between daily consumption of more than six aspirin and prostate cancer risk.

Authors: Habel LA; Zhao W; Stanford JL

Cancer Causes Control. 2002 Jun;13(5):427-34.

PubMed abstract

Severity of premenstrual symptoms in a health maintenance organization population

OBJECTIVE: To describe severity of emotional and physical symptoms in a large diverse sample; to examine demographic, health status, and behavioral correlates of symptom severity; and to describe use of medications and alternative remedies for premenstrual symptoms. METHODS: A total of 1194 women, ages 21-45, selected from members of a large northern California health maintenance organization, completed daily ratings of symptom severity for two menstrual cycles. An empirically derived algorithm defined symptom severity groups as minimal (n = 186), moderate (n = 801), severe (n = 151), or premenstrual dysphoric disorder (n = 56). Symptom severity as a continuous variable was defined by the two-cycle mean symptom ratings in the luteal phase. Demographic, health status, and behavioral factors and use of treatments for premenstrual symptoms were assessed by self-report. RESULTS: Luteal phase symptom-specific ratings were generally significantly greater in the premenstrual dysphoric disorder group than in the other groups (P <.001). Symptom severity score increased with each comorbidity and decreased with each year of age. Symptom severity was also inversely associated with oral contraceptive use (emotional symptoms) and better perceived health (physical symptoms). Hispanics reported greater severity of symptoms, and Asians less, relative to whites. Use of herbal and nutritional supplements for premenstrual symptoms steadily increased from 10.8% in the minimal group to 30.4% in the premenstrual dysphoric disorder group (P <.01). CONCLUSION: The degree of premenstrual symptom severity varies in the population, is relatively constant within each woman over two consecutive cycles, particularly for emotional symptoms, and is influenced by age, race/ethnicity, and health status.

Authors: Sternfeld B; Swindle R; Chawla A; Long S; Kennedy S

Obstet Gynecol. 2002 Jun;99(6):1014-24.

PubMed abstract

Ethnic disparities in diabetic complications in an insured population

CONTEXT: Higher rates of microvascular complications have been reported for minorities. Disparate access to quality health care is a common explanation for ethnic disparities in diabetic complication rates in the US population. Examining an ethnically diverse population with uniform health care coverage may be useful. OBJECTIVE: To assess ethnic disparities in the incidence of diabetic complications within a nonprofit prepaid health care organization. DESIGN AND SETTING: Longitudinal observational study conducted January 1, 1995, through December 31, 1998, at Kaiser Permanente Medical Care Program in northern California. PARTICIPANTS: A total of 62 432 diabetic patients, including Asians (12%), blacks (14%), Latinos (10%), and whites (64%). MAIN OUTCOME MEASURES: Incident myocardial infarction (MI), stroke, congestive heart failure (CHF), and nontraumatic lower extremity amputation (LEA), defined by primary hospitalization discharge diagnosis, procedures, or underlying cause of death; and end-stage renal disease (ESRD), defined as renal insufficiency requiring renal replacement therapy or transplantation for survival or by underlying cause of death. RESULTS: Patterns of ethnic differences were not consistent across complications and frequently persisted despite adjustment for a wide range of demographic, socioeconomic, behavioral, and clinical factors. Adjusted hazard ratios (relative to that of whites) were 0.56, 0.68, and 0.68 for blacks, Asians, and Latinos, respectively (P<.001), for MI; 0.76 and 0.72 for Asians and Latinos, respectively (P<.01), for stroke; 0.70 and 0.61 for Asians and Latinos, respectively (P<.01), for CHF; 0.40 for Asians (P<.001) for LEA; and 2.03, 1.85, and 1.46 for blacks, Asians, and Latinos, respectively (P<.01), for ESRD. There were no statistically significant black-white differences for stroke, CHF, or LEA and no Latino-white differences for LEA. CONCLUSIONS: This study confirms previous reports of elevated incidence of ESRD among ethnic minorities, despite uniform medical care coverage, and provides new evidence that rates of other complications are similar or lower relative to those of whites. The persistence of ethnic disparities after adjustment suggests a possible genetic origin, the contribution of unmeasured environmental factors, or a combination of these factors.

Authors: Karter AJ; Ferrara A; Liu JY; Moffet HH; Ackerson LM; Selby JV

JAMA. 2002 May 15;287(19):2519-27.

PubMed abstract

Racial/ethnic variation in asthma status and management practices among children in managed medicaid

OBJECTIVE: Racial/ethnic disparities in hospitalization rates among children with asthma have been documented but are not well-understood. Medicaid programs, which serve many minority children, have markedly increased their use of managed care in recent years. It is unknown whether racial/ethnic disparities in health care use or other processes of care exist in managed Medicaid populations. This study of Medicaid-insured children with asthma in 5 managed care organizations aimed to 1) compare parent-reported health status and asthma care processes among black, Latino, and white children and 2) test the hypothesis that racial/ethnic variations in processes of asthma care exist after adjusting for socioeconomic status and asthma status. METHODS: This cross-sectional study collected data via telephone interviews with parents and computerized records for Medicaid-insured children with asthma in 5 managed care organizations in California, Washington, and Massachusetts. The American Academy of Pediatrics (AAP) Children’s Health Survey for Asthma was used to measure parent-reported asthma status. We used multivariate models to evaluate associations between race/ethnicity and asthma status while controlling for other sociodemographic variables. We evaluated racial/ethnic variations in selected processes of asthma care while controlling for other demographic variables and asthma status. RESULTS: The response rate was 63%. Of the 1658 children in the respondent group, 38% were black, 19% were Latino, and 31% were white. Black children had worse asthma status than white children on the basis of the AAP asthma physical and emotional health scores, symptom-days, and school days missed in the past 2 weeks. Latino children had equivalent AAP scores but missed more school days than white children. On the basis of the AAP asthma physical health score, the black-white disparity persisted after adjusting for other sociodemographic variables. After adjusting for sociodemographic variables and asthma status, black and Latino children were less likely to be using inhaled antiinflammatory medication than white children (relative risk for blacks: 0.69; relative risk for Latinos: 0.58). They were more likely to have home nebulizers. Other processes of asthma care, including ratings of providers and asthma care, use of written management plans, use of preventive visits and specialists, and having no pets or smokers at home, were equal or better for minority children compared with white children. CONCLUSIONS: Black and Latino children had worse asthma status and less use of preventive asthma medications than white children within the same managed Medicaid populations. Most other processes of asthma care seemed to be equal or better for minorities in the populations that we studied. Increasing the use of preventive medications is a natural focus for reducing racial disparities in asthma.

Authors: Lieu TA; Lozano P; Finkelstein JA; Chi FW; Jensvold NG; Capra AM; Quesenberry CP; Selby JV; Farber HJ

Pediatrics. 2002 May;109(5):857-65.

PubMed abstract

Different slopes for different folks: socioeconomic and racial/ethnic disparities in asthma and hay fever among 173,859 U.S. men and women

Although allergic diseases such as asthma and hay fever are a major cause of morbidity in industrialized countries, most studies have focused on patterns of prevalence among children and adolescents, with relatively few studies on variations in prevalence by race/ethnicity and socioeconomic position among adults. Our study examined racial/ethnic and socioeconomic patterns in the prevalence of asthma overall, asthma with hay fever, asthma without hay fever, and hay fever overall, in a population of 173,859 women and men in a large prepaid health plan in northern California. Using education as a measure of socioeconomic position, we found evidence of a positive gradient for asthma with hay fever with increasing level of education but an inverse gradient for asthma without hay fever. Hay fever was also strongly associated with education. Compared with their White counterparts, Black women and men were more likely to report asthma without hay fever, and Black women were less likely to have asthma with hay fever. Asian men were also more likely to report asthma with hay fever, and Asian women and men were much more likely to have hay fever. Racial/ethnic disparities in prevalence of allergic diseases were largely independent of education. We discuss implications for understanding these social inequalities in allergic disease risk in relation to possible differences in exposure to allergens and determinants of immunologic susceptibility and suggest directions for future research.

Authors: Chen JT; Krieger N; Van Den Eeden SK; Quesenberry CP

Environ Health Perspect. 2002 Apr;110 Suppl 2:211-6.

PubMed abstract

Race, epithelial ovarian cancer survival, and membership in a large health maintenance organization

BACKGROUND: African-American ovarian cancer patients present with more advanced disease and have poorer survival than do white patients. METHODS: To determine whether these differences occur among African-American and white patients who have equal access to medical care, we analyzed ovarian cancer patient characteristics separately for 1,587 members of the Kaiser Permanente Medical Plan of Northern California and 5,757 non-members. RESULTS: The distributions of disease stage at diagnosis were similar among African-American and white patients, both in the Kaiser plan and elsewhere. However, ovarian cancer death rates, adjusted for disease stage and age at diagnosis and for histology, were higher for African-American patients compared with white patients, regardless of Kaiser membership status. The death rate ratios for African-Americans compared with whites were 1.32 (95% CI = 1.02-1.70) for Kaiser members and 1.20 (95% CI = 1.04-1.40) for Kaiser non-members. CONCLUSION: Further research within an equal-access care system is needed to evaluate other important factors such as specialty of surgeon, extent of residual tumor after surgery, chemotherapy treatment, and postoperative management to determine whether these factors are contributing to the differences in survival between African-American and white ovarian cancer patients.

Authors: McGuire V; Herrinton L; Whittemore AS

Epidemiology. 2002 Mar;13(2):231-4.

PubMed abstract

The development of a questionnaire to assess past year physical activity in a multi-ethnic/racial urban population

OBJECTIVES: Describe the development of a questionnaire to assess past year physical activity, including activities of daily living, in a multi-ethnic/racial cohort. Describe energy expenditure (EE) patterns in the sample used for questionnaire development. METHODS: 24-hour activity recalls were collected from a convenience sample (N = 367) at four New York City health agencies (October 1999-February 2000). EE was determined at the population, subgroup, and individual level. EE distributions were compared. RESULTS: Activities identified were similar to those on established questionnaires. Subgroup and individual EE differences were noted. Median EE at the Chinese and Puerto Rican sites were lower than those at the Caribbean or Dominican sites. No clear age pattern was apparent. Overall, a greater percentage of daily EE was spent in low intensity activities. The resultant 30-minute interviewer-administered questionnaire ascertains patterns (frequency and duration) of domain-specific (recreational, household, occupational, and transportation) activity. This information combined with published intensity levels provides summary EE measures. CONCLUSION: Variation in EE levels requires information on activity type and amount. Summary activity measures can be used to rank individuals analogous to nutrient food frequency measures.

Authors: Britton JA; Kushi LH; Morabia A; Bernstein J; Shore R; Geringer W; Rohan T

Soz Praventivmed. 2002;47(3):178-94.

PubMed abstract

Oesophageal and gastric cardia adenocarcinomas: analysis of regional variation using the Cancer Incidence in Five Continents database

BACKGROUND: Adenocarcinomas of the oesophagus and proximal stomach are the most rapidly increasing malignancies in some countries; however, there are no comparative studies on global disease incidence, and the relationships between these two malignancies are undefined. METHODS: We evaluated the cumulative rates and age-specific incidence rates per 100 000 population for adenocarcinomas of the oesophagus and proximal stomach for all countries in the Cancer Incidence in Five Continents database, and compared them with rates for oesophageal squamous cell carcinoma. RESULTS: Substantial variations in cumulative cancer rates were found between genders, between countries, between different ethnicities within the same country, and within the same ethnicity residing in different countries. Cumulative rates (ages 0-74 years) for oesophageal adenocarcinoma varied from 0 (e.g. Thailand) to 0.6 (Scotland, males, 95% CI : 0.56, 0.64); for proximal stomach cancer from 0 (Singapore, Malay females, 95% CI : -0.01, 0.11) to 0.52 (The Netherlands, males, 95% CI : 0.49, 0.55); and for oesophageal squamous cell carcinomas from 0 (non-Jews in Israel, females) to 1.84 (Brazil, Porto Alegre, males, 95% CI : 1.42, 2.26). There was a continuous increase in age-specific incidence rates with advancing age for oesophageal/proximal stomach adenocarcinomas, but a decrease in age-specific incidence rates for oesophageal squamous cell carcinoma after age 75 years. The cumulative rate trends for adenocarcinomas of the oesophagus and proximal stomach were often dissimilar, and varied by country, gender, and ethnicity. CONCLUSIONS: These results suggest that different risk factors may be associated with adenocarcinomas of the oesophagus versus the proximal stomach; the marked rate variation implies a substantial environmental component to the recent incidence changes.

Authors: Corley DA; Buffler PA

Int J Epidemiol. 2001 Dec;30(6):1415-25.

PubMed abstract

Asthma is associated with weight gain in females but not males, independent of physical activity

We tested whether asthma diagnosis is associated with weight gain and physical activity in 4,547 18 to 30-yr-old African American and white men and women, followed prospectively for up to 10 yr. Baseline asthma was most frequent in African American men. Incident asthma was more frequent in women. Incident asthma was associated with highest and lowest baseline and change in body mass index (BMI), in a J-shaped curve, after adjustment for other factors. When stratified by sex, this association was seen only in females. Subjects on average decreased physical activity and gained weight over time, but there was no significant difference in asthma prevalence by physical activity at baseline or asthma incidence by change in physical activity. Cigarette smoking in females was significantly associated with asthma incidence, but serum cotinine level at baseline among nonsmokers (reflecting environmental tobacco smoke [ETS] exposure) was not significantly associated with asthma. We conclude that gain in BMI predisposes to new asthma diagnosis in female young adults, but decreased physical activity does not explain the association of weight gain with asthma.

Authors: Beckett WS; Jacobs DR Jr; Yu X; Iribarren C; Williams OD

Am J Respir Crit Care Med. 2001 Dec 1;164(11):2045-50.

PubMed abstract

Predictors of substance abuse treatment retention among women and men in an HMO

BACKGROUND: Although prior research has examined predictors of treatment retention in public alcohol and drug treatment programs, little is known about factors that influence treatment retention in an insured outpatient population. Because there is growing evidence that the factors which influence treatment retention may differ by gender, we identify sex-specific predictors. METHODS: We recruited all eligible intakes to a health maintenance organization’s outpatient alcohol and drug treatment program during a 2-year period and obtained a sample of 317 women and 599 men. The programs, day hospital and traditional outpatient modalities, were abstinence based. We separated our sample by sex and used least squares and logistic regression to identify independent predictors of length of stay and program completion, respectively. RESULTS: One general pattern of predictors of increased retention was shared by women and men in this alcohol and drug treatment program–fewer and less severe drug problems. However, most predictors were sex-specific. Among women, retention was predicted by having higher incomes, belonging to ethnic categories other than African American, being unemployed, being married, and having lower levels of psychiatric severity. Among men, predictors of higher retention included being older, receiving employer suggestions to enter treatment, and having abstinence goals. CONCLUSIONS: These findings highlight the importance of examining aspects of the course of treatment separately by sex. They also suggest treatment factors that may enhance retention among insured populations, including employer referrals, psychiatric services, and drug-related services.

Authors: Mertens JR; Weisner CM

Alcohol Clin Exp Res. 2000 Oct;24(10):1525-33.

PubMed abstract

Risk of pulmonary embolism and/or deep venous thrombosis in Asian-Americans

Several reports from Asian countries suggest a low prevalence of pulmonary embolism (PE) and deep venous thrombosis (DVT) in Asians, and sparse US data show that a slightly higher prevalence of PE/DVT in ‘nonwhites’ than in whites is evident in all geographic regions except the Pacific region (California, Oregon, and Washington) where ‘nonwhites’ include a larger proportion of Asians and Hispanics than in other US locations. We prospectively studied PE/DVT hospitalizations in 128,934 persons in relation to traits determined at health examinations in 1978 to 1985. Through 1994, 337 persons were subsequently hospitalized for PE and/or DVT (for PE first, n = 206). Cox proportional-hazards models with 9 covariates were used. In multivariate models, the following RRs (95% confidence intervals) were found for PE/DVT combined: black/white = 1.1 (0.4 to 1.4); Hispanic/white = 0.7 (0.3 to 1.5); and Asian/white = 0.2 (0.1 to 0. 5; p = 0.002). The lower risk of Asians was present in each sex and for persons first hospitalized for either PE or DVT. Covariates with significant positive relations to risk were age, male sex, body mass index, and a composite coronary disease risk/symptom variable; covariates not significantly related were education, marital status, smoking, and alcohol. These data suggest that Asians have very low risk of PE/DVT, which may account for US geographic variations in white/non-white risk differences. Possible explanations include the absence of hazardous mutations or unspecified PE/DVT protective traits in Asians.

Authors: Klatsky AL; Armstrong MA; Poggi J

Am J Cardiol. 2000 Jun 1;85(11):1334-7.

PubMed abstract

Body size, age at shaving initiation, and prostate cancer in a large, multiracial cohort

BACKGROUND: The purpose of this study was to examine the potential relationship between body size, self-reported age at initiation of shaving, and subsequent risk of prostate cancer in a large, racially diverse cohort of men followed for up to 32 years. METHODS: The study population included 70,712 male subscribers to the Kaiser Permanente Medical Care Program who had received a multiphasic health checkup between 1964-1973. This general health checkup consisted of a number of laboratory tests and physical measurements, as well as a self-completed health questionnaire that included a request for men to record the age when they began shaving. Subjects were followed for the development of prostate cancer, using the local tumor registry. Cox regression was used to estimate relative risks (RR) and 95% confidence intervals (CI). RESULTS: Altogether, 2, 079 men in the study cohort were diagnosed with prostate cancer. There was a very strong positive association between prostate cancer risk and birth cohort. After adjusting for race, age, and birth year, there was no association between height, weight, body mass index, or several other anthropometric measures and prostate cancer risk in the full cohort. There was a suggestion of a very weak positive association between height and prostate cancer risk among white men. There also was no overall association between age at shaving initiation and prostate cancer risk, although nonwhite men who started shaving at a young age (

Authors: Habel LA; Van Den Eeden SK; Friedman GD

Prostate. 2000 May 1;43(2):136-43.

PubMed abstract

Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes

OBJECTIVE: Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes care, but little is known about barriers to this self-care practice. RESEARCH DESIGN AND METHODS: This cross-sectional study examines SMBG practice patterns and barriers in 44,181 adults with pharmacologically treated diabetes from the Kaiser Permanente Northern California Region who responded to a health survey (83% response rate). The primary outcome is self-reported frequency of SMBG. RESULTS: Although most patients reported some level of SMBG monitoring, 60% of those with type 1 diabetes and 67% of those with type 2 diabetes reported practicing SMBG less frequently than recommended by the American Diabetes Association (three to four times daily for type 1 diabetes, and once daily for type 2 diabetes treated pharmacologically). Significant independent predictors of nonadherent practice of SMBG included longer time since diagnosis, less intensive therapy, male sex, age, belonging to an ethnic minority, having a lower education and neighborhood income, difficulty communicating in English, higher out-of-pocket costs for glucometer strips (especially for subjects with lower incomes), smoking, and excessive alcohol consumption. CONCLUSIONS: Considerable gaps persist between actual and recommended SMBG practices in this large managed care organization. A somewhat reduced SMBG frequency in subjects with linguistic barriers, some ethnic minorities, and subjects with lower education levels suggests the potential for targeted, culturally sensitive, multilingual health education. The somewhat lower frequency of SMBG among subjects paying higher out-of-pocket expenditures for strips suggests that removal of financial barriers by providing more comprehensive coverage for these costs may enhance adherence to recommendations for SMBG.

Authors: Karter AJ; Ferrara A; Darbinian JA; Ackerson LM; Selby JV

Diabetes Care. 2000 Apr;23(4):477-83.

PubMed abstract

Changes in US health care access in the 90s: race and income differences from the CARDIA Study. Coronary Artery Risk Development in Young Adults

OBJECTIVE: Health care financing is changing rapidly in the United States. We investigated whether and how health care access is changing concurrently with changes in financing, with special attention to a minority population. METHODS: We examined a longitudinal biracial (half African-American, half White) urban cohort of 3,565 individuals, aged 25-37 years old, in 1992-93 and again in 1995-96. We measured access by self-reported (1) health insurance status, (2) regular source of medical care, and (3) lack of care due to financial problems. RESULTS: In 1992-93, 30.3% of the cohort experienced at least one access barrier, with a decline to 26.8% in 1995-96 (P<.005). However, access improved more for Whites than for African Americans; and access improved for higher, but not for lower, income groups (7% improvement for high income, vs 2% deterioration for lower income, P<.01). In addition, there was an 11% to 19% absolute increase in individuals making co-payments for health care utilization across all race/sex groups, with African Americans having markedly higher proportions of cost-sharing. African-American, low income, and unemployed individuals reported more acute care, but fewer outpatient visits. Income and employment explained racial differences. CONCLUSION: While access has improved or stabilized for higher income groups, there is a widening gap according to income, accompanied by an acute care pattern for low income groups that may be both inadequate and cost inefficient.

Authors: Kiefe CI; Williams OD; Weissman NW; Schreiner PJ; Sidney S; Wallace DD

Ethn Dis. 2000 Autumn;10(3):418-31.

PubMed abstract

Identifying women with cervical neoplasia: using human papillomavirus DNA testing for equivocal Papanicolaou results

CONTEXT: A Papanicolaou (Pap) test result of atypical squamous cells of undetermined significance (ASCUS) presents a clinical challenge. Only 5% to 10% of women with ASCUS harbor serious cervical disease, but more than one third of the high-grade squamous intraepithelial lesions (HSILs) in screening populations are identified from ASCUS Pap test results. OBJECTIVE: To determine whether human papillomavirus (HPV) DNA testing of residual material from liquid-based Pap tests and referral of cases found to be HPV-positive directly to colposcopy could provide sensitive detection of underlying HSILs in women with ASCUS Pap results, compared with repeat Pap testing. DESIGN AND SETTING: Natural history of women with ASCUS Pap smear results, all of whom had liquid-based cytology, HPV testing, and subsequent repeat Pap tests and colposcopy with histologic evaluation, conducted at 12 gynecology clinics in a large managed care organization between October 1995 and June 1996. PARTICIPANTS: From a cohort of 46009 women who had routine cervical examinations, 995 women with Pap test results of ASCUS who consented to participate were identified. MAIN OUTCOME MEASURES: Cervical histology, HPV test results, and repeat Pap smear results, and sensitivity of HPV testing to identify patients found to have HSIL+ histology. RESULTS: Of 995 participants with ASCUS Pap test results, 973 had both a definitive histologic diagnosis and HPV result. Sixty-five (6.7%) had histologic HSIL or cancer. For women with histologic HSIL+, the HPV test was positive in 89.2% (95% confidence interval [CI], 78.4%-95.2%), and the specificity was 64.1 % (95% CI, 60.9%-67.2%). The repeat Pap smear result was abnormal in 76.2% (95% CI, 63.5%-85.7%). Triage based on HPV testing only or on repeat Pap testing only would refer similar proportions (approximately 39%) to colposcopy. The sensitivity of HPV DNA testing for HSIL was equivalent to, if not greater than, that of the repeat Pap test. We further estimated that an HPV-based algorithm including the immediate colposcopy of HPV-positive women, and then repeat Pap testing of all others, would provide an overall sensitivity of 96.9% (95% CI, 88.3%-99.5%). CONCLUSIONS: For women with ASCUS Pap tests, HPV DNA testing of residual specimens collected for routine cervical cytology can help identify those who have underlying HSIL. By testing the specimen collected at initial screening, the majority of high-risk cases can be identified and referred for colposcopy based on a single screening.

Authors: Manos MM; Hiatt RA; et al.

JAMA. 1999 May 5;281(17):1605-10.

PubMed abstract

Association of total and central adiposity measures with fasting insulin in a biracial population of young adults with normal glucose tolerance: the CARDIA study

OBJECTIVE: To determine the association of computed tomography (CT)-measured visceral adipose tissue (AT) and other measures of adiposity with fasting insulin in a biracial (African American and Caucasian) study population of young adults. RESEARCH METHODS AND PROCEDURES: The study population consisted of 251 young adults with normal glucose tolerance (NGT), ages 28-40 years, who were volunteers from the Birmingham, Alabama, and Oakland, California centers of the Coronary Artery Risk Development in Young Adults (CARDIA) study. RESULTS: In regression models with total adiposity measures (body mass index or dual-energy X-ray absorptiometry-measured percent fat), visceral AT (measured as a cross-sectional area in cm2) was generally a stronger predictor of insulin than overall adiposity in all race/gender groups (partial correlation coefficients ranging from 0.31 to 0.47) except for black men, in whom the associations were nonsignificant. Partial correlation coefficients between waist circumference and insulin, controlling for percent fat, were nearly identical to those between visceral AT and insulin in women and in white men. Analyses performed on 2060 NGT CARDIA subjects who were not in this study of visceral AT showed significant correlations of waist circumference with insulin in all race/gender groups, including black men, and that black men in the visceral AT study group were significantly leaner than other black male CARDIA subjects. DISCUSSION: We conclude that visceral AT was associated with fasting insulin in NGT participants in three of the four race/gender groups (black men excepted) and that waist circumference was a good surrogate for visceral AT in examining associations of central adiposity with fasting insulin.

Authors: Sidney S; Lewis CE; Hill JO; Quesenberry CP Jr; Stamm ER; Scherzinger A; Tolan K; Ettinger B

Obes Res. 1999 May;7(3):265-72.

PubMed abstract

Differences in calcium metabolism between black and white men and women

To determine whether environmental factors influence racial differences in calcium metabolism, the authors evaluated the influence of three factors (season, length of sunlight exposure, and diet) on calciotropic hormones, renal calcium excretion, and markers of bone turnover in an a