Abstract Studies suggest disparities in physical function between Black and White adults, but most lack longitudinal, objective functional measures across race and geographic regions. We examined Short Physical Performance Battery (SPPB) changes among 5,836 Black and White older adults (>65 years, 22% Black, 41% men) with up to three SPPB assessments. Exams were conducted in the Atherosclerosis Risk in Communities Study (Visit 5 (2011-13)-Visit 7 (2017-19), median follow-up 5.8 years (max 8.4)) in four US communities: North Carolina (n=1248; 7% Black), Mississippi (n=1179, 100% Black), Maryland (n=1618; 0.9% Black) and Minnesota (N=1791; n=0.5% Black). A difference of 0.5 SPPB points (scored 0-12) is clinically meaningful. SPPB declines were estimated using marginal standardization following GEE (with log-links, negative binomial distributions, exchangeable covariance, robust SE, adjusting for demographics, BMI, diabetes, hypertension, smoking, drinking status, heart failure, heart disease, and stroke). SPPB declines were 3.4 times greater among Black versus White participants overall; -1.99 versus -0.59 points; absolute difference=-1.41 (95% CI: -1.67,-1.14), relative difference=3.40 (2.65, 4.15). However, some within-race, between-site differences were similar; Maryland-White SPPB declines were 3.8 (2.3, 6.3) times greater than North Carolina-White SPPB declines, and Mississippi-Black declines were 2.5 (1.10, 5.90) times greater than North Carolina-Black declines. Furthermore, between-race (Black versus White) differences were less supported statistically within the same site; SPPB declines were 2.2 (0.85, 5.80) greater in Black than White participants in North Carolina. This suggests that regional variations in physical function declines may be at least as strong as differences attributed to race; both are important to consider.
Hypothesis: We hypothesized that outpatient management of patients at risk for a HF hospitalization is associated with lower mortality following an incident HF hospitalization. Methods: Patterns of outpatient visits prior to incident HF hospitalization were assessed among CMS Medicare beneficiaries with continuous fee-for-service eligibility residing during 2003-2006 in four geographic areas of CVD surveillance conducted by the ARIC Study. Incident HF hospitalization was defined as hospitalization with ICD9 code 428.x with no HF hospitalizations in preceding 2 years. Outpatient visits to primary care physicians, general internists, or cardiologists were identified from Carrier files. A comorbidity score was calculated from ICD9 codes at the time of incident HF hospitalization. Cox proportional hazard models adjusted for age, comorbidity score, gender, and race were used to estimate mortality. Results: Mean age among beneficiaries with observed incident HF hospitalization (n=2006; 90.4% white, 45.1% male) was 79.8 years (SD 7.4). Mean comorbidity score was 3.6 (SD 1.9). Mean number of outpatient physician visits occurring in two years preceding the incident HF hospitalization, was 9.6 (SD 9.0); 19.6% beneficiaries had no observed prior outpatient physician visits. Risk of death within one year of incident HF hospitalization was greater among those with no preceding outpatient physician visits as compared to those with at least one physician visit (adjusted HR=1.81 (95% CI 1.50, 2.18); Figure). Adjustment for the presence of an outpatient visit within 2 weeks following the HF hospitalization attenuated the risk of death (HR=1.56 (1.29, 1.89)). Conclusion: Lack of outpatient care in two years prior to a HF-related hospitalization is associated with increased mortality within one year following hospitalization. Further inquiry is warranted to assess whether the association reflects diversity in causes/manifestations of HF, ambulatory care received in ED settings, or benefits associated with outpatient care.
Introduction: Contralateral differences in systolic blood pressure (SBP) are a risk assessment tool and indicative of underlying cardiovascular issues. Most of the available studies focused on brachial blood pressure and its clinical impact. This study evaluated whether interankle SBP differences and contralateral differences in pulse wave velocity (PWV) are associated with incident heart failure (HF) and all-cause and cardiovascular mortality in a community-dwelling sample of older adults. Methods: Sample included 5,077 participants (75.2 ± 5.1 years old) of the Atherosclerosis Risk in Communities (ARIC) study. The OMRON VP-1000 plus was used to measure PWV and blood pressure in the ankles. PWV was assessed between the brachial artery and ankle (baPWV) and heart and ankle (haPWV) on the right and left sides. Cut points for contralateral differences in PWV were set at the 90th percentile in our sample. Outcomes included incident HF (first definite or probable hospitalization for acute decompensated HF), all-cause and cardiovascular mortality (until December 31, 2020). Cox proportional hazards regression models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI). Results: Over a mean follow-up of 7.5 ± 2.1 years, incident HF was diagnosed in 457 participants, and 1,275 all-cause and 363 cardiovascular deaths occurred. The prevalence of interankle SBP difference ≥10 and ≥15 mmHg was 24.9% (1,268) and 12.0% (605), respectively. The prevalence of contralateral differences in baPWV (>240 cm/s) and haPWV (>80 cm/s) was 10.1% (513) and 9.1% (464), respectively. Interankle SBP difference ≥10 mmHg (HR 1.13; 95% CI 1.00-1.29), ≥15 mmHg (HR 1.25; 95% CI 1.06-1.48), contralateral difference in baPWV >240 cm/s (HR 1.18; 95% CI 1.00-1.41), and haPWV >80 cm/s (HR 1.21; 95% CI 1.01-1.44) were each independently associated with all-cause mortality after adjustment for demographics, traditional cardiovascular risk factors, and extreme values of ankle-brachial index ≤0.9 or >1.40. Contralateral differences in ankle SBP ≥15 mmHg (HR 1.55; 95% CI 1.16-2.06), and haPWV >80 cm/s (HR 1.40; 95% CI 1.02-1.91) were both independently associated with cardiovascular mortality. Crude analysis revealed that those with contralateral differences in ankle SBP ≥10 and ≥15 mmHg, baPWV >240 cm/s, and haPWV >80 cm/s had a significantly higher risk of HF (p<0.05 for all). However, these HF relationships were no longer statistically significant after adjustment for confounders. Conclusions: Contralateral differences in ankle SBP and PWV were independently associated with all-cause and cardiovascular mortality risk even after accounting for traditional cardiovascular risk factors and the ankle-brachial index. These results underscore the significance of evaluating contralateral differences in ankle SBP and PWV as potential markers of increased mortality risk among older adults.
Physical activity has been associated with longer chronic disease-free life expectancy, but specific cancer types have not been investigated. We examined whether leisure-time moderate-to-vigorous physical activity (LTPA) and television (TV) viewing were associated with life expectancy cancer-free.
Background Standardization of evidence‐based medical therapies has improved outcomes for patients with non– ST ‐segment–elevation myocardial infarction ( NSTEMI ). Although racial differences in NSTEMI management have previously been reported, it is uncertain whether these differences have been ameliorated over time. Methods and Results The ARIC (Atherosclerosis Risk in Communities) Community Surveillance study conducts hospital surveillance of acute myocardial infarction in 4 US communities. NSTEMI was classified by physician review, using a validated algorithm. From 2000 to 2014, 17 755 weighted hospitalizations for NSTEMI (patient race: 36% black, 64% white) were sampled by ARIC . Black patients were younger (aged 60 versus 66 years), more often female (45% versus 38%), and less likely to have medical insurance (88% versus 93%) but had more comorbidities. Black patients were less often administered aspirin (85% versus 92%), other antiplatelet therapy (45% versus 60%), β‐blockers (85% versus 88%), and lipid‐lowering medications (68% versus 76%). After adjustments, black patients had a 24% lower probability of receiving nonaspirin antiplatelets (relative risk: 0.76; 95% confidence interval, 0.71–0.81), a 29% lower probability of angiography (relative risk: 0.71; 95% confidence interval, 0.67–0.76), and a 45% lower probability of revascularization (relative risk: 0.55; 95% confidence interval, 0.50–0.60). No suggestion of a changing trend over time was observed for any NSTEMI therapy ( P values for interaction, all >0.20). Conclusions This longitudinal community surveillance of hospitalized NSTEMI patients suggests black patients have more comorbidities and less likelihood of receiving guideline‐based NSTEMI therapies, and these findings persisted across the 15‐year period. Focused efforts to reduce comorbidity burden and to more consistently implement guideline‐directed treatments in this high‐risk population are warranted.
Background: Estimation of disease incidence from administrative data requires an adequate look-back (prevalence) period to exclude pre-existing conditions from the incidence risk set. We characterized optimal lengths of the prevalence period to minimize misclassification of incident heart failure (HF) hospitalization, a proxy for incident HF. Methods: Data for participants of the ARIC Study (a prospective longitudinal cohort of 15,792 individuals sampled from 4 US communities) were linked with CMS Medicare claims from the years 2000-2012. We included only participants with >36 months of continuous CMS Medicare fee for service (FFS) enrollment. Each participant’s time-in-observation was divided into two phases. The first 36 months were the prevalence period. Observation time after an index date 36 months following the date of enrollment was the incidence period. HF hospitalizations were identified from CMS MedPAR records using ICD-9 code 428.xx in any position. Patients were classified as having a HF hospitalization in (a) both the prevalence and incidence periods, (b) in the prevalence period only, (c) in the incidence period only, or (d) neither. Incident HF was defined as the first HF hospitalization in the incidence period not preceded by a HF hospitalization in the prevalence period. The proportion of events misclassified as incident HF hospitalization was estimated from incremental reductions of the prevalence period to start 36, 30, 24, 18, 12, or 6 months before the index date. The impact of misclassification was estimated as differences in incidence per 1,000 patients at risk. Results: Of 11,054 ARIC participants enrolled in Medicare FFS, 9,568 met the study inclusion criteria. A total of 1,129 incident HF hospitalizations were identified based on the 36 month prevalence period, considered as the referent (incidence rate 118 HF hospitalizations per 1,000 patients at risk). Shortening the prevalence period to 24 months increased the HF incidence rate to 123 per 1,000, overestimating the number of incident HF hospitalizations by 4.2% while retaining over 90% of the sample. A 12 month prevalence period yielded an overestimation of the number of incident HF hospitalizations by 11% (incidence rate 129 per 1,000 patients at risk) while retaining 95% of the sample. Conclusions: Selection of too short of a prevalence period to define incident hospitalized HF from CMS Medicare claims data can introduce substantial misclassification. Consideration of several prevalence periods indicates that a 24 month prevalence period reduces the potential for bias in the estimation of incident hospitalized HF while retaining most observations.
Background: Studies of the use of health care after the onset of disease are important for assessing quality of care, treatment disparities, and guideline compliance. Cohort definition and analysis method are important considerations for the generalizability and validity of study results. We compared different approaches for cohort definition (restriction by survival time vs. comorbidity score) and analysis method [Kaplan-Meier (KM) vs. competing risk] when assessing patterns of guideline adoption in elderly patients. Methods: Medicare beneficiaries aged 65–95 years old who had an acute myocardial infarction (AMI) in 2008 were eligible for this study. Beneficiaries with substantial frailty or an AMI in the prior year were excluded. We compared KM with competing risk estimates of guideline adoption during the first year post-AMI. Results: At 1-year post-AMI, 14.2% [95% confidence interval (CI), 14.0%–14.5%) of beneficiaries overall initiated cardiac rehabilitation when using competing risk analysis and 15.1% (95% CI, 14.8%–15.3%) from the KM analysis. Guideline medication adoption was estimated as 52.3% (95% CI, 52.0%–52.7%) and 53.4% (95% CI, 53.1%–53.8%) for competing risk and KM methods, respectively. Mortality was 17.0% (95%CI, 16.8%–17.3%) at 1 year post-AMI. The difference in cardiac rehabilitation initiation at 1-year post-AMI from the overall population was 0.1%, 1.7%, and 1.9% compared with 30-day survivor, 1-year survivor, and comorbidity-score restricted populations, respectively. Conclusions: In this study, the KM method consistently overestimated the competing risk method. Competing risk approaches avoid unrealistic mortality assumptions and lead to interpretations of estimates that are more meaningful.
