Association of Acculturation and Country of Origin with Self-Reported Hypertension and Diabetes in a Heterogeneous Hispanic Population

Background: Hispanics are the fasting growing population in the U.S. and disproportionately suffer from chronic diseases such as hypertension and diabetes. Little is known about the complex interplay between acculturation and chronic disease prevalence in the growing and increasingly diverse Hispanic population. We explored the association between diabetes and hypertension prevalence among distinct U.S. Hispanic subgroups by country of origin and by degree of acculturation. Methods: We examined the adult participants in the 2001, 2003, 2005, and 2007 California Health Interview Survey (CHIS). Using weighted logistic regression stratified by nativity, we measured the association between country of origin and self-reported hypertension and diabetes adjusting for participants’ demographics, insurance status, socio-economic status and degree of acculturation measured by citizenship, English language proficiency and the number of years of residence in the U.S. Results: There were 33,633 self-identified Hispanics (foreign-born: 19,988; U.S.-born: 13,645). After multivariable adjustment, we found significant heterogeneity in self-reported hypertension and diabetes prevalence among Hispanic subgroups. Increasing years of U.S. residence was associated with increased disease prevalence. Among all foreign-born subgroups, only Mexicans reported lower odds of hypertension after adjustment for socioeconomic and acculturation factors. Both U.S.-born and foreign-born Mexicans had higher rates of diabetes as compared to non-Hispanic whites. Conclusions: We found significant heterogeneity among Hispanics in self-reported rates of hypertension and diabetes by acculturation and country of origin. Our findings highlight the importance of disaggregation of Hispanics by country of origin and acculturation factors whenever possible

Bridging the Digital Divide in Health Care: The Role of Health Information Technology in Addressing Racial and Ethnic Disparities

Racial and ethnic disparities in health care have been consistently documented in the diagnosis, treatment, and outcomes of many common clinical conditions. There has been an acceleration of health information technology (HIT) implementation in the United States, with health care reform legislation including multiple provisions for collecting and using health information to improve and monitor quality and efficiency in health care. Despite an uneven and generally low level of implementation, research has demonstrated that HIT has the potential to improve quality of care and patient safety. If carefully designed and implemented, HIT also has the potential to eliminate disparities. Several root causes for disparities are amenable to interventions using HIT, particularly innovations in electronic health records, as well as strategies for chronic disease management. Recommendations regarding health care system, provider, and patient factors can help health care organizations address disparities as they adopt, expand, and tailor their HIT systems. In terms of health care system factors, organizations should (1) automate and standardize the collection of race/ethnicity and language data, (2) prioritize the use of the data for identifying disparities and tailoring improvement efforts, (3) focus HIT efforts to address fragmented care delivery for racial/ethnic minorities and limited-English-proficiency patients, (4) develop focused computerized clinical decision support systems for clinical areas with significant disparities, and (5) include input from racial/ethnic minorities and those with limited English proficiency in developing patient HIT tools to address the digital divide. As investments are made in HIT, consideration must be given to the impact that these innovations have on the quality and cost of health care for all patients, including those who experience disparities

Cardiovascular Risk Score, Cognitive Decline, and Dementia in Older Mexican Americans: The Role of Sex and Education

Background: The purpose of this study was to examine the associations of cardiovascular disease (CVD) risk with cognitive decline and incidence of dementia and cognitive impairment but not dementia (CIND) and the role of education as a modifier of these effects. Methods and Results: One thousand one hundred sixteen Mexican American elderly were followed annually in the Sacramento Area Latino Study on Aging. Our sex‐specific 10‐year CVD risk score included baseline age, systolic blood pressure, total cholesterol, high‐density lipoprotein, smoking, body mass index, and diabetes. From adjusted linear mixed models, errors on the Modified Mini–Mental State Exam (3MSE) were annually 0.41% lower for women at the 25th percentile of CVD risk, 0.11% higher at the 50th percentile, and 0.83% higher at the 75th percentile (P value of CVDrisk×time <0.01). In men, 3MSE errors were annually 1.76% lower at the 25th percentile of CVD risk, 0.96% lower at the 50th percentile, and 0.12% higher at the 75th percentile (P value of CVDrisk×time <0.01). From adjusted linear mixed models, the annual decrease in the Spanish and English Verbal Learning Test score was 0.09 points for women at the 25th percentile of CVD risk, 0.10 points at the 50th percentile, and 0.12 points at the 75th percentile (P value of CVDrisk×time=0.02). From adjusted Cox models in women, compared with having <6 years of education, having 12+ years of education was associated with a 76% lower hazard of dementia/CIND (95% CI, 0.08 to 0.71) at the 25th percentile of CVD risk and with a 45% lower hazard (95% CI, 0.28 to 1.07) at the 75th percentile (P value of CVDrisk×education=0.05). Conclusions: CVD risk score may provide a useful tool for identifying individuals at risk for cognitive decline and dementia

Text to Move: A Randomized Controlled Trial of a Text-Messaging Program to Improve Physical Activity Behaviors in Patients With Type 2 Diabetes Mellitus

Background: Text messages are increasingly being used because of the low cost and the ubiquitous nature of mobile phones to engage patients in self-care behaviors. Self-care is particularly important in achieving treatment outcomes in type 2 diabetes mellitus (T2DM).Objective: This study examined the effect of personalized text messages on physical activity, as measured by a pedometer, and clinical outcomes in a diverse population of patients with T2DM.Methods: Text to Move (TTM) incorporates physical activity monitoring and coaching to provide automated and personalized text messages to help patients with T2DM achieve their physical activity goals. A total of 126 English- or Spanish-speaking patients with glycated hemoglobin A1c (HbA1c) >7 were enrolled in-person to participate in the study for 6 months and were randomized into either the intervention arm that received the full complement of the intervention or a control arm that received only pedometers. The primary outcome was change in physical activity. We also assessed the effect of the intervention on HbA1c, weight, and participant engagement.Results: All participants (intervention: n=64; control: n=62) were included in the analyses. The intervention group had significantly higher monthly step counts in the third (risk ratio [RR] 4.89, 95% CI 1.20 to 19.92, P=.03) and fourth (RR 6.88, 95% CI 1.21 to 39.00, P=.03) months of the study compared to the control group. However, over the 6-month follow-up period, monthly step counts did not differ statistically by group (intervention group: 9092 steps; control group: 3722 steps; RR 2.44, 95% CI 0.68 to 8.74, P=.17). HbA1c decreased by 0.07% (95% CI –0.47 to 0.34, P=.75) in the TTM group compared to the control group. Within groups, HbA1c decreased significantly from baseline in the TTM group by –0.43% (95% CI –0.75 to –0.12, P=.01), but nonsignificantly in the control group by –0.21% (95% CI –0.49 to 0.06, P=.13). Similar changes were observed for other secondary outcomes.Conclusion: Personalized text messaging can be used to improve outcomes in patients with T2DM by employing optimal patient engagement measures

A Telehealth-Based Randomized Controlled Trial: A Model for Outpatients Trials of Off-Label Medications During the COVID-19 Pandemic

The study was registered at clinicaltrials.gov: NCT0436320

A systematic review of risk factors for mortality among tuberculosis patients in South Africa

Background Tuberculosis (TB)-associated mortality in South Africa remains high. This review aimed to systematically assess risk factors associated with death during TB treatment in South African patients. Methods We conducted a systematic review of TB research articles published between 2010 and 2018. We searched BioMed Central (BMC), PubMed®, EBSCOhost, Cochrane, and SCOPUS for publications between January 2010 and December 2018. Searches were conducted between August 2019 and October 2019. We included randomised control trials (RCTs), case control, cross sectional, retrospective, and prospective cohort studies where TB mortality was a primary endpoint and effect measure estimates were provided for risk factors for TB mortality during TB treatment. Due to heterogeneity in effect measures and risk factors evaluated, a formal meta-analysis of risk factors for TB mortality was not appropriate. A random effects meta-analysis was used to estimate case fatality ratios (CFRs) for all studies and for specific subgroups so that these could be compared. Quality assessments were performed using the Newcastle-Ottawa scale or the Cochrane Risk of Bias Tool. Results We identified 1995 titles for screening, 24 publications met our inclusion criteria (one cross-sectional study, 2 RCTs, and 21 cohort studies). Twenty-two studies reported on adults (n = 12561) and two were restricted to children < 15 years of age (n = 696). The CFR estimated for all studies was 26.4% (CI 18.1–34.7, n = 13257 ); 37.5% (CI 24.8-50.3, n = 5149) for drug-resistant (DR) TB; 12.5% (CI 1.1–23.9, n = 1935) for drug-susceptible (DS) TB; 15.6% (CI 8.1–23.2, n = 6173) for studies in which drug susceptibility was mixed or not specified; 21.3% (CI 15.3-27.3, n = 7375) for people living with HIV/AIDS (PLHIV); 19.2% (CI 7.7–30.7, n = 1691) in HIV-negative TB patients; and 6.8% (CI 4.9–8.7, n = 696) in paediatric studies. The main risk factors associated with TB mortality were HIV infection, prior TB treatment, DR-TB, and lower body weight at TB diagnosis. Conclusions In South Africa, overall mortality during TB treatment remains high, people with DR-TB have an elevated risk of mortality during TB treatment and interventions to mitigate high mortality are needed. In addition, better prospective data on TB mortality are needed, especially amongst vulnerable sub-populations including young children, adolescents, pregnant women, and people with co-morbidities other than HIV. Limitations included a lack of prospective studies and RCTs and a high degree of heterogeneity in risk factors and comparator variables

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Cost-Related Access Barriers, Medical Debt, and Dissatisfaction with Care Among Privately Insured Americans.

BACKGROUND: Understanding experiences with private important to improving the quality of health care coverage. OBJECTIVE: To examine the association of health with cost-related access barriers, medical debt, and dissatisfaction with care among privately insured Americans. DESIGN: We classified Americans with private insurance by self-reported health status into five groups (excellent, very good, good, fair, and poor health). We examined self-reported difficulty seeing a doctor due to costs, not taking medications due to costs, medical debt, and dissatisfaction with care among individuals with differing health status. We used logistic regression to examine the association of health status with individuals experiences after accounting for baseline characteristics. The analysis was repeated among individuals with different forms of private insurance. Odds ratios were converted to risk ratios to improve ease of interpretation of the results. SETTING: Behavioral Risk Factor Surveillance System of Americans in 17 states RESULTS: The sample included 82,494 US adults with private insurance. Following adjustment, compared to individuals with excellent health those in very good health, good health, fair health, and poor health reported increasingly higher risks of difficulty seeing a doctor due to costs with risk ratios of 1.02 (95% CI 1.01, 1.03), 1.07 (95% CI 1.06, 1.08), 1.18 (95% CI 1.17, 1.20), and 1.29 (95% CI 1.27, 1.31), respectively. Compared to individuals with excellent health, those in very good health, good health, fair health, and poor health reported increasingly higher risks of not taking medication due to costs, outstanding medical debt, and dissatisfaction with care. Similar relationships were seen across individually purchased and employer-sponsored insurance. CONCLUSION: Cost-related access barriers, medical debt, and dissatisfaction with care were common among individuals with private insurance and most pronounced among those with fair and poor health who likely need and use their health insurance the most

The Impact of Educational Attainment on Observed Race/Ethnic Disparities in Inflammatory Risk in the 2001–2008 National Health and Nutrition Examination Survey

Inflammation has shown to be an independent predictor of cardiovascular disease (CVD) and growing evidence suggests Non-Hispanic Blacks (NHBs) and certain Hispanic subgroups have higher inflammation burden compared to Non-Hispanic Whites (NHWs). Socioeconomic status (SES) is a hypothesized pathway that may account for the higher inflammation burden for race/ethnic groups yet little is known about the biological processes by which SES “gets under the skin” to affect health and whether income and education have similar or distinct influences on elevated inflammation levels. The current study examines SES (income and education) associations with multiple levels of C-Reactive Protein (CRP), an important biomarker of inflammation, in a sample of 13,362 NHWs, 7696 NHBs and 4545 Mexican Americans (MAs) in the United States from the 2001 to 2008 National Health and Nutrition Examination Survey. After adjusting for age, sex, and statin use, NHBs and MAs had higher intermediate and high CRP levels compared to NHWs. Income lessened the magnitude of the association for both race/ethnic groups. The greater intermediate and high CRP burden for NHBs and MAs was strongly explained by educational attainment. MAs were more vulnerable to high CRP levels for the lowest (i.e., less than nine years) and post high school (i.e., associates degree) educational levels. After additional adjustment for smoking, heavy drinking, high waist circumference, high blood pressure, diabetes and statin use, the strength of the association between race/ethnicity and inflammation was reduced for NHBs with elevated intermediate (RR = 1.31; p ≤ 0.001) and high CRP levels (RR = 1.14; p ≤ 0.001) compared to NHWs but the effect attenuated for MAs for both intermediate (RR = 0.74; p ≤ 0.001) and high CRP levels (RR = 0.38; p ≤ 0.001). These findings suggest educational attainment is a powerful predictor of elevated CRP levels in race/ethnic populations and challenges studies to move beyond examining income as a better predictor in the SES-inflammation pathway