Implementation of a multi-modal intervention adopting new technologies, clinical services, and feedback improves catheter-associated urinary tract infections.

OBJECTIVES: Catheter-associated urinary tract infections (CAUTI) are a significant cause of morbidity and financial burden to healthcare systems. The aim of this study was to develop and implement a program designed to reduce Foley catheter use days and associated CAUTI rates. METHODS: A retrospective evaluation of a multi-modal program aimed toward reducing Foley catheter use days and associated CAUTI rates across the Indiana University Health (IUH) system was conducted. IUH is comprised of 16 hospitals and 2,703 available beds. The program included the adoption of new technologies with evidence-based clinical training materials based on change management and feedback from clinicians. National Healthcare Safety Network Standardized Infection Ratio (SIR), Standardized Utilization Ratio (SUR), and Incidence Density Ratio (IDR) rates were assessed. RESULTS: Implementation of the multi-modal program resulted in a significant reduction in SIR, SUR, and IDR in the post-implementation compared to the baseline periods. CONCLUSIONS: Through CAUTI bundle workflow assessments, education, and interventions designed to standardize practice variation, the program was successfully implemented and resulted in a significant decrease in Foley Catheter use days, and associated CAUTI rates.

Impact of automated dispensing solutions in long-term care facilities and closed-door pharmacies: A mixed methods study of medication management.

BACKGROUND: Financial, operational, and clinical workflow impacts of deploying an automated dispensing cabinet (ADC) in long-term care (LTC) facilities based on actual observations have not been documented in peer-reviewed literature. OBJECTIVES: To evaluate the impact of a closed-door pharmacy (CDP) implementing an ADC with unique secure, removable, and transportable locked pockets in an unstudied setting (LTC facilities) for management of first and emergency dose medications. PRACTICE DESCRIPTION: This study was conducted in 1 CDP and 2 LTC facilities. PRACTICE INNOVATION: Enhancing emergency medication management and inventory tracking in an unstudied setting through implementation of an ADC system featuring unique electronically encoded medication storage pockets that can be prepared in the CDP, locked and securely transported to the LTC, and when inserted into ADC it informs staff of its presence, position, and contents. EVALUATION METHODS: Mixed methods, pre- and poststudy to assess the impact of replacing manual emergency medication kits with an ADC. Outcomes were evaluated using rapid ethnography with workflow modeling; inventory and delivery reports; a nursing perception survey; and transactional data from the ADC during postimplementation phase. RESULTS: Pharmacy technician preparation time and pharmacist checking time decreased by 59% and 80%, respectively, and standing inventory was reduced by more than $10,000 combined for the CDP and 2 LTCs by replacing emergency medication kits with the ADC. In the LTCs, this change led to a 71% reduction in emergency medication retrieval time, an increase in emergency medication utilization, and a 96% reduction in the cost of unscheduled deliveries. Over 70% of the nurses surveyed favored replacement of the emergency medication kits with the ADC system. CONCLUSION: Replacing manual emergency medication kit with the described ADC system improved workflow efficiency in the CDP and LTC. It also significantly reduced unscheduled (STAT) deliveries and standing inventory and increased the availability of medications commonly used.

Catheter-associated urinary tract infections (CAUTIs) and non-CAUTI hospital-onset urinary tract infections: Relative burden, cost, outcomes and related hospital-onset bacteremia and fungemia infections.

OBJECTIVE: To describe the relative burden of catheter-associated urinary tract infections (CAUTIs) and non-CAUTI hospital-onset urinary tract infections (HOUTIs). METHODS: A retrospective observational study of patients from 43 acute-care hospitals was conducted. CAUTI cases were defined as those reported to the National Healthcare Safety Network. Non-CAUTI HOUTI was defined as a positive, non-contaminated, non-commensal culture collected on day 3 or later. All HOUTIs were required to have a new antimicrobial prescribed within 2 days of the first positive urine culture. Outcomes included secondary hospital-onset bacteremia and fungemia (HOB), total hospital costs, length of stay (LOS), readmission risk, and mortality. RESULTS: Of 549,433 admissions, 434 CAUTIs and 3,177 non-CAUTI HOUTIs were observed. The overall rate of HOB likely secondary to HOUTI was 3.7%. Total numbers of secondary HOB were higher in non-CAUTI HOUTIs compared to CAUTI (101 vs 34). HOB secondary to non-CAUTI HOUTI was more likely to originate outside the ICU compared to CAUTI (69.3% vs 44.1%). CAUTI was associated with adjusted incremental total hospital cost and LOS of $9,807 (P < .0001) and 3.01 days (P < .0001) while non-CAUTI HOUTI was associated with adjusted incremental total hospital cost and LOS of $6,874 (P < .0001) and 2.97 days (P < .0001). CONCLUSION: CAUTI and non-CAUTI HOUTI were associated with deleterious outcomes. Non-CAUTI HOUTI occurred more often and was associated with a higher facility aggregate volume of HOB than CAUTI. Patients at risk for UTIs in the hospital represent a vulnerable population who may benefit from surveillance and prevention efforts, particularly in the non-ICU setting.

Prevalence of Hospital-Onset Bacteremia Pre- and Post-Implementation of a Needleless Blood Sampling Device From Existing Peripheral Catheters.

Repeated access of peripheral intravenous (IV) devices theoretically increases the risk of bacterial exposure. PIVO™ (VelanoVascular) is a needleless, single-use device that enables blood sampling from an existing peripheral IV. The goal of this retrospective observational exploratory study was to evaluate the influence of PIVO use on rates of hospital-onset bacteremia and fungemia (HOB) by comparing HOB rates in the year before and after PIVO introduction in hospitals implementing PIVO and over similar time periods in "control" hospitals with no PIVO. Two hospitals implementing PIVO (Hospital 1, a large community hospital; Hospital 2, a tertiary oncology center), and 71 control hospitals were included. During the 1-year period before and after PIVO introduction, HOB rates decreased in hospitals 1 and 2 by 31.9% and 41.8%, respectively. Control hospitals that did not use PIVO had a 12.4% decrease in HOB rates. Multivariable logistic regression analyses found that PIVO was associated with a lower risk (Hospital 1 odds ratio [OR]: 0.63; 95% CI, 0.42-0.94) or no change (Hospital 2 OR: 1.05; 95% CI, 0.72-1.52) in HOB rates. Control hospitals also showed no change in HOB rates between the 2 time periods. These data do not support concerns about increased risk of bacteremia with PIVO.

Characteristics, costs, and outcomes associated with central-line-associated bloodstream infection and hospital-onset bacteremia and fungemia in US hospitals.

OBJECTIVES: To compare characteristics and outcomes associated with central-line-associated bloodstream infections (CLABSIs) and electronic health record-determined hospital-onset bacteremia and fungemia (HOB) cases in hospitalized US adults. METHODS: We conducted a retrospective observational study of patients in 41 acute-care hospitals. CLABSI cases were defined as those reported to the National Healthcare Safety Network (NHSN). HOB was defined as a positive blood culture with an eligible bloodstream organism collected during the hospital-onset period (ie, on or after day 4). We evaluated patient characteristics, other positive cultures (urine, respiratory, or skin and soft-tissue), and microorganisms in a cross-sectional analysis cohort. We explored adjusted patient outcomes [length of stay (LOS), hospital cost, and mortality] in a 1:5 case-matched cohort. RESULTS: The cross-sectional analysis included 403 patients with NHSN-reportable CLABSIs and 1,574 with non-CLABSI HOB. A positive non-bloodstream culture with the same microorganism as in the bloodstream was reported in 9.2% of CLABSI patients and 32.0% of non-CLABSI HOB patients, most commonly urine or respiratory cultures. Coagulase-negative staphylococci and Enterobacteriaceae were the most common microorganisms in CLABSI and non-CLABSI HOB cases, respectively. In case-matched analyses, CLABSIs and non-CLABSI HOB, separately or combined, were associated with significantly longer LOS [difference, 12.1-17.4 days depending on intensive care unit (ICU) status], higher costs (by $25,207-$55,001 per admission), and a >3.5-fold increased risk of mortality in patients with an ICU encounter. CONCLUSIONS: CLABSI and non-CLABSI HOB cases are associated with significant increases in morbidity, mortality, and cost. Our data may help inform prevention and management of bloodstream infections.

Differential Screening for Nonviral Sexually Transmitted Infections by Type of Vaginitis Testing.

BACKGROUND: Data are lacking on adherence to Centers for Disease Control and Prevention testing guidelines among insured US women presenting with vaginal health complaints; thus, we quantified vaginitis testing frequency and assessed the co-testing rate for causes of vaginitis and Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). METHODS: This was a retrospective analysis of deidentified data from a medical database. Information from women aged 18 to 50 years was obtained from the Truven MarketScan Commercial Database (2012-2017) using Current Procedural Terminology ( CPT ) codes; χ2 testing was applied to determine co-testing differences for CT/NG based on vaginitis test type. Odds ratios were calculated to determine the association with CT/NG screening across vaginitis testing categories. RESULTS: Approximately 48% of 1,359,289 women received a vaginitis diagnosis that involved a laboratory-based test. Of these women, only 34% were co-tested for CT/NG. CT/NG co-testing was highest for those with nucleic acid amplification testing for vaginitis and lowest for those with no vaginitis testing CPT code (71% vs. 23%, respectively; P < 0.0001). CONCLUSIONS: The vaginitis nucleic acid amplification test, indicated by CPT code, was associated with statistically significantly higher CT/NG testing rates. Molecular diagnostics may support vaginitis testing in settings that have limited opportunities for microscopy and clinical examinations and offer greater opportunity to offer comprehensive women's health care that includes testing for chlamydia and/or gonorrhea infections.

Medication Prescribing for Type 2 Diabetes in the US Long-Term Care Setting: Observational Study.

OBJECTIVES: To characterize prescribing of glucose-lowering medication annually and to quantify the annual frequency of hypoglycemia among residents in long-term care (LTC) facilities with type 2 diabetes mellitus (T2DM). DESIGN: Serial cross-sectional study using a deidentified real-world database comprising electronic health records from LTC facilities. SETTING AND PARTICIPANTS: Individuals eligible for this study were ≥65 years old with T2DM and recorded stay of ≥100 days at an LTC facility in the United States in any of 5 study years (2016-2020), excluding individuals receiving palliative or hospice care. METHODS: Drug orders (prescriptions) for glucose-lowering medications for each LTC resident with T2DM in each calendar year were summarized by administration route (oral or injectable) and by drug class as ever-prescribed (ie, multiple prescriptions were included once), overall and stratified by age subgroup, <3 vs ≥3 comorbidities, and obesity status. We calculated the annual percentage of patients ever prescribed glucose-lowering medication each year, overall and by medication category, who experienced ≥1 hypoglycemic events. RESULTS: Among 71,200 to 120,861 LTC residents with T2DM included each year from 2016 to 2020, 68% to 73% (depending on the year) were prescribed ≥1 glucose-lowering medications, among them oral agents for 59% to 62% and injectable agents for 70% to 71%. Metformin was the most commonly prescribed oral agent, followed by sulfonylureas and dipeptidyl peptidase 4 inhibitors; basal plus prandial insulin was the most commonly prescribed injectable regimen. Prescribing patterns remained relatively consistent from 2016 to 2020, both overall and by patient subgroup. During each study year, 35% of LTC residents with T2DM experienced level 1 hypoglycemia (glucose ≥54 to <70 mg/dL), including 10% to 12% of those prescribed only oral agents and ≥44% of those prescribed injectable agents. Overall, 24% to 25% experienced level 2 hypoglycemia (glucose concentration <54 mg/dL). CONCLUSIONS AND IMPLICATIONS: Study findings suggest that opportunities exist for improving diabetes management for LTC residents with T2DM.

Unplanned 120-Day ED Visits and Readmission Rates Following Common Stone Procedures.

OBJECTIVE: To quantify emergency department (ED) visits and hospital admissions (HA) after common urologic stone procedures including ureteroscopy (URS), shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCL) which are a concern of payors, providers, and patients. MATERIALS AND METHODS: This is a retrospective cohort study using claims data from the IBM MarketScan Commercial and Medicare Supplement databases. Adults with a urologic stone diagnosis and no history of stone procedure in prior 12 months who underwent stone procedures between 2012 and 2017 were included. All-cause ED visits and HA were evaluated during 30, 60, 90, and 120-day periods following the index urologic stone procedure. RESULTS: A total of 166,287 patients were included in the analytic cohort. For inpatient-indexed procedures, cumulative ED visits rates following stone procedure at 120 days was 18.8% for URS, 19.2% for SWL, and 23.6% for PCL. A similar trend was observed with ED visit rates, following outpatient indexed procedures at 120 days with a cumulative rate of 14.2% of SWL patients, 14.9% of URS patients, and 17.3% of PCL. A similar trend was found when examining HA. ED and HA rates increased steadily through the 120-day time period. CONCLUSION: Rates of ED visits and HA following common stone procedures continue to rise at least up to 120 days following the index procedure whether in the outpatient or inpatient settings. While rates of unplanned care are similar for URS and SWL, patients undergoing PCL return to the hospital at higher rates.

Frequency and timing of emergency department visits and hospital admissions in stented patients following common stone procedures.

Emergency department (ED) visits and hospital admissions (HA) following urologic procedures are a concern for payors, providers, and patients. We seek to quantify ED visits and HA after urologic stone procedures. This is a retrospective cohort study using claims data from the IBM MarketScan Commercial and Medicare Supplement database. Adults with a urologic stone diagnosis and no history of stone procedure in prior 12 months who underwent stone procedures with ureteral stent codes between 2012 and 2017 were included. All-cause vs genitourinary (GU)-related ED visits and HA were evaluated during 30, 60, 90, and 120-day periods following the index urologic stone procedure. 88,047 patients were included in the analytic cohort. For inpatients, rate of all-cause vs GU-related ED visits was 10% vs 9% at 30 days and 19% vs 15% at 120 days. For outpatients, rate of all-cause vs GU-related ED visits was 9% vs 8% at 30 days and 15% vs 12% at 120 days. A similar trend was found when examining HA. Younger patients (18-44 years old) had higher rates of all-cause ED visits following inpatient index stone procedure (13% vs 10% at 30 days, p ≤ 0.0001). Twenty percent of patients have an ED visit or HA up to 120 days after having a stone procedure with most returning with GU-related complaint. Younger patients had the greatest burden among the study cohort. Further studies need to determine causation of these unplanned visits to guide appropriate intervention.

Religiosity prevalence and its association with depression and anxiety symptoms among Hispanic/Latino adults.

OBJECTIVES: Religion plays an important role in the lives of people in the United States. We examined the prevalence of religiosity among Hispanic/Latinos in four regions of the United States and looked at its correlation to depression and anxiety symptoms. DESIGN: The population-based Hispanic Community Health Study/ Study of Latinos enrolled a cohort of Hispanic/Latino adults (N = 16,415) ages 18-74 in four US cities from June 2008 to June 2011. Participants with complete data on religiosity (i.e., religious affiliation, frequency of attending religious activities and importance of religion), depression (assessed with the CESD-10), and trait anxiety (assessed with the STAI-10) were included in the present study. Distribution of religiosity is described by sociodemographic characteristics. Associations between religiosity with depression and anxiety were examined with logistic regression models controlling for sex, age group, education, Hispanic/Latino background, clinical center, and nativity. RESULTS: The majority of the population (89.5%) reported having a religious affiliation. Weekly attendance at religious activities was reported by 41.6% of participants, while 20.6% did not attend any religious activities. Religion was very important to 63.9% and not at all important to 6.7% of the population. The CES-D scores and trait anxiety scores were not significantly related in the overall group to frequency of attending religious activity or perceived importance of religion. However, in age-stratified analyses, among older individuals (65+ years old) reporting "never" participating in religious activities compared to more than once per week was associated with an 80% higher likelihood of having high depressive symptomatology. Similarly, in the older age group, no religious affiliation or reporting that religion is "not at all important" was associated with greater anxiety symptomatology. CONCLUSION: Religiosity varied by Hispanic/Latino background. Lack of religiosity was associated with elevated depressive or anxiety symptomology in older adults but not in young or middle-aged adults.

Performance of non-traditional hyperglycemia biomarkers by chronic kidney disease status in older adults with diabetes: Results from the Atherosclerosis Risk in Communities Study.

BACKGROUND: In people with chronic kidney disease (CKD), HbA1c may be a problematic measure of glycemic control. Glycated albumin and fructosamine have been proposed as better markers of hyperglycemia in CKD. In the present study we investigated associations of HbA1c, glycated albumin, and fructosamine with fasting glucose by CKD categories. METHODS: A cross-sectional analysis was performed of 1665 Atherosclerosis Risk in Communities Study participants with diagnosed diabetes aged ≥65 years. Spearman's rank correlations (r) were compared and Deming regression was used to obtain root mean square errors (RMSEs) for the associations across CKD categories defined using estimated glomerular filtration rate and urine albumin:creatinine ratio. RESULTS: Correlations of HbA1c, glycated albumin, and fructosamine with fasting glucose were lowest in people with severe CKD (HbA1c r = 0.52, RMSE = 0.91; glycated albumin r = 0.39, RMSE = 1.89; fructosamine r = 0.41, RMSE = 1.87) and very severe CKD (r = 0.48 and RMSE = 1.01 for HbA1c; r = 0.36 and RMSE = 2.14 for glycated albumin; r = 0.36 and RMSE = 2.22 for fructosamine). Associations of glycated albumin and fructosamine with HbA1c were relatively similar across CKD categories. CONCLUSIONS: In older adults with severe or very severe CKD, HbA1c, glycated albumin, and fructosamine were not highly correlated with fasting glucose. The results suggest there may be no particular advantage of glycated albumin or fructosamine over HbA1c for monitoring glycemic control in CKD.

Oral Health Care Receipt and Self-Rated Oral Health for Diverse Asian American Subgroups in New York City.

OBJECTIVES: To identify determinants of receipt of annual oral health examinations and self-rated oral health among diverse Asian American subgroups. METHODS: We used data from the Community Health Resources and Needs Assessment, a community-based survey of Asian American immigrant adults conducted in the New York City metropolitan region from 2013 to 2016 (n = 1288). We used multivariable logistic regression models to assess determinants of oral health care receipt and self-rated oral health. RESULTS: Failure to receive an annual oral health examination was common in this sample (41.5%) and was more frequent for participants who were younger and male and those who had poorer English fluency and lower educational attainment. Not having dental insurance versus having private dental insurance resulted in 2 to 3 times the odds of nonreceipt of oral health care and poor self-rated oral health. CONCLUSIONS: Nonreceipt of annual oral health examinations and poor self-rated oral health were common across Asian American subgroups. Facilitating dental insurance sign-up and providing in-language services may improve oral health care access and ultimately oral health among Asian American immigrants.

American College of Cardiology/American Heart Association (ACC/AHA) Class I Guidelines for the Treatment of Cholesterol to Reduce Atherosclerotic Cardiovascular Risk: Implications for US Hispanics/Latinos Based on Findings From the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

BACKGROUND: The prevalence estimates of statin eligibility among Hispanic/Latinos living in the United States under the new 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol treatment guidelines are not known. METHODS AND RESULTS: We estimated prevalence of statin eligibility under 2013 ACC/AHA and 3rd National Cholesterol Education Program Adult Treatment Panel (NCEP/ATP III) guidelines among Hispanic Community Health Study/Study of Latinos (n=16 415; mean age 41 years, 40% males) by using sampling weights calibrated to the 2010 US census. We examined the characteristics of Hispanic/Latinos treated and not treated with statins under both guidelines. We also redetermined the statin-therapy eligibility by using black risk estimates for Dominicans, Cubans, Puerto Ricans, and Central Americans. Compared with NCEP/ATP III guidelines, statin eligibility increased from 15.9% (95% CI 15.0-16.7%) to 26.9% (95% CI 25.7-28.0%) under the 2013 ACC/AHA guidelines. This was mainly driven by the ≥7.5% atherosclerotic cardiovascular disease risk criteria (prevalence 13.9% [95% CI 13.0-14.7%]). Of the participants eligible for statin eligibility under NCEP/ATP III and ACC/AHA guidelines, only 28.2% (95% CI 26.3-30.0%) and 20.6% (95% CI 19.4-21.9%) were taking statins, respectively. Statin-eligible participants who were not taking statins had a higher prevalence of cardiovascular risk factors compared with statin-eligible participants who were taking statins. There was no significant increase in statin eligibility when atherosclerotic cardiovascular disease risk was calculated by using black estimates instead of recommended white estimates (increase by 1.4%, P=0.12) for Hispanic/Latinos. CONCLUSIONS: The eligibility of statin therapy increased consistently across all Hispanic/Latinos subgroups under the 2013 ACC/AHA guidelines and therefore will potentially increase the number of undertreated Hispanic/Latinos in the United States.

The Association of Parental/Caregiver Chronic Stress with Youth Obesity: Findings from the Study of Latino Youth and the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study.

BACKGROUND: Prior studies indicate that chronic stress is associated with obesity in adults. However, whether parental/caregiver stress is associated with obesity in their offspring has not been widely examined in Hispanic/Latino populations. In this study, we evaluated the role of caregiver chronic stress on child obesity and whether home food environment or child lifestyle behaviors explained the association. METHODS: The study included a sample of Hispanic/Latino youth and their caregivers (n = 473) from the Study of Latinos (SOL) Youth study and the Hispanic Community Health Study/SOL Sociocultural Study, which enrolled children aged 8-16 years from four cities (Bronx, Chicago, Miami, and San Diego), and provided assessments of adult chronic stress. Poisson regression models were used to assess the association between parental/caregiver stress and child obesity, adjusting for potential confounders. RESULTS: Twenty-two percent of caregivers did not report any chronic stressors, 48% reported 1-2, and 29% reported ≥3 stressors. The prevalence of obesity in youth increased with number of caregiver stressors from 23% among those without caregiver stressors to 35% among those with ≥3 stressors (p for trend 0.03). After model adjustment, youths whose caregivers reported ≥3 stressors were more likely to be obese than youths whose caregivers reported no stressors (prevalence ratio = 1.53; 95% confidence interval 1.01-2.32). This association was independent of food home environment, child diet quality, and child physical activity, but it was not independent of caregiver obesity. CONCLUSIONS: These findings suggest that parental/caregiver chronic stress is related to obesity in their children. Future research is needed to confirm this association in longitudinal studies and in other population groups.

Association of systemic inflammation, adiposity, and metabolic dysregulation with asthma burden among Hispanic adults.

RATIONALE: Obesity-related asthma is associated with higher disease burden than normal-weight asthma among Hispanics. Adiposity, metabolic dysregulation, and inflammation are all implicated in pathogenesis of obesity-related asthma, but their independent contributions are poorly understood. OBJECTIVE: To examine the independent contributions of body fat distribution, metabolic abnormalities and inflammation on asthma symptoms and pulmonary function among Hispanics. METHODS: Participants of the Hispanic Community Health Study/Study of Latinos with doctor-diagnosed asthma who completed an asthma symptom questionnaire and performed a valid spirometry were included in the analysis (n = 1126). Multivariate analysis was used to examine the independent association of general adiposity (assessed using body mass index), truncal adiposity (assessed by waist circumference), metabolic dysregulation (presence of insulin resistance and low HDL) and inflammation (high-sensitivity C-Reactive Protein≥3 mg/L) with reported asthma symptoms or pulmonary function measures (FEV1, and FVC) while adjusting for demographic and clinical covariates. RESULTS: Of the 1126 participants, 334 (29.5%) were overweight, and 648 (57.8%) were obese. FEV1 and FVC were lower in obese compared to normal-weight asthmatics. In analyses controlling for metabolic and adiposity factors, high hs-CRP (>7 mg/L) was associated with more symptoms (prevalence-ratio 1.27 (95%CI 1.05, 1.54), and lower FVC (ß -138 ml (95%CI -27 ml, -249 ml)) and FEV1 (ß -155 ml (95% CI -38 ml, -272 ml). Low HDL was also associated with lower FVC (ß -111 ml (-22 ml, -201 ml) and FEV1 (ß -100 ml (-12 ml, -188 ml)). Results were similar in men and women. CONCLUSIONS: Our findings suggest that hs-CRP and low HDL, rather than general and truncal adiposity, are associated with asthma burden among overweight and obese Hispanic adults.

Actigraphic sleep measures and diet quality in the Hispanic Community Health Study/Study of Latinos Sueño ancillary study.

Using a cross-sectional probability sample with actigraphy data and two 24-h dietary recalls, we quantified the association between sleep duration, continuity, variability and timing with the Alternative Healthy Eating Index-2010 diet quality score and its components in 2140 Hispanic Community Health Study/Study of Latinos participants. The Alternative Healthy Eating Index diet quality-2010 score ranges from 0 to 110, with higher scores indicating greater adherence to the dietary guidelines and lower risk from major chronic disease. None of the sleep measures was associated with total caloric intake as assessed using dietary recalls. However, both an increase in sleep duration and sleep efficiency were associated with healthier diet quality. Each standard deviation increase in sleep duration (1.05 h) and sleep efficiency (4.99%) was associated with a 0.30 point increase and 0.28 point increase, respectively, in the total Alternative Healthy Eating Index-2010 score. The component of Alternative Healthy Eating Index-2010 most strongly associated with longer sleep duration was increased nuts and legumes intake. The components of Alternative Healthy Eating Index-2010 most strongly associated with higher sleep efficiency were increased whole fruit intake and decreased sodium intake. Both longer sleep duration and higher sleep efficiency were significantly associated with better diet quality among US Hispanic/Latino adults. The dietary components most strongly associated with sleep duration and sleep efficiency differed, suggesting potentially independent mechanisms by which each aspect of sleep impacts dietary choices. Longitudinal research is needed to understand the directionality of these identified relationships and the generalizability of these data across other ethnic groups.

Trends in Nonlipid Cardiovascular Disease Risk Factor Management in the Women's Interagency HIV Study and Association with Adherence to Antiretroviral Therapy.

Cardiovascular disease (CVD) is increasingly common among women with HIV, but literature on nonlipid CVD risk factor management is lacking. We examined semiannual trends from 2006 to 2014 in hypertension treatment and control (blood pressure <140/90 mmHg), diabetes treatment and control (fasting glucose <130 mg/dL), and smoking quit rates in the Women's Interagency HIV Study. Unadjusted and adjusted Poisson regression models tested time trends and differences between HIV+ and HIV- women. Among antiretroviral therapy (ART) users, we examined the association of ART adherence and virologic suppression with each outcome. We evaluated 1636 HIV+ and 683 HIV- women, with a hypertension prevalence of 40% and 38%, respectively; diabetes prevalence of 21% and 22%; and smoking prevalence of 37% and 48%. Hypertension treatment was higher among HIV+ than HIV- women (77% vs. 67%, p < 0.001) and increased over time with no difference in trend by HIV status. Hypertension control was greater among HIV+ women (56% vs. 43%, p < 0.001) and increased over time among HIV+ but not HIV- women. Diabetes treatment was similar among HIV+ and HIV- women (48% vs. 49%) and increased over time in both groups. Diabetes control was greater among HIV+ women (73% vs. 64%, p = 0.03) and did not change over time. The percent of recent smokers who reported no longer smoking was similar between HIV+ and HIV- women (10% vs. 9%), with no differences over time. Virologic suppression was significantly associated with increased hypertension treatment and greater control. HIV+ women have better control of hypertension and diabetes than HIV- women, but many are still not at target levels.

Macronutrient Intake, Diagnosis Status, and Glycemic Control Among US Hispanics/Latinos With Diabetes.

CONTEXT: Diet modification is a mainstay of diabetes management. US Hispanics/Latinos are disproportionately affected by diabetes, but few studies have examined dietary intake among US Hispanics/Latinos with diabetes, and little is known regarding the influence of diabetes awareness on dietary intake. OBJECTIVE: We evaluated macronutrient intake and its associations with diabetes awareness and glycemic control among US Hispanics/Latinos with diabetes. PARTICIPANTS: This analysis included 3310 diabetic adults aged 18­74 years from the Hispanic Community Health Study/Study of Latinos (2008­2011). MAIN OUTCOME MEASURES: Diabetes was defined as diagnosed (based on medical history or antihyperglycemic medication use) or undiagnosed diabetes (based on fasting glucose ≥ 126 mg/dL, glycated hemoglobin [HbA1c] ≥ 6.5%, or 2 h glucose ≥ 200 mg/dL in the absence of a physician diagnosis). Dietary intake was assessed using two 24-hour recalls. RESULTS: Among Hispanic/Latino adults with diabetes, 21.2%, 55.7%, and 71.2% met the American Diabetes Association recommendations for fiber (≥14 g per 1000 kcal), saturated fat (<10% of total energy), and cholesterol intake (<300 mg), respectively. Compared with those with undiagnosed diabetes, people with diagnosed diabetes consumed less carbohydrate (50.3 vs 52.4% of total energy; P = .017), total sugar (19.1 vs 21.5% of total energy; P = .002), added sugar (9.8 vs 12.1% of total energy; P < .001), and more total fat (30.7 vs 29.3% of total energy; P = .048) and monounsaturated fat (11.5 vs 10.7% of total energy; P = .021). Association between diabetes awareness and low total and added sugar intake was observed in individuals of Mexican and Puerto Rican background but not in other groups (P for interaction < .05). Among people with diagnosed diabetes, those with HbA1c of 7% or greater consumed more total fat, saturated fat, and cholesterol than those with HbA1c less than 7% (all P < .05). CONCLUSIONS: Among US Hispanics/Latinos with diabetes, fiber intake is low, and diabetes awareness is associated with reduced carbohydrate and sugar intake and increased monounsaturated fat intake. Sugar intake may require special attention in certain Hispanic/Latino background groups.

Sleep Apnea Is Associated with Hearing Impairment: The Hispanic Community Health Study/Study of Latinos.

STUDY OBJECTIVE: Sleep apnea (SA) may promote hearing impairment (HI) through ischemia and inflammation of the cochlea. Our objective was to assess an independent association between SA and HI in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) participants. METHODS: We used data from the HCHS/SOL, a multicenter population-based study of self- identifying Hispanic/Latinos 18- to 74-y-old adults from four US urban communities. We performed home SA testing and in-clinic audiometry testing in all participants. SA was defined as an apnea-hypopnea index (AHI) ≥ 15 events/h. HI was defined as a mean hearing threshold > 25 dB hearing level in either ear at the frequencies: 3,000 to 8,000 Hz for high-frequency HI (HF-HI) and 500 to 2,000 Hz for low-frequency HI (LF-HI). Combined-frequency HI (CF-HI) was defined as both conditions present, and Any-HI was considered as HI in either low or high frequencies. RESULTS: Of 13,967 participants, 9.9% had SA and 32.3% had Any-HI. Adjusted for risk factors for HI, those with SA had a 30% higher odds of Any-HI (95% confidence interval [CI] = 8% to 57%), 26% higher odds of HF-HI (CI = 3% to 55%), 127% higher odds of LF-HI (CI = 21% to 326%), and 29% higher odds of CF-HI (CI = 0% to 65%). A dose-response association was observed between AHI severity and Any-HI (versus no SA, OR for AHI ≥ 15 and < 30 = 1.22, CI = 0.96 to 1.54, and OR for AHI ≥ 30 = 1.46, CI = 1.11 to 1.91, p = 0.002). CONCLUSION: SA is associated with HF-HI and LF-HI, independent of snoring and other confounders. COMMENTARY: A commentary on this article appears in this issue on page 641.

Awareness of Hepatitis C Virus Seropositivity and Chronic Infection in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

Few population-based studies have assessed awareness of hepatitis C virus (HCV) seropositivity and chronic infection. We report awareness of HCV seropositivity and chronic infection and correlates of awareness in a multi-city (Bronx, Miami, Chicago, and San Diego) community-dwelling population sample of United States (US) Hispanics/Latinos recruited during 2008-2011. Included were 260 HCV-seropositive participants, among whom 190 had chronic HCV. Among those with chronic HCV, 46 % had been told by a doctor that they had liver disease and 32 % had been told that they had HCV-related liver disease. Among those with chronic HCV who also lacked health insurance (37 % of those with chronic HCV), only 8 % had been told that they had HCV-related liver disease. As compared with the uninsured, those with insurance were over five times more likely to be aware of having HCV-related liver disease (44 %). Sex, age, education, city of residence, and birthplace were not associated with HCV awareness. Less than half of Hispanics/Latinos were aware of their HCV chronic infection. Lack of health insurance may be an important barrier to HCV awareness in this population.