Effects of a community-wide health education program on cardiovascular disease morbidity and mortality: the Stanford Five-City Project.

The authors examined changes in morbidity and mortality from 1979 through 1992 during the Stanford Five-City Project, a comprehensive community health education study conducted in northern California. The intervention (1980-1986), a multiple risk factor strategy delivered through multiple educational methods, targeted all residents in two treatment communities. Potentially fatal and nonfatal myocardial infarction and stroke events were identified from death certificates and hospital records. Clinical information was abstracted from hospital charts and coroner records; for fatal events, it was collected from attending physicians and next of kin. Standard diagnostic criteria were used to classify all events, without knowledge of the city of origin. All first definite events were analyzed; denominators were estimated from 1980 and 1990 US Census figures. Mixed model regression analyses were used in statistical comparisons. Over the full 14 years of the study, the combined-event rate declined about 3% per year in all five cities. However, during the first 7-year period (1979-1985), no significant trends were found in any of the cities; during the late period (1986-1992), significant downward trends were found in all except one city. The change in trends between periods was slightly but not significantly greater in the treatment cities. It is most likely that some influence affecting all cities, not the intervention, accounted for the observed change.

Ethnic and socioeconomic differences in cardiovascular disease risk factors: findings for women from the Third National Health and Nutrition Examination Survey, 1988-1994.

CONTEXT: Cardiovascular disease (CVD) risk factors are higher among ethnic minority women than among white women in the United States. However, because ethnic minority women are disproportionately poor, socioeconomic status (SES) may substantially explain these risk factor differences. OBJECTIVE: To determine whether differences in CVD risk factors by ethnicity could be attributed to differences in SES. DESIGN: Third National Health and Nutrition Examination Survey conducted between 1988 and 1994. SETTING: Eighty-nine mobile examination centers. PARTICIPANTS: A total of 1762 black, 1481 Mexican American, and 2023 white women, aged 25 to 64 years, who completed both the home questionnaire and medical examination. MAIN OUTCOME MEASURES: Ethnicity and years of education (SES) in relation to systolic blood pressure, cigarette smoking, body mass index (BMI, a measure of weight in kilograms divided by the square of height in meters), physical inactivity, non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]), and non-insulin-dependent diabetes mellitus. RESULTS: As expected, most CVD risk factors were higher among ethnic minority women than among white women. After adjusting for years of education, highly significant differences in blood pressure, BMI, physical inactivity, and diabetes remained for both black and Mexican American women compared with white women (P<.001). In addition, women of lower SES from each of the 3 ethnic groups had significantly higher prevalences of smoking and physical inactivity and higher levels of BMI and non-HDL-C than women of higher SES (P<.001). CONCLUSIONS: These findings provide the greatest evidence to date of higher CVD risk factors among black and Mexican American women than among white women of comparable SES. The striking differences by both ethnicity and SES underscore the critical need to improve screening, early detection, and treatment of CVD-related conditions for black and Mexican American women, as well as for women of lower SES in all ethnic groups.

Differences in treatment of acute myocardial infarction by sex, age, and other factors (the Stanford Five-City Project).

This study examines the temporal trends in the use of angiography followed by revascularization procedures for acute myocardial infarction (AMI) in 2,021 hospitalized men and 995 women aged 30 to 74 years who participated in the Stanford Five-City Project during the years 1986 to 1992. Our sample included hospitalized patients who received a discharge diagnosis code of 410 through 414 and met study criteria for either a definite or possible AMI. Incident and recurrent infarctions occurring in the years 1986 through 1992 were included, but only the first event in this period for each patient. We performed stepwise multiple logistic regression analysis to determine the probability of: (1) receiving coronary angiography, (2) revascularization by either coronary bypass surgery or angioplasty among those with angiogram, and (3) thrombolytic therapy. Age, year of procedure, disease severity, and time between symptom onset and medical treatment were included as covariates. After adjustment of these factors, women were less likely than men to undergo angiography but were equally likely to undergo revascularization and thrombolysis. Hispanics and whites were equally likely to receive angiography and thrombolysis, but Hispanics were less likely than whites to undergo revascularization. Age and disease severity were inverse predictors of coronary angiography but not of revascularization. Age, severity, and delay time between onset of symptoms and medical therapy were inverse predictors of thrombolysis; delay time was significantly greater in women than in men and averaged > 6 hours in both sexes. The likelihood of receiving angiography, revascularization, and thrombolysis increased sharply over the study period.

Interactive effects of depression symptoms, nicotine dependence, and weight change on late smoking relapse.

Signal detection methods were used to develop an algorithm useful in distinguishing those at risk for late relapse from those likely to maintain abstinence. Four subgroups with 24-month survival (nonrelapse) rates ranging from 79% to 33% were identified. Among participants whose depression symptoms decreased from baseline to the end of treatment, lower levels of nicotine dependence were associated with less relapse at the 24-month follow-up (odds ratio = 2.77; 95% confidence interval: 1.36-5.62). Among participants whose depression symptoms increased from baseline to the end of treatment, greater weight gain was associated with less relapse at follow-up (odds ratio = 2.90; 95% confidence interval: 1.41-5.96). This study suggested that it may become possible to use both baseline and treatment information to "titrate" interventions.

Mortality from coronary heart disease and stroke for six ethnic groups in California, 1985 to 1990.

Coronary heart disease and stroke death rates were compared for six ethnic groups (non-Hispanic white, Hispanic, African-American, Chinese, Japanese, and Asian Indian) by sex and age (25 to 44, 45 to 64, 65 to 84, and 25 to 84 years old) using California census and 1985 to 1990 death data. African-American men and women in all age groups had the highest rates of death from coronary heart disease, stroke, and all causes (except for coronary heart disease in the oldest men). Hispanics, Chinese, and Japanese in all age-sex groups had comparatively low death rates for coronary heart disease and stroke, although stroke was proportionally an important cause of death for Chinese and Japanese groups. Coronary heart disease was an important cause of death for Asian Indians although death rates were generally not higher than those for other ethnic groups. Ethnic differences were most marked for women and younger age groups.

Community surveillance of cardiovascular diseases in the Stanford Five-City Project. Methods and initial experience.

The Stanford Five-City Project is a long-term field evaluation of the effects of community health education on cardiovascular disease risk factors and event rates. One major end point of the project is the difference between treatment and control group trends in morbidity and mortality rates ascertained through community-wide surveillance of deaths and hospital discharges. This surveillance system includes continuous review of death certificates and hospital discharge records, interviews with the families and physicians of decedents who died outside the hospital, abstraction of the hospital records of possible myocardial infarction and stroke cases (fatal and nonfatal), and systematic validation of diagnosis by the use of standard criteria. Initial experience with information access, availability of diagnostic information, costs, and reliability are described. This standardized approach to community surveillance of cardiovascular disease events rates, both fatal and nonfatal, is a feasible method for evaluating large-scale intervention programs and may be applicable to monitoring secular trends in the absence of intervention.