Health utilities associated with hemoglobin levels and blood loss in postmenopausal women: the Women's Health Initiative.

OBJECTIVES: The purpose of our study was to use health-related quality of life data from the Women's Health Initiative to calculate health-related utility weights and examine differences in these health utility weights across different hemoglobin (Hgb) levels. These utility weights could then be used in future cost-effectiveness studies. METHODS: Health utility weights were measured by the Short Form-6D (SF-6D), a health utility index derived from the Short Form Medical Outcomes questionnaire. Adjusted least square means were calculated for each level of Hgb at baseline and in longitudinal regression analysis the relationship between change in Hgb and change in the SF-6D was examined. Both baseline and longitudinal analyses were performed for all postmenopausal women and separately for those with self-reported heart failure, cancer, and osteoarthritis. RESULTS: Women with Hgb in the anemic range had lower health utility weights than those with higher Hgb levels. Longitudinally, a loss of of 2 g/dl Hgb or more was associated with a statistically significant and clinically meaningfully decline in SF-6D in all participants and also in the group of participants with cancer and osteoarthritis, but not in those with heart failure. CONCLUSIONS: Lower levels of Hgb and a loss of Hgb are associated with a statistically significant and clinically meaningful decrement in health utility in all postmenopausal women we studied and also in those with chronic conditions.

Persistence with non-selective NSAIDs and celecoxib among patients with gastroesophageal reflux disease and osteoarthritis or rheumatoid arthritis.

OBJECTIVE: Gastrointestinal (GI) symptoms are common in patients taking nonselective, nonsteroidal anti-inflammatory drugs (nsNSAIDs) and are often a reason for therapy discontinuation. In osteoarthritis (OA) and rheumatoid arthritis (RA) patients requiring pain control, selective COX-2 NSAID use is typically associated with less dyspepsia than is nsNSAID use. Little is known about NSAID tolerance in patients with gastroesophageal reflux disease (GERD). This study assessed nsNSAID and celecoxib prescription patterns, in particular persistence, in OA/RA patients with concomitant diagnosis of GERD. METHODS: An observational study of GERD patients with a diagnosis of OA/RA using two separate databases, the IMS Lifelink Health Plan Claims Database (PharMetrics) and Market Scan Claims Database (Medstat) was conducted. In each database, parallel and separate analyses were performed in adult patients who had their first GERD diagnosis in 2006 and who were subsequently diagnosed with OA or RA in the same year. From this subset of patients, celecoxib-naïve and nsNSAID-naïve cohorts were identified and patients were selected. Patients with pre-existing GI conditions were excluded from the study. Persistence, measured as time to discontinuation, was evaluated by Kaplan-Meier survival curves and Cox proportional hazards models. Reasons for discontinuations were not available in these databases. RESULTS: Fewer patients discontinued celecoxib as compared to nsNSAIDs during the 60 days of the first prescription and throughout the entire follow-up period. After adjusting for baseline characteristics, celecoxib patients still had significantly decreased risk of discontinuation as compared to nsNSAID patients (p < 0.0001). Replication of these observations in two separate, large patient databases increases the confidence in this study's conclusion. LIMITATIONS: Limitations include those inherent to claims data analyses and retrospective review, e.g. these data do not provide clinical information related to reasons for medication discontinuation. CONCLUSION: In patients with concomitant GERD and OA or RA who require anti-inflammatory treatment, significantly more patients treated with celecoxib were persistent with their treatment than were patients treated with nsNSAIDs.

Coronary heart disease surveillance: field application of an epidemiologic algorithm.

This report describes the performance of a surveillance system and computerized algorithm for the assignment of definite or probable hospitalized cardiac events for large epidemiologic studies. The algorithm, developed by the Coordinating Committee for Community Demonstration Studies (CCCDS), evolved from the Gillum criteria, and included selected ICD-9-CM codes including codes 410 through 414 for discharge record screening, plus creatine kinase. For the small percentage of cases in which enzyme analysis was inconclusive (8%), presence of pain and/or Minnesota-coded electrocardiograms were included to define the outcome. All data items were easily obtained from medical records by trained lay record abstractors and required no interpretation. From January 1980 through December 1991, 21,183 medical records were screened for ICD-9-CM codes 410 through 414. Of all 410 to 411 ICD-9-CM codes (n = 9026), 36.9% (n = 3220) were classified as definite cardiac events and 10.6% (n = 1057) as probable events. Of all 412 through 414 codes (n = 9070), only 1.8% (n = 227) were classified as definite cardiac events and 5.4% (n = 716) as probable events. The epidemiologic diagnostic algorithm presented in this article used computerized data to assign diagnoses in a standard, objective manner, and was a lower cost alternative to classification of cardiac events on the basis of clinical review and/or more complex record abstraction approaches.

The association between perceived risk and actual cardiovascular disease.

We examined the association between self-rated risk of stroke or myocardial infarction and actual morbidity and mortality by gender among participants of the Pawtucket Heart Health Program Health Survey in a nested case-control study. We defined cases (N = 191) as survey participants who later had a cardiac event registered in the Pawtucket Heart Health Program cardiovascular disease morbidity and mortality surveillance system. We matched controls (N = 573) on age, sex, date of survey, and city of residence. Women reporting a high perceived risk of stroke or myocardial infarction were four times as likely as women who indicated low perceived risk to have a future cardiovascular event [adjusted odds ratio = 4.0; 95% confidence interval (CI) = 1.5-10.3]. Men who perceived their risk as average were twice as likely as those who rated their risk as low to have a future myocardial infarction or stroke (adjusted odds ratio = 1.9; 95% CI = 1.0-3.6), whereas those who perceived their risk as high were at only slightly higher risk of morbid or mortal events (adjusted odds ratio = 1.8; 95% CI = 0.9-3.9).

Sedentary lifestyle and risk of coronary heart disease in women.

Relatively few studies have assessed the prospective relationship of sedentary lifestyle and coronary heart disease (CHD) in women. We performed a nested case-control study, identifying 50 cases of acute CHD in women and 150 age-matched controls. Risk factors including sedentary lifestyle, cigarette smoking, hypertension, diabetes mellitus, total, and HDL cholesterol levels had been previously determined in this cohort using household survey techniques. The odds ratio (OR) of CHD in sedentary women was 2.1 (95% CI 1.0-4.3, P = 0.046). The odds ratio was similar (OR = 2.3, 95% CI 1.0-5.7, P = 0.051) after adjusting for potential confounders of hypertension, cigarette smoking, low HDL cholesterol, diabetes mellitus, and being U.S. born. This study suggests that sedentary lifestyle may be an independent risk factor for CHD in women, but its results are open to several contradictory interpretations. Further studies to investigate the prospective relationship of sedentary lifestyle and the risk of CHD in women are needed.

Cross-sectional relationship between diet and physical activity in two southeastern New England communities.

The hypothesis that health promotive diets associated with higher levels of habitual physical activity confound the relationship between regular physical activity and health has not been well explored in epidemiologic studies. We evaluated self-reported physical activity, Willett Food Frequency dietary data, sociodemographic and physiologic factors cross-sectionally for 2,004 household survey participants in two southeastern New England communities. We compared the dietary habits of sedentary participants (n = 964) to those of moderately active (n = 600) and very active (n = 440) participants after adjusting for age, gender, education, smoking status, year of survey, and total calories. Our results showed that moderately active and very active participants consumed more fiber, less total fat, and less saturated fat than sedentary participants (P < .01). They also consumed more vitamins (A, C, D, E), beta carotene, and calcium, (P < .01), and ate more fruits and vegetables (P < .001) than sedentary participants. We found these relationships in both New England communities studied. This association between regular physical activity and diet suggests that the relationship of habitual physical activity and chronic disease may be confounded by diet.

The Pawtucket Heart Health Program: community changes in cardiovascular risk factors and projected disease risk.

OBJECTIVES: Whether community-wide education changed cardiovascular risk factors and disease risk in Pawtucket, RI, relative to a comparison community was assessed. METHODS: Random-sample, cross-sectional surveys were done of people aged 18 through 64 years at baseline, during, and after education. Baseline cohorts were reexamined. Pawtucket citizens of all ages participated in multilevel education, screening, and counseling programs. RESULTS: The downward trend in smoking was slightly greater in the comparison city. Small, insignificant differences favored Pawtucket in blood cholesterol and blood pressure. In the cross-sectional surveys, body mass index increased significantly in the comparison community; a similar change was not seen in cohort surveys. Projected cardiovascular disease rates were significantly (16%) less in Pawtucket during the education program. This difference lessened to 8% posteducation. CONCLUSIONS: The hypothesis that projected cardiovascular disease risk can be altered by community-based education gains limited support from these data. Achieving cardiovascular risk reduction at the community level was feasible, but maintaining statistically significant differences between cities was not. Accelerating risk factor changes will likely require a sustained community effort with reinforcement from state, regional, and national policies and programs.

Physical activity, physical fitness, and coronary heart disease risk factors.

The relationships between physical activity, physical fitness, and coronary heart disease risk factors measured in a large community sample were evaluated. Self-reported physical activity using a single question, maximal oxygen consumption estimates derived from the Pawtucket Heart Health Step Test, blood pressure, nonfasting lipids, and body mass index were cross-sectionally evaluated in 381 men and 556 women. The correlation of estimated maximal oxygen consumption and self-reported physical activity was modest but statistically significant (r = 0.13 in men and r = 0.19 in women). Blood pressure, body mass index, and HDL cholesterol were correlated with physical fitness (r = 0.24-0.65) and correlated to self-reported physical activity (r = 0.09-0.14). Evaluation of coronary heart disease risk factors using both physical activity and physical fitness revealed a complex relationship that generally showed a stronger relationship with measures of physical fitness than with physical activity. This study suggests that simultaneous measurement of physical activity and physical fitness may be useful in epidemiologic studies of habitual physical activity and chronic disease.

Measuring cardiovascular disease risk factor levels: international comparisons between Bremen-north/west (Germany) and two southeastern New England (USA) cities.

Cardiovascular disease risk factor comparisons were made on study populations from communities in two different countries with similar ongoing intervention programs. Baseline survey data from the intervention and comparison communities of the Pawtucket Heart Health Program in Pawtucket, Rhode Island, and from the intervention Region of Bremen-North/West of the German Cardiovascular Prevention Study were compared with respect to these cardiovascular disease risk factors: smoking, overweight, physical inactivity, hypertension, and hypercholesterolemia. The relationship between these variables and social class was also examined in an attempt to partially explain some of the cross cultural differences in risk factors and predicted CHD and CVD mortality. Results indicated statistically significant differences in amount of cigarettes smoked, exercise frequency, diet, body mass index, total cholesterol, HDL, and blood pressure. These risk factors were generally higher in the German population than in the American population as were the predicted CHD and CVD mortality. For the study populations of both countries, however, the lower the social class, the more prevalent the smoking, excess weight, and lack of physical activity.

Program evaluation strategies for community-based health promotion programs: perspectives from the cardiovascular disease community research and demonstration studies.

Community-based programs are being widely adopted in the struggle to prevent chronic disease. Program evaluation of community-based programs involves a particular set of problems stemming from the variety of activities being undertaken simultaneously, the multiple intermediate goals of the programs and the rapidity with which the programs evolve. An analysis of the experience of four large community-based cardiovascular disease research and demonstration studies (Stanford Five-City Project, Minnesota Heart Health Program, Pawtucket Heart Health Program and the German Cardiovascular Prevention Project) provides valuable models, methodologies and strategies for planning and conducting evaluations of public health programs or community studies. By comparing and combining their experiences, the four programs have identified eight categories of evaluation for community studies, including formative evaluation, quality assurance, assessment of delivered dose, assessment of received dose, component program impact, intermediate outcomes, community impact and cost analysis. This paper presents information on the strategies by which each of the four programs addressed these evaluation categories.

Prevalence of hypertension, dyslipidemia, and dyslipidemic hypertension.

BACKGROUND: It has been proposed that dyslipidemic hypertension is part of a distinct metabolic syndrome related to insulin resistance. This paper describes the prevalence and cross-sectional relations of dyslipidemic hypertension in a population-based sample of men and women. METHODS: In two southeastern New England communities, 11,199 randomly selected participants were evaluated as part of a cross-sectional surveillance program of coronary heart disease risk factors between 1981 and 1990. RESULTS: The frequency of dyslipidemia was 38% and of hypertension was 26.5%; the conjoint frequency (dyslipidemic hypertension) was 15.0%, which is 1.49 times the expected value if the two diseases were independent P < .05). Using a discrete multivariate model, dyslipidemia and hypertension were associated with sex, obesity, and diabetes mellitus. The excess association of dyslipidemic hypertension, compared with individual effects of dyslipidemia and hypertension, was not related to these factors. CONCLUSIONS: This study suggests that dyslipidemic hypertension is common but may not be a unique entity associated with a distinct metabolic syndrome.

Education and risk factors for coronary heart disease: results from a New England community.

This article investigates the association of education with the estimated coronary heart disease (CHD) risk and the prevalence of CHD risk factors for men and women in a New England community over a period of 10 years. Educational differentials in knowledge of cardiovascular disease prevention, body mass index (BMI), total and high-density lipoprotein (HDL) cholesterol, cigarette smoking, and hypertension were examined for 3,765 respondents 25-64 years of age from five surveys of the Pawtucket Heart Health Program. We found a clear negative association between education and composite CHD risk. A stable separation in risk level was maintained across time between the least educated (< 12 years of education) and the other two educational groups (12, > or = 13 years of education) in both men and women. Educational differentials were observed in BMI and total and HDL cholesterol of the women 25-44 years of age. For men and women 25-44 years of age, smoking was negatively associated with education. Hypertension differed by education level among the women 45-64 years of age. These findings are highly comparable with the national data from aggregate vital statistics and the results of the National Health and Nutrition Examination Survey (NHANES) cohort follow-up.

Possible influence of the prospective payment system on the assignment of discharge diagnoses for coronary heart disease.

BACKGROUND: The prospective payment system, under which diagnosis-related groups (DRGs) are used to reimburse hospitals for the care of Medicare patients, replaced the fee-for-service method of payment in Rhode Island in 1983 and in Massachusetts in 1985. Changes in financial incentives resulting from the use of the DRG system may have influenced the assignment of discharge diagnostic codes away from those with lower reimbursement toward codes with higher reimbursement. METHODS: We collected data from the hospital records of patients 35 through 74 years of age who were discharged with codes 410 through 414 (representing various categories of coronary heart disease) of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The patients were discharged from seven hospitals in two New England communities (one in Rhode Island and one in Massachusetts) between 1980 and 1988. The rates of diagnosis of various forms of coronary heart disease were determined by studying ICD-9-CM hospital discharge codes (codes 410 and 411 for acute forms of coronary heart disease and codes 412, 413, and 414 for chronic forms) and by using a computerized diagnostic algorithm designed to detect definite myocardial infarction and fatal coronary heart disease. RESULTS: The rates of definite coronary events diagnosed by the algorithm and by the study of ICD-9-CM codes 410 through 414 were constant or increased slightly during the study period. However, the frequency of assignment of codes for the acute forms of coronary heart disease (which entail higher reimbursement) rose from 35.2 percent to 48.4 percent among discharged patients with cardiac disease after the institution of DRGs. The majority of this increase was associated with the code for unstable angina pectoris. The frequency of assignment of codes for the chronic forms of coronary heart disease (which entail lower reimbursement) decreased reciprocally, from 64.8 percent to 51.6 percent (P < 0.001). CONCLUSIONS: Our data are consistent with the hypothesis that the prospective reimbursement system has influenced the assignment of hospital discharge codes in a way that would increase payment to hospitals. However, the data do not permit us to distinguish whether hospitals began to assign more precise diagnoses with the advent of the DRG system, or whether they began to favor diagnoses of acute conditions solely for financial reasons.

Predicting physical activity change in men and women in two New England communities.

We describe the predictors of change in physical activity in a population-derived sample of residents of two New England communities. In 1986-1987 and again in 1990-1991, we assessed the self-reported physical activity of 1,081 survey respondents using a single question concerning the frequency of exercise-induced sweating. We measured and analyzed sociodemographic variables, cardiovascular disease risk factors, health knowledge and beliefs, social support variables, and exercise performance variables at baseline as potential predictors of physical activity change. We defined physical activity change in subjects as follows: maintainers (12.2%) persisted with > or = 3 times per week of activity, adopters (16.0%) increased activity to > or = 3 times per week, quitters (11.9%) decreased activity to < 3 times per week, and sedentary (59.9%) individuals persisted with < 3 times per week of activity. Using polychotomous multiple logistic regression analysis, we found that short-term success with exercise and weight loss, school children's recommendation of exercise, and work outside the home predicted adoption or maintenance of increased physical activity in women. For men, short-term success with exercise and weight loss and health beliefs regarding the role of exercise in preventing heart attacks and stroke were the major determinants of maintaining or adopting increased physical activity. This identification of the predictors of physical activity change provides the rationale for future sex-specific strategies aimed at increasing regular physical activity and long-term adherence to an active lifestyle.

The drug data base of the Pawtucket Heart Health Program: development and description.

Pharmacoepidemiology has become an important tool for identifying patterns of drug use and adverse drug reactions in the general population. Drug data bases derived from population-based samples have been particularly useful in addressing questions such as adherence to national guidelines for the treatment of chronic diseases. As part of the Pawtucket Heart Health Program, a continuing community-based research and demonstration project, detailed information regarding the use of drugs among the general population of two southeastern New England cities was collected using cross-sectional and longitudinal methodologies.

Changing trends in antihypertensive therapy in two New England communities during the 1980s.

The prevalence rates and correlates of antihypertensive drug use among individuals with hypertension were determined using data derived from five biennial population-based surveys conducted between 1981 and 1990 in two New England communities. Point prevalence estimates were determined for nine categories of antihypertensive agents at five time points, and were analyzed by age and sex using multiple logistic regression. In the first cross-sectional survey, the prevalence of use per 1000 individuals with hypertension was 235.4 for diuretics, 57.1 for beta-blockers, 65.5 for combination products, 29.2 for central alpha-agonists, 2.8 for peripheral alpha-antagonists, and 8.4 each for adrenergic blockers and direct vasodilators. The prevalence rates for calcium channel blockers and angiotensin-converting enzyme inhibitors increased sharply between the third and fourth survey cycles. Significant age- and sex-related differences in antihypertensive use were detected.

Prevalence and descriptors of aspirin use as an antiplatelet agent in two New England communities.

OBJECTIVE: To determine the overall prevalence of aspirin use as an antiplatelet agent in a population-based sample of respondents between the ages of 18 and 64 years, and to describe their sociodemographic characteristics. DESIGN: Data were derived from five biennial cross-sectional household surveys conducted between 1981 and 1990 in two southeastern New England communities by the Pawtucket Heart Health Program. Individuals reporting aspirin use as an antiplatelet agent were identified using data from a structured medication interview. RESULTS: The prevalence of aspirin use per 1000 population was 2.5 (95 percent confidence interval [CI] 0.5, 4.4), 5.0 (95 percent CI 2.4, 7.6), 7.8 (95 percent CI 4.6, 11.0), 7.5 (95 percent CI 4.3, 10.6), and 11.8 (95 percent CI 7.1, 16.5) in the first through the fifth survey periods, respectively (p = 0.0002). The prevalence of aspirin use per 1000 men increased from 4.9 (95 percent CI 0.6, 9.1), 8.7 (95 percent CI 3.3, 14.1), 12.3 (95 percent CI 6.1, 18.5), 8.5 (95 percent CI 3.5, 13.5) to 23.2 (95 percent CI 13.4, 32.9) for the first through the fifth survey periods, respectively. The corresponding prevalence rates of aspirin use per 1000 women were 0.7 (95 percent CI 0, 2.1), 2.43 (95 percent CI 0.05, 4.80), 4.6 (95 percent CI 1.4, 7.8), 6.6 (95 percent CI 2.7, 10.6), and 2.7 (95 percent CI 0, 5.7). Both a gender trend (p = 0.0002) and a survey trend (p = 0.0001) were detected. A gender-survey interaction was not found. CONCLUSIONS: In this population, aspirin use was reported primarily by middle-aged men who had coexisting cardiovascular disease as indicated by concurrent medications. Aspirin use as antiplatelet therapy increased in the population-based samples of two New England communities over the past nine years, with slightly more than one percent of the respondents reporting its use in the fifth cross-sectional survey conducted in 1989-1990. This finding may reflect the publication of important clinical trials near the time the survey was performed and subsequent dissemination of the findings both in the professional and lay press.

The FPbase microcomputer system for managing community health screening and intervention data bases.

Health promotion and intervention projects at State and community levels need computerized data bases to assist in making policy decisions and in operating the projects. Computer data base systems are used in entering, storing, retrieving, and analyzing information about health project activities and their participants in a timely and cost-effective manner. Computer support is essential for such labor-intensive tasks as post-screening followup of participants, identifying subpopulations, and evaluating recruitment efforts and behavior change programs. The Pawtucket Heart Health Program developed a microcomputer software package, FPbase, for community health project data base management. FPbase is described and is available for use by other organizations. FPbase incorporates formative and process interactive data base activities and is suitable for use in operating intervention and screening programs at State and local levels. The system accommodates management of data for social marketing, evaluation, followup, and promotional activities.