Development of a Multicomponent Intervention to Decrease Racial Bias Among Healthcare Staff.

BACKGROUND: Real or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists). METHODS: Utilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback. RESULTS: Fifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to -0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether "it was made clear how to apply the presented content in practice" and "this module was worth the time spent" was ≥4.1 for all modules. CONCLUSIONS: There was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated.

Exploring the Association of Healthcare Worker Race and Occupation with Implicit and Explicit Racial Bias.

BACKGROUND: Racial bias is associated with suboptimal healthcare treatment for minorities. Research focuses on bias among physicians rather than non-physician healthcare staff (e.g., receptionists). Patients spend considerable amounts of time with non-physician staff. Therefore, we investigate differences in implicit and explicit racial bias by healthcare staff race and occupation using the Implicit Association Test and Modern Racism Scale, respectively. METHODS: Staff (n = 107) were recruited using the Alabama based Primary Care Research Coalition. Occupation was categorized into "medical doctors/registered nurses" (MD/RN) and "non-MD/RN" (e.g., receptionists). RESULTS: Implicit bias scores were higher among whites compared with blacks (0.62, -0.04, respectively; p < 0.01). Among whites, non-MD/RNs demonstrated more pro-white implicit bias compared with MD/RNs (0.67, 0.44, respectively; p < 0.01). Whites had higher explicit bias scores than blacks (17.7, 12.3, respectively; p < 0.01). CONCLUSION: Non-MD/RNs should not be overlooked for cultural competency training, and efforts are needed to reduce racial bias among healthcare workers identified as having higher levels of bias.

Blood Pressure Measurement Biases in Clinical Settings, Alabama, 2010-2011.

INTRODUCTION: Blood pressure measurement in clinical care settings seldom follows the protocol recommended by national guidelines, potentially leading to overestimates or underestimates of blood pressure control. We evaluated blood pressure measurement methods as a source of bias in determining blood pressure control among community-dwelling adults with diabetes. METHODS: In a community-based trial of patients with diabetes, we measured both "clinical blood pressure" (clinical BP) (taken by a community nurse or medical assistant instructed to "take the participant's blood pressure like you do in your own clinic") and "research blood pressure" (research BP) (research staff followed a guideline-concordant protocol). Each participant had both types of blood pressure assessment on the same day over the course of 2 hours. RESULTS: The 227 participants had a mean age of 59 years; 86% were black and 74% were women. The mean clinical BP was 5 mm Hg higher than the mean research BP for systolic blood pressure (P < .001) and 2 mm Hg higher for diastolic blood pressure (P < .001). The proportion of participants whose clinical BP was 130/80 mm Hg or higher was 8 percentage points higher than the proportion whose research BP was 130/80 mm Hg or higher (P < .001), and the proportion whose clinical BP was 140/90 mm Hg or higher was 10 percentage points higher than the proportion whose research BP was 140/90 mm Hg or higher (P < .001). Among those aged 65 years or older, the proportion whose clinical BP was 130/80 mm Hg or higher was 10 percentage points higher than proportion whose research BP was 130/80 mm Hg or higher, and the proportion whose clinical BP was 140/90 mm Hg or higher was 14 percentage points higher than the proportion whose research BP was 140/90 mm Hg or higher. Whites and smokers had the greatest risk for having a clinical BP 5 mm Hg or more higher than their research BP. CONCLUSION: Measurement biases in clinical settings may be a component of observed poor blood pressure control rates in real-world settings.

Acute Liver Failure after Initiation of Rivaroxaban: A Case Report and Review of the Literature.

CONTEXT: Rivaroxaban is a direct factor Xa inhibitor approved for the prevention of thromboembolism. Drug induced liver injury has been increasingly reported with rivaroxaban recently, but actual liver failure has not been reported. CASE REPORT: We present a case report on the probable occurrence of acute liver failure with rivaroxaban therapy. An 89 year old woman with history of atrial fibrillation was hospitalized for biventricular congestive heart failure with passive congestion of liver, which responded to furosemide. She was discharged home on rivaroxaban for prevention of thrombo-embolism. Liver function tests upon discharge returned to almost normal range. One week later, she presented with abdominal pain and was found to have highly elevated liver enzymes, elevated bilirubin, and an abnormal coagulation profile. A day later, she developed hepatic encephalopathy, suggesting liver failure. CONCLUSION: Liver enzymes declined rapidly with the discontinuation of all of her medications, however patient died because of multi-organ failure. The causality assessment in this patient was "probable" with rivaroxaban.

"We'll Get to You When We Get to You": Exploring Potential Contributions of Health Care Staff Behaviors to Patient Perceptions of Discrimination and Satisfaction.

OBJECTIVES: We qualitatively assessed patients' perceptions of discrimination and patient satisfaction in the health care setting specific to interactions with nonphysician health care staff. METHODS: We conducted 12 focus-group interviews with African American and European American participants, stratified by race and gender, from June to November 2008. We used a topic guide to facilitate discussion and identify factors contributing to perceived discrimination and analyzed transcripts for relevant themes using a codebook. RESULTS: We enrolled 92 participants: 55 African Americans and 37 European Americans, all of whom reported perceived discrimination and lower patient satisfaction as a result of interactions with nonphysician health care staff. Perceived discrimination was associated with 2 main characteristics: insurance or socioeconomic status and race. Both verbal and nonverbal communication style on the part of nonphysician health care staff were related to individuals' perceptions of how they were treated. CONCLUSIONS: The behaviors of nonphysician health care staff in the clinical setting can potentially contribute to patients' perceptions of discrimination and lowered patient satisfaction. Future interventions to reduce health care discrimination should include a focus on staff cultural competence and customer service skills.

Peer Coaches to Improve Diabetes Outcomes in Rural Alabama: A Cluster Randomized Trial.

PURPOSE: It is unclear whether peer coaching is effective in minority populations living with diabetes in hard-to-reach, under-resourced areas such as the rural South. We examined the effect of an innovative peer-coaching intervention plus brief education vs brief education alone on diabetes outcomes. METHODS: This was a community-engaged, cluster-randomized, controlled trial with primary care practices and their surrounding communities serving as clusters. The trial enrolled 424 participants, with 360 completing baseline and follow-up data collection (84.9% retention). The primary outcomes were change in glycated hemoglobin (HbA1c), systolic blood pressure (BP), low density lipoprotein cholesterol (LDL-C), body mass index (BMI), and quality of life, with diabetes distress and patient activation as secondary outcomes. Peer coaches were trained for 2 days in community settings; the training emphasized motivational interviewing skills, diabetes basics, and goal setting. All participants received a 1-hour diabetes education class and a personalized diabetes report card at baseline. Intervention arm participants were also paired with peer coaches; the protocol called for telephone interactions weekly for the first 8 weeks, then monthly for a total of 10 months. RESULTS: Due to real-world constraints, follow-up was protracted, and intervention effects varied over time. The analysis that included the 68% of participants followed up by 15 months showed only a significant increase in patient activation in the intervention group. The analysis that included all participants who eventually completed follow-up revealed that intervention arm participants had significant differences in changes in systolic BP (P = .047), BMI (P = .02), quality of life (P = .003), diabetes distress (P = .004), and patient activation (P = .03), but not in HbA1c (P = .14) or LDL-C (P = .97). CONCLUSION: Telephone-delivered peer coaching holds promise to improve health for individuals with diabetes living in under-resourced areas.

Depressive symptoms are associated with incident coronary heart disease or revascularization among blacks but not among whites in the Reasons for Geographical and Racial Differences in Stroke study.

PURPOSE: To examine the association of depressive symptoms with coronary heart disease (CHD) end points by race and income. METHODS: Study participants were blacks and whites (n = 24,443) without CHD at baseline from the national Reasons for Geographical and Racial Differences in Stroke cohort. Outcomes included acute CHD and CHD or revascularization. We estimated race-stratified multivariate Cox proportional hazards models of incident CHD and incident CHD or revascularization with the 4-item Center for Epidemiological Studies Depression Scale, adjusting for risk factors. RESULTS: Mean follow-up was 4.2 ± 1.5 years; CHD incidence was 8.3 events per 1000 person-years (n = 366) among blacks and 8.8 events per 1000 person-years (n = 613) among whites. After adjustment for age, sex, marital status, region, and socioeconomic status, depressive symptoms were significantly associated with incident CHD among blacks (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.00-1.91) but not among whites (HR, 1.10; 95% CI, 0.74-1.64). In the fully adjusted model, compared with blacks who reported no depressive symptoms, those reporting depressive symptoms had greater risk for the composite end point of CHD or revascularization (HR, 1.36; 95% CI, 1.01-1.81). Depressive symptoms were not associated with incident CHD end points among whites. CONCLUSIONS: High depressive symptoms were associated with higher risk of CHD or revascularization for blacks but not whites.

Assessing peer advisor intervention fidelity using video skits in a peer support implementation trial.

In community-based interventions involving lay health workers, or "community health workers," peer-client interactions are not typically observed by investigators, creating challenges in assessing intervention fidelity. In the context of a community-based randomized controlled trial of the effectiveness of peer support on diabetes outcomes of people with diabetes in rural Alabama, a region characterized by poverty and low literacy, we developed a video assessment tool that assessed participant perceptions of peer-client interactions. The video assessment consisted of four short skits on areas of emphasis during peer training: directive versus nondirective counseling style and setting a specific versus a more general goal. The video tool was evaluated for association with questionnaire-derived measures of counseling style and goal setting among 102 participants. For counseling style, 44% of participants reported that their peer advisor was most similar to the nondirective skit. For goal setting, 42% reported that their peer advisor was most similar to the specific goal skit. There was no statistically significant relationship between skit selection and questionnaire-derived measures. The video assessment was feasible, but results suggest that video and questionnaire assessments in this population yield different results. Further validation to better understand the differences between questionnaire reports and video assessment is warranted.

Perceived weight discrimination in the CARDIA study: differences by race, sex, and weight status.

OBJECTIVE: To examine self-reported weight discrimination and differences based on race, sex, and BMI in a biracial cohort of community-based middle-aged adults. DESIGN AND METHODS: Participants (3,466, mean age = 50 years, mean BMI = 30 kg/m²) of the Coronary Artery Risk Development in Young Adults (CARDIA) Study who completed the 25-year examination of this epidemiological investigation in 2010-2011 were reported. The sample included normal weight, overweight, and obese participants. CARDIA participants are distributed into four race-sex groups, with about half being African-American and half White. Participants completed a self-reported measure of weight discrimination. RESULTS: Among overweight/obese participants, weight discrimination was lowest for White men (12.0%) and highest for White women (30.2%). The adjusted odds ratio (95% CI) for weight discrimination in those with class 2/3 obesity (BMI ≥ 35 kg/m²) versus the normal-weight was most pronounced: African American men, 4.59 (1.71-12.34); African American women, 7.82 (3.57-17.13); White men, 6.99 (2.27-21.49); and White women, 18.60 (8.97-38.54). Being overweight (BMI = 25-29.9 kg/m²) vs. normal weight was associated with increased discrimination in White women only: 2.10 (1.11-3.96). CONCLUSIONS: Novel evidence for a race-sex interaction on perceived weight discrimination, with White women more likely to report discrimination at all levels of overweight and obesity was provided. Pychosocial mechanisms responsible for these differences deserve exploration.

The relationship between coping styles in response to unfair treatment and understanding of diabetes self-care.

PURPOSE: This study examined the relationship between coping style and understanding of diabetes self-care among African American and white elders in a southern Medicare-managed care plan. METHODS: Participants were identified through a diabetes-related pharmacy claim or ICD-9 code and completed a computer-assisted telephone survey in 2006-2007. Understanding of diabetes self-care was assessed using the Diabetes Care Profile Understanding (DCP-U) scale. Coping styles were classified as active (talk about it/take action) or passive (keep it to yourself). Linear regression was used to estimate the associations between coping style with the DCP-U, adjusting for age, sex, education, and comorbidities. Based on the conceptual model, 4 separate categories were established for African American and white participants who displayed active and passive coping styles. RESULTS: Of 1420 participants, the mean age was 73 years, 46% were African American, and 63% were female. Most respondents (77%) exhibited active coping in response to unfair treatment. For African American participants in the study, active coping was associated with higher adjusted mean DCP-U scores when compared to participants with a passive coping style. No difference in DCP-U score was noted among white participants on the basis of coping style. CONCLUSIONS: Active coping was more strongly associated with understanding of diabetes self-care among older African Americans than whites. Future research on coping styles may give new insights into reducing diabetes disparities among racial/ethnic minorities.

Hospital laboratory reporting may be a barrier to detection of 'microsize' myocardial infarction in the US: an observational study.

BACKGROUND: International guidelines recommend that the decision threshold for troponin should be the 99th percentile of a normal population, or, if the laboratory assay is not sufficiently precise at this low level, the level at which the assay achieves a 10% or better coefficient of variation (CV). Our objectives were to examine US hospital laboratory troponin reports to determine whether either the 99th percentile or the 10% CV level were clearly indicated, and whether nonconcordance with these guidelines was a potential barrier to detecting clinically important microscopic or 'microsize' myocardial infarctions (MIs). To confirm past reports of the clinical importance of microsize MIs, we also contrasted in-hospital, 28-day and 1-year mortality among those with microsize and nonmicrosize MI. METHODS: In the REasons for Geographic And Racial Differences in Stroke national prospective cohort study (n=30,239), 1029 participants were hospitalized for acute coronary syndrome (ACS) between 2003-2009. For each case, we recorded all thresholds of abnormal troponin on the laboratory report and whether the 99th percentile or 10% CV value were clearly identified. All cases were expert adjudicated for presence of MI. Peak troponin values were used to classify MIs as microsize MI (< five times the lowest listed upper limit of normal) and nonmicrosize MI. RESULTS: Participants were hospitalized at 649 acute care US hospitals, only 2% of whose lab reports clearly identified the 99th percentile or the 10% CV level; 52% of reports indicated an indeterminate range, a practice that is no longer recommended. There were 183 microsize MIs and 353 nonmicrosize MIs. In-hospital mortality tended to be lower in the microsize than in the nonmicrosize MI group (1.1 vs. 3.6%, p = 0.09), but 28-day and 1-year mortality were similar (2.5% vs. 2.7% [p = 0.93] and 5.2% vs. 4.3% [p = 0.64], respectively). CONCLUSIONS: Current practices in many US hospitals created barriers to the clinical recognition of microsize MI, which was common and clinically important in our study. Improved hospital troponin reporting is warranted.

Association of race and sex with risk of incident acute coronary heart disease events.

CONTEXT: It is unknown whether long-standing disparities in incidence of coronary heart disease (CHD) among US blacks and whites persist. OBJECTIVE: To examine incident CHD by black and white race and by sex. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 24,443 participants without CHD at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, who resided in the continental United States and were enrolled between 2003 and 2007 with follow-up through December 31, 2009. MAIN OUTCOME MEASURE: Expert-adjudicated total (fatal and nonfatal) CHD, fatal CHD, and nonfatal CHD (definite or probable myocardial infarction [MI]; very small non-ST-elevation MI [NSTEMI] had peak troponin level <0.5 µg/L). RESULTS: Over a mean (SD) of 4.2 (1.5) years of follow-up, 659 incident CHD events occurred (153 in black men, 138 in black women, 254 in white men, and 114 in white women). Among men, the age-standardized incidence rate per 1000 person-years for total CHD was 9.0 (95% CI, 7.5-10.8) for blacks vs 8.1 (95% CI, 6.9-9.4) for whites; fatal CHD: 4.0 (95% CI, 2.9-5.3) vs 1.9 (95% CI, 1.4-2.6), respectively; and nonfatal CHD: 4.9 (95% CI, 3.8-6.2) vs 6.2 (95% CI, 5.2-7.4). Among women, the age-standardized incidence rate per 1000 person-years for total CHD was 5.0 (95% CI, 4.2-6.1) for blacks vs 3.4 (95% CI, 2.8-4.2) for whites; fatal CHD: 2.0 (95% CI, 1.5-2.7) vs 1.0 (95% CI, 0.7-1.5), respectively; and nonfatal CHD: 2.8 (95% CI, 2.2-3.7) vs 2.2 (95% CI, 1.7-2.9). Age- and region-adjusted hazard ratios for fatal CHD among blacks vs whites was near 2.0 for both men and women and became statistically nonsignificant after multivariable adjustment. The multivariable-adjusted hazard ratio for incident nonfatal CHD for blacks vs whites was 0.68 (95% CI, 0.51-0.91) for men and 0.81 (95% CI, 0.58-1.15) for women. Of the 444 nonfatal CHD events, 139 participants (31.3%) had very small NSTEMIs. CONCLUSIONS: The higher risk of fatal CHD among blacks compared with whites was associated with cardiovascular disease risk factor burden. These relationships may differ by sex.

Awareness and management of chronic disease, insurance status, and health professional shortage areas in the REasons for Geographic And Racial Differences in Stroke (REGARDS): a cross-sectional study.

BACKGROUND: Limited financial and geographic access to primary care can adversely influence chronic disease outcomes. We examined variation in awareness, treatment, and control of hypertension, diabetes, and hyperlipidemia according to both geographic and financial access to care. METHODS: We analyzed data on 17,458 participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study with either hypertension, hyperlipidemia, or diabetes and living in either complete Health Professional Shortage Area (HPSA) counties or non-HPSA counties in the U.S. All analyses were stratified by insurance status and adjusted for sociodemographics and health behaviors. RESULTS: 2,261 residents lived in HPSA counties and 15,197 in non-HPSA counties. Among the uninsured, HPSA residents had higher awareness of both hypertension (adjusted OR 2.30, 95% CI 1.08, 4.89) and hyperlipidemia (adjusted OR 1.50, 95% CI 1.01, 2.22) compared to non-HPSA residents. Also among the uninsured, HPSA residents with hypertension had lower blood pressure control (adjusted OR 0.45, 95% CI 0.29, 0.71) compared with non-HPSA residents. Similar differences in awareness and control according to HPSA residence were absent among the insured. CONCLUSIONS: Despite similar or higher awareness of some chronic diseases, uninsured HPSA residents may achieve control of hypertension at lower rates compared to uninsured non-HPSA residents. Federal allocations in HPSAs should target improved quality of care as well as increasing the number of available physicians.

Awareness, treatment and control of hypertension, diabetes and hyperlipidemia and area-level mortality regions in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.

BACKGROUND: Health Professional Shortage Areas (HPSA) receive extra federal resources, but recent reports suggest that HPSA may not consistently identify areas of need. PURPOSE: To assess areas of need based on county-level ischemic heart disease (IHD) and stroke mortality regions. METHODS: Need was defined by lack of awareness, treatment, or control of hypertension, diabetes, or hyperlipidemia. Counties were categorized into race-specific tertiles of IHD and stroke mortality using 1999-2006 CDC data. Multivariable logistic regression was used to model the relationships between IHD and stroke mortality region and each element of need. RESULTS: Awareness and treatment of cardiovascular (CVD) risk factors were similar for residents in counties across IHD and stroke mortality tertiles, but control tended to be lower in counties with the highest mortality. CONCLUSIONS: High stroke and IHD mortality identify distinct regions from current HPSA designations, and may be an additional criterion for designating areas of need.

Recruitment of a rural, southern, predominantly African-American population into a diabetes self-management trial.

We are conducting a community-based cluster-randomized trial in rural Alabama, testing a peer-support intervention designed to improve diabetes self-care behaviors. We describe recruitment and data collection approaches used, focusing on strategies that created community partnerships and facilitated recruitment in underserved, rural, largely minority communities. Key recruitment and data collection strategies included early community engagement; pilot testing of procedures; inclusion of community members as study team members, recruiters, and data collectors; data collection at community venues to minimize participant travel requirements; and provision of a multi-disciplinary diabetes education program to both intervention and control participants. A total of 424 participants were recruited and enrolled (400 targeted). Of the 759 referrals received, 78.9% (n=599) successfully completed telephone screening. Of these, 78.8% (n=472) were eligible and scheduled for a local enrollment day, and 81.4% (n=384) attended and enrolled in the study. In addition, community members who walked in and expressed interest were screened, and 40 eligible and willing individuals were consented and enrolled. We exceeded recruitment goals in underserved, rural communities in Alabama. This success was due in large part to community partnerships that facilitated community involvement on several levels: engaging the community early in study proposal and design; hiring community members to fill various capacities as research team members, recruiters, and data collectors; conducting data collection within communities; and collecting additional contact information to maintain communication. Providing diabetes education to all participants, including intervention and control, helped ensure that everyone stood to benefit and likely enhanced overall participation.

Sexual health knowledge of male and female Latino immigrants.

To explore sexual health knowledge among Latino immigrants in a Southern U.S. city, we conducted 20 qualitative interviews, (10 Women and 10 Men). We explored knowledge and factors associated with sexual health among male and female Latino immigrants in a Southern U.S. city experiencing a major growth of Latino immigrants in the past 10 years. Both genders demonstrated limited knowledge of Human Papillomavirus (HPV) and risks of sexually transmitted infection (STI) acquisition. Neither gender perceived that they could have an asymptomatic STI, including HPV. Gender differences exist in sexual behaviors and perceptions of STI risk. Females indicated that female Latinas tend to have older sexual initiation age, fewer lifetime sexual partners and more pro-active sexual health than did Latinos when referring to Latino males. Consequently, male and female Latino immigrants could benefit from culturally relevant programs to alleviate STI disparities.

Intervention mapping as a guide for the development of a diabetes peer support intervention in rural Alabama.

INTRODUCTION: Peer support is a promising strategy for the reduction of diabetes-related health disparities; however, few studies describe the development of such strategies in enough detail to allow for replication. The objective of this article is to describe the development of a 1-year peer support intervention to improve diabetes self-management among African American adults with diabetes in Alabama's Black Belt. METHODS: We used principles of intervention mapping, including literature review, interviews with key informants, and a discussion group with community health workers, to guide intervention development. Qualitative data were combined with behavioral constructs and principles of diabetes self-management to create a peer support intervention to be delivered by trained peer advisors. Feedback from a 1-month pilot was used to modify the training and intervention. RESULTS: The resulting intervention includes a 2-day training for peer advisors, who were each paired with 3 to 6 clients. A one-on-one in-person needs assessment begins an intensive intervention phase conducted via telephone for 8 to 12 weeks, followed by a maintenance phase of at least once monthly contacts for the remainder of the intervention period. A peer support network and process measures collected monthly throughout the study supplement formal data collection points at baseline, 6 months, and 12 months. DISCUSSION: Intervention mapping provided a useful framework for the development of culturally relevant diabetes peer support intervention for African Americans living in Alabama's Black Belt. The process described could be implemented by others in public health to develop or adapt programs suitable for their particular community or context.

Health Professional Shortage Areas, insurance status, and cardiovascular disease prevention in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

Individuals with cardiovascular disease (CVD) living in Health Professional Shortage Areas (HPSA) may receive less preventive care than others. The Reasons for Geographic And Racial Differences in Stroke Study (REGARDS) surveyed 30,239 African American (AA) and White individuals older than 45 years of age between 2003-2007. We compared medication use for CVD prevention by HPSA and insurance status, adjusting for sociodemographic factors, health behaviors, and health status. Individuals residing in partial HPSA counties were excluded. Mean age was 64±9 years, 42% were AA, 55% were women, and 93% had health insurance; 2,545 resided in 340 complete HPSA counties and 17,427 in 1,145 non-HPSA counties. Aspirin, beta-blocker, and ACE-inhibitor use were similar by HPSA and insurance status. Compared with insured individuals living in non-HPSA counties, statin use was lower among uninsured participants living in non-HPSA and HPSA counties. Less medication use for CVD prevention was not associated with HPSA status, but less statin use was associated with lack of insurance.

Low medication adherence and the incidence of stroke symptoms among individuals with hypertension: the REGARDS study.

The authors analyzed data on 9950 participants taking antihypertensive medications in the nationwide Reasons for Geographic and Racial Differences in Stroke (REGARDS) study to determine the association between medication adherence and incident stroke symptoms. Medication adherence was assessed using a validated 4-item self-report scale and participants were categorized into 4 groups (scores of 0, 1, 2, and 3 or 4, with higher scores indicating worse adherence). The incidence of 6 stroke symptoms (sudden weakness on one side of the body, numbness, painless loss of vision in one or both eyes, loss of half vision, losing the ability to understand people, and losing the ability to express oneself verbally or in writing) was assessed via telephone interviews every 6 months. During a median of 4 years, the incidence of any stroke symptom was 14.6%, 17.9%, 20.2%, and 24.9% among participants with adherence scores of 0, 1, 2, and 3 or 4, respectively (P<.001). The multivariable adjusted hazard ratio (95% confidence interval) for any stroke symptom associated with adherence scores of 1, 2, and 3 or 4, vs 0, was 1.20 (1.04-1.39), 1.23 (0.94-1.60), and 1.59 (1.08-2.33), respectively (P<.001). Worse adherence was also associated with higher multivariable adjusted hazard ratios for each of the 6 stroke symptoms.

The association between income, education, and experiences of discrimination in older African American and European American patients.

OBJECTIVE: Racial/ethnic discrimination has adverse effects on health outcomes, as does low income and education, but the relationship between discrimination, income, and education is not well characterized. In this study, we describe the associations of discrimination with income and education in elderly African Americans (AA) and European Americans (EA). DESIGN: Cross-sectional observational study involving computer-assisted telephone survey. SETTING: Southeastern United States. PARTICIPANTS: AA and EA Medicare managed care enrollees. MAIN OUTCOME MEASURES: Discrimination was measured with the Experience of Discrimination (EOD) scale (range 0-35). We used zero-inflated negative binomial models to determine the association between self-reported income and education and 1) presence of any discrimination and 2) intensity of discrimination. RESULTS: Among 1,800 participants (45% AA, 56% female, and mean age 73 years), EA reported less discrimination than AA (4% vs. 47%; P < .001). AA men reported more discrimination and more intense discrimination than AA women (EOD scores 4.35 vs. 2.50; P < .001). Both income and education were directly and linearly associated with both presence of discrimination and intensity of discrimination in AA, so that people with higher incomes and education experienced more discrimination. In adjusted models, predicted EOD scores among AA decreased with increasing age categories (3.42, 3.21, 2.99, 2.53; P < .01) and increased with increasing income (2.36, 3.44, 4.17; P < .001) and education categories (2.31, 3.09, 5.12; P < .001). CONCLUSIONS: This study suggests future research should focus less on differences between racial/ethnic groups and more on factors within minority populations that may contribute to healthcare disparities.