A descriptive study of racial inequalities in mortality from hepatocellular cancer before and after licensure of lifesaving drugs for hepatitis C virus in the United States.

BACKGROUND: Since 1979, mortality from hepatocellular cancer (HCC) has doubled in the United States (US). Lifesaving drugs, prohibitively expensive for some, were approved and marketed to treat hepatitis C virus (HCV), a major risk factor for HCC, beginning in 1997. After the prior introduction of other lifesaving innovations, including active retroviral drug therapy for human immunodeficiency virus and surfactant for respiratory distress syndrome of the newborn, racial inequalities in their mortalities increased in the US. In this descriptive study, we explored racial inequalities in mortality from HCC before and after licensure of HCV drugs in the US. METHODS: The US Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research (WONDER) were used to describe HCC mortality rates from 1979 to 2016 in those 55 years of age and older, because they suffer the largest disease burden. Joinpoint regression was used to analyze trends. To estimate excess deaths, we applied White age-sex-specific rates to corresponding Black populations. FINDINGS: From 1979 to 1998, racial inequalities in mortality from HCC in the US were declining but from 1998 to 2016 racial inequalities steadily increased. From 1998 to 2016, of the 16,770 deaths from HCC among Blacks, the excess relative to Whites increased from 27.8% to 45.4%, and the trends were more prominent in men. Concurrently, racial inequalities in mortality decreased for major risk factors for HCC, including alcohol, obesity and diabetes. INTERPRETATION: These descriptive data, useful to formulate but not test hypotheses, demonstrate decreasing racial inequalities in mortality from HCC which were followed by increases after introduction of lifesaving drugs for HCV in the US. Among many plausible hypotheses generated are social side effects, including unequal accessibility, acceptability and/or utilization. Analytic epidemiological studies designed a priori to do so are necessary to test these and other hypotheses.

Lack of validity of self-reported mammography data.

This qualitative literature review aimed to describe the totality of peer-reviewed scientific evidence from 1990 to 2017 concerning validity of self-reported mammography. This review included articles about mammography containing the words accuracy, validity, specificity, sensitivity, reliability or reproducibility; titles containing self-report, recall or patient reports, and breast or 'mammo'; and references of identified citations focusing on evaluation of 2-year self-reports. Of 45 publications meeting the eligibility criteria, 2 conducted in 1993 and 1995 at health maintenance organisations in Western USA which primarily served highly educated whites provided support for self-reports of mammography over 2 years. Methodological concerns about validity of self-reports included (1) telescoping, (2) biased overestimates particularly among black women, (3) failure to distinguish screening and diagnostic mammography, and (4) failure to address episodic versus consistent mammography use. The current totality of evidence supports the need for research to reconsider the validity of self-reported mammography data as well as the feasibility of alternative surveillance data sources to achieve the goals of the Healthy People Initiative.

Altitude and Variable Effects on Infant Mortality in the United States.

Levine, Robert S., Jason L. Salemi, Maria C. Mejia de Grubb, Sarah K. Wood, Lisa Gittner, Hafiz Khan, Michael A. Langston, Baqar A. Husaini, George Rust, and Charles H. Hennekens. Altitude and variable effects on infant mortality in the United States. High Alt Med Biol. 19:265-271, 2018. AIMS: To explore whether altitude has different effects on infant mortality from newborn respiratory distress, nontraumatic intracranial hemorrhage, and necrotizing enterocolitis. RESULTS: Infants born in the US Mountain Census Division (AR, CO, ID, NV, NM, UT, and WY) had lower mortality from newborn respiratory distress (p < 0.001, mortality rate ratios [MRR] = 0.5 for non-Hispanic blacks and non-Hispanic whites and 0.6 for Hispanic whites) relative to infants born elsewhere in the United States, while Mountain Division non-Hispanic white infants had significantly higher mortality from nontraumatic intracranial hemorrhage (MRR = 1.3 [1.1, 1.6] p < 0.001). After adjustment for state average birth weight, gestational age, and income inequality, a statistically significant, inverse association remained between state average altitude and non-Hispanic white infant mortality from newborn respiratory distress. County altitude (3058 counties in 9 categories from ≤0 to ≥7000 feet) was negatively correlated with newborn respiratory distress (r = -0.91, p < 0.001) and necrotizing enterocolitis (r = -0.81, p = 0.006) at ≤0 to ≥7000 feet and positively correlated with nontraumatic intracranial hemorrhage at ≤0 to 6000-6999 feet (r = 0.78, p = 0.02). CONCLUSIONS: These data show variable cause-specific effects of altitude on infant mortality. Analytic epidemiologic research is needed to confirm or refute the hypotheses generated by these descriptive data.

Depression Effects on Hospital Cost of Heart Failure Patients in California: An Analysis by Ethnicity and Gender.

BACKGROUND: Depression often interferes with self-management and treatment of medical conditions. This may result in serious medical complications and escalated health-care cost. OBJECTIVES: Study distribution of heart failure (HF) cases estimates the prevalence of depression and its effects on HF-related hospital costs by ethnicity and gender. METHODS: Secondary data files of California Hospital Discharge System for he year 2010 were examined. For patients with a HF diagnosis, details regarding depression, demographics, comorbid conditions, and hospital costs were studied. Age-adjusted HF rates and depression were examined for whites, blacks, Hispanics, and Asians/Pacific Islanders (AP) by comparing HF patients with depression (HF+D) versus HF without depression (HFND). RESULTS: HF cases (n = 62,685; average age: 73) included nearly an equal number of males and females. HF rates were higher (P < 0.001) among blacks compared to Hispanics, AP, and whites and higher among males than females. One-fifth of HF patients had depression, higher among females and whites compared to males and other ethnic groups. Further, HF hospital costs for blacks and AP were higher (P < 0.001) compared to other groups. The cost for HF+D was 22% higher compared to HFND, across all gender and ethnic groups, largely due to higher comorbidities, more admissions, and longer hospitalization. CONCLUSION: Depression, ethnicity, and gender are all associated with increased hospital costs of HF patients. The higher HF and HF+D costs among blacks, AP, and males reflect additional burden of comorbidities (hypertension and diabetes). Prospective studies to assess if selective screening and treating depression among HF patients can reduce hospital costs are warranted.

Infant Deaths and Mortality from Gun Violence: Causal or Casual?

OBJECTIVE: Describe trends in non-Hispanic black infant mortality (IM) in the New York City (NYC) counties of Bronx, Kings, Queens, and Manhattan and correlations with gun-related assault mortality. METHODS: Linked Birth/Infant Death data (1999-2013) and Compressed Mortality data at ages 1 to ≥85 years (1999-2013). NYC and United States (US) Census data for income inequality and poverty. Pearson coefficients were used to describe correlations of IM with gun-related assault mortality and other causes of death. RESULTS: In NYC, the risk of non-Hispanic black IM in 2013 was 49% lower than in 1995 (rate ratio: 0.51; 95% CI: 0.43, 0.61). Yearly declines between 1999 and 2013 were significantly correlated with declines in gun-related assault mortality (correlation coefficient (r) = 0.70, p = 0.004), drug-related mortality (r = 0.59, p = 0.020), major heart disease and stroke (r = 0.85, p < 0.001), malignant neoplasms (r = 0.57, p = 0.026), diabetes mellitus (r = 0.63, p = 0.011), and pneumonia and influenza (r = 0.78, p < 0.001). There were no significant correlations of IM with chronic lower respiratory or liver disease, non-drug-related accidental deaths, and non-gun-related assault. Yearly IM (1995-2012) was inversely correlated with income share of the top 1% of the population (r = -0.66, p = 0.007). CONCLUSIONS: In NYC, non-Hispanic black IM declined significantly despite increasing income inequality and was strongly correlated with gun-related assault mortality and other major causes of death. These data are compatible with the hypothesis that activities related to overall population health, including those pertaining to gun-related homicide, may provide clues to reducing IM. Analytic epidemiological studies are needed to test these and other hypotheses formulated from these descriptive data.

Smoking, depression, and hospital costs of respiratory cancers: Examining race and sex variation.

OBJECTIVE: The role of smoking and depression relative to hospital cost for lung cancer (LC) remains unknown. METHODS: We extracted data on depression, smoking history, demographics, and hospital charges on patients with respiratory cancers (ICD-9 codes 161-163,165) from the 2008 Tennessee Hospital Discharge Data System. The sample (n=6,665) was mostly white (86%) and male (57). Age-adjusted rates were developed per CDC methodology, and hospital costs were compared for LC with vs. without depression and smoking. RESULTS: Three findings (p<.001) emerged: (i) LC rate was higher among blacks than whites, and higher among males than females; (ii) While 66% of LC smoked (more males than females without racial variation), 24% had depression (more females and whites were depressed); (iii) The LC hospital cost was 54% higher compared to non-LC, and this cost doubled for LC with depression and smoking vs. those without such characteristics. CONCLUSION: While LC is more prevalent among blacks and males, depression is higher among female and white patients. Since depression with higher costs existed among LC patients, our findings point to: (i) possibility of cost savings by diagnosing and treating depression among LC, and (ii) implementing proven smoking cessation programs to reduce LC morbidity and hospital costs.

Availability of Low-Fat Milk and Produce in Small and Mid-Sized Grocery Stores After 2014 WIC Final Rule Changes, Tennessee.

INTRODUCTION: The 2007 Interim Rule mandated changes to food packages in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for implementation by 2009. The 2014 Final Rule required additional changes, including increasing the cash value voucher for fruits and vegetables from $6 to $8 for children by June 2014, and allowing only low-fat (1%) or nonfat milk for mothers and children aged 2 to 4 years by October 2014. This study evaluated the effect of the 2014 Final Rule changes on the food environment of small and mid-sized WIC-authorized grocery stores. METHODS: We analyzed secondary data using a natural experimental design to compare the percentage of shelf space for low-fat and nonfat milk and the number of fresh fruit and vegetable varieties in stock before and after the changes. We collected observational data on 18 small and mid-sized WIC-authorized grocery stores in Nashville, Tennessee, using the Nutrition Environment Measures in Store tool in March 2014 and February 2016. RESULTS: The mean percentage of shelf space occupied by low-fat and nonfat milk increased from 2.5% to 14.4% (P = .003), primarily because of an increase in the proportion of low-fat milk (P = .001). The mean number of fresh fruit and vegetable varieties increased from 24.3 to 27.7 (P = .01), with a significant increase for vegetables (P = .008) but not fruit. CONCLUSION: Availability of low-fat milk and variety of fresh vegetables increased after the Final Rule changes in the observed stores. Future research should examine outcomes in other cities.

A Smartphone App for Families With Preschool-Aged Children in a Public Nutrition Program: Prototype Development and Beta-Testing.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the United States provides free supplemental food and nutrition education to low-income mothers and children under age 5 years. Childhood obesity prevalence is higher among preschool children in the WIC program compared to other children, and WIC improves dietary quality among low-income children. The Children Eating Well (CHEW) smartphone app was developed in English and Spanish for WIC-participating families with preschool-aged children as a home-based intervention to reinforce WIC nutrition education and help prevent childhood obesity. OBJECTIVE: This paper describes the development and beta-testing of the CHEW smartphone app. The objective of beta-testing was to test the CHEW app prototype with target users, focusing on usage, usability, and perceived barriers and benefits of the app. METHODS: The goals of the CHEW app were to make the WIC shopping experience easier, maximize WIC benefit redemption, and improve parent snack feeding practices. The CHEW app prototype consisted of WIC Shopping Tools, including a barcode scanner and calculator tools for the cash value voucher for purchasing fruits and vegetables, and nutrition education focused on healthy snacks and beverages, including a Yummy Snack Gallery and Healthy Snacking Tips. Mothers of 63 black and Hispanic WIC-participating children ages 2 to 4 years tested the CHEW app prototype for 3 months and completed follow-up interviews. RESULTS: Study participants testing the app for 3 months used the app on average once a week for approximately 4 and a half minutes per session, although substantial variation was observed. Usage of specific features averaged at 1 to 2 times per month for shopping-related activities and 2 to 4 times per month for the snack gallery. Mothers classified as users rated the app's WIC Shopping Tools relatively high on usability and benefits, although variation in scores and qualitative feedback highlighted several barriers that need to be addressed. The Yummy Snack Gallery and Healthy Snacking Tips scored higher on usability than benefits, suggesting that the nutrition education components may have been appealing but too limited in scope and exposure. Qualitative feedback from mothers classified as non-users pointed to several important barriers that could preclude some WIC participants from using the app at all. CONCLUSIONS: The prototype study successfully demonstrated the feasibility of using the CHEW app prototype with mothers of WIC-enrolled black and Hispanic preschool-aged children, with moderate levels of app usage and moderate to high usability and benefits. Future versions with enhanced shopping tools and expanded nutrition content should be implemented in WIC clinics to evaluate adoption and behavioral outcomes. This study adds to the growing body of research focused on the application of technology-based interventions in the WIC program to promote program retention and childhood obesity prevention.

Time from Screening Mammography to Biopsy and from Biopsy to Breast Cancer Treatment among Black and White, Women Medicare Beneficiaries Not Participating in a Health Maintenance Organization.

PURPOSE: There is a breast cancer mortality gap adversely affecting Black women in the United States. This study assessed the relationship between number of days between abnormal mammogram, biopsy, and treatment among Medicare (Part B) beneficiaries ages 65 to 74 and 75 to 84 years, accounting for race and comorbidity. METHODS: A cohort of non-Hispanic Black and non-Hispanic White women residing in the continental United States and receiving no services from a health maintenance organization was randomly selected from the Center for Medicare and Medicaid Services denominator file. The cohort was followed from 2005 to 2008 using Center for Medicare and Medicaid Services claims data. The sample included 4,476 women (weighted n = 70,731) with a diagnosis of breast cancer. Cox proportional hazard modeling was used to identify predictors of waiting times. FINDINGS: Black women had a mean of 16.7 more days between biopsy and treatment (p < .001) and 15.7 more days from mammogram to treatment (p = .003) than White women. Median duration from abnormal mammogram to treatment exceeded National Quality Measures for Breast Centers medians regardless of race, age, or number of comorbidities (overall 43 days vs. the National Quality Measures for Breast Centers value of 28 days). CONCLUSIONS: Medical care delays may contribute, in part, to the widening breast cancer mortality gap between Black women and White women. Further study, with additional clinical and social information, is needed to broaden scientific understanding of racial determinants and assess the clinical significance of mammogram to treatment times among Medicare beneficiaries.

Heart Failure Hospitalization by Race/Ethnicity, Gender and Age in California: Implications for Prevention.

OBJECTIVE: We examined variation in rates of hospitalization, risk factors, and costs by race/ethnicity, gender and age among heart failure (HF) patients. METHODS: We analyzed California hospital discharge data for patients in 2007 (n=58,544) and 2010 (n=57,219) with a primary diagnosis of HF (ICD-9 codes: 402, 404, 428). HF cases included African Americans (Blacks; 14%), Hispanic/Latinos (21%), and non-Hispanic Whites (65%). Age-adjusted prevalence rates per 100,000 US population were computed per CDC methodology. RESULTS: Four major trends emerged: 1) Overall HF rates declined by 7.7% from 284.7 in 2007 to 262.8 in 2010; despite the decline, the rates for males and Blacks remained higher compared with others in both years; 2) while rates for Blacks (aged ≤54) were 6 times higher compared with same age Whites, rates for Hispanics were higher than Whites in the middle age category; 3) risk factors for HF included hypertension, chronic heart disease, chronic kidney disease, atrial fibrillation, and chronic obstructive pulmonary disease; and 4) submitted hospitalization costs were higher for males, Blacks, and younger patients compared with other groups. CONCLUSIONS: Health inequality in HF persists as hospitalization rates for Blacks remain higher compared with Whites and Hispanics. These findings reinforce the need to determine whether increased access to providers, or implementing proven hypertension and diabetes preventive programs among minorities might reduce subsequent hospitalization for HF in these populations.

Risk Factors and Hospitalization Costs of Dementia Patients: Examining Race and Gender Variations.

AIMS: To examine the variation in risk factors and hospitalization costs among four elderly dementia cohorts by race and gender. MATERIALS AND METHODS: The 2008 Tennessee Hospital Discharged database was examined. The prevalence, risk factors and cost of inpatient care of dementia were examined for individuals aged 65 years and above, across the four race gender cohorts - white males (WM), black males (BM), white females (WF), and black females (BF). RESULTS: 3.6% of patients hospitalized in 2008 had dementia. Dementia was higher among females than males, and higher among blacks than whites. Further, BF had higher prevalence of dementia than WF; similarly, BM had a higher prevalence of dementia than WM. Overall, six risk factors were associated with dementia for the entire sample including HTN, DM, CKD, CHF, COPD, and stroke. These risk factors varied slightly in predicting dementia by race and gender. Hospital costs were 14% higher among dementia patients compared to non-dementia patients. CONCLUSIONS: There exist significant race and gender disparities in prevalence of dementia. A greater degree of co-morbidity, increased duration of hospital stay, and more frequent hospitalizations, may result in a higher cost of inpatient dementia care. Aggressive management of risk factors may subsequently reduce stroke and cost of dementia care, especially in the black population. Race and gender dependent milestones for management of these risk factors should be considered.

Mammography Screening Among the Elderly: A Research Challenge.

BACKGROUND: Randomized trials demonstrate clear benefits of mammography screening in women through age 74 years. We explored age- and race-specific rates of mammography screening and breast cancer mortality among women aged 69 to 84 years. METHODS: We analyzed Medicare claims data for women residing within Surveillance, Epidemiology and End Results geographic areas from 1995 to 2009 from 64,384 non-Hispanic women (4886 black and 59,498 white) and ascertained all primary breast cancer cases diagnosed between ages 69 and 84 years. The exposure was annual or biennial screening mammography during the 4 years immediately preceding diagnosis. The outcome was breast cancer mortality during the 10 years immediately after diagnosis. RESULTS: After adjustment for stage at diagnosis, radiation therapy, chemotherapy, comorbid conditions, and contextual socioeconomic status, hazard ratios (and 95% confidence intervals) for breast cancer mortality relative to no/irregular mammography at 10 years for women aged 69 to 84 years at diagnosis were 0.31 (0.29-0.33) for annual mammography and 0.47 (0.44-0.51) for biennial mammography among whites and 0.36 (0.29-0.44) for annual mammography and 0.47 (0.37-0.58) for biennial mammography among blacks. Trends were similar at 5 years overall and stratified by ages 69 to 74 years, 75 to 78 years, and 79 to 84 years. CONCLUSIONS: In these Medicare claims and Surveillance, Epidemiology and End Results data, elderly non-Hispanic women who self-selected for annual mammography had lower 10-year breast cancer mortality than corresponding women who self-selected for biennial or no/irregular mammography. These findings were similar among black and white women. The data highlight the evidentiary limitations of data used for current screening mammography recommendations.

Use of Six Sigma for eliminating missed opportunities for prevention services.

Delivery of primary care preventative services can be significantly increased utilizing Six Sigma methods. Missed preventative service opportunities were compared in the study clinic with the community clinic in the same practice. The study clinic had 100% preventative services, compared with only 16.3% in the community clinic. Preventative services can be enhanced to Six Sigma quality when the nurse executive and medical staff agree on a single standard of nursing care executed via standing orders.

Social determinants and the classification of disease: descriptive epidemiology of selected socially mediated disease constellations.

BACKGROUND: Most major diseases have important social determinants. In this context, classification of disease based on etiologic or anatomic criteria may be neither mutually exclusive nor optimal. METHODS AND FINDINGS: Units of analysis comprised large metropolitan central and fringe metropolitan counties with reliable mortality rates--(n = 416). Participants included infants and adults ages 25 to 64 years with selected causes of death (1999 to 2006). Exposures included that residential segregation and race-specific social deprivation variables. Main outcome measures were obtained via principal components analyses with an orthogonal rotation to identify a common factor. To discern whether the common factor was socially mediated, negative binomial multiple regression models were developed for which the dependent variable was the common factor. Results showed that infant deaths, mortality from assault, and malignant neoplasm of the trachea, bronchus and lung formed a common factor for race-gender groups (black/white and men/women). Regression analyses showed statistically significant, positive associations between low socio-economic status for all race-gender groups and this common factor. CONCLUSIONS: Between 1999 and 2006, deaths classified as "assault" and "lung cancer", as well as "infant mortality" formed a socially mediated factor detectable in population but not individual data. Despite limitations related to death certificate data, the results contribute important information to the formulation of several hypotheses: (a) disease classifications based on anatomic or etiologic criteria fail to account for social determinants; (b) social forces produce demographically and possibly geographically distinct population-based disease constellations; and (c) the individual components of population-based disease constellations (e.g., lung cancer) are phenotypically comparable from one population to another but genotypically different, in part, because of socially mediated epigenetic variations. Additional research may produce new taxonomies that unify social determinants with anatomic and/or etiologic determinants. This may lead to improved medical management of individuals and populations.

Association of infant feeding with adiposity in early childhood in a WIC sample.

OBJECTIVES: To evaluate the association of different infant feeding practices with adiposity in early childhood. METHODS: Survey was conducted among 150 White, Black, and Hispanic low-income families with children ages 2­4. RESULTS: History of supplementing breast milk with formula (mixed feeding) was more prevalent among Hispanic children (67.4%) than either White (8.5%) or Black children (22.7%) (p<.001). African American children had the highest BMI percentile of the three groups (p=.043), although Hispanic children had slightly higher birth weight than the other two groups (p=.06). Among Hispanic children, after adjusting for confounding variables including maternal BMI, the mixed feeding group and the exclusive formula-feeding group had significantly higher BMI percentile (b=3.068 and b=2.936, respectively) than the exclusive breastfeeding group. These associations were not observed among Blacks and Whites. CONCLUSION: Further research is warranted on the impact of different feeding practices during infancy on subsequent adiposity during pre-school years

Prescribing patterns in the treatment of hypertension among underserved African American elderly.

INTRODUCTION: Hypertension among African Americans is higher compared to Whites and has an early onset, greater severity, and is associated with more organ damage. We examined whether pharmaceutical treatment of hypertension among underserved African American elderly is consistent with the current treatment guidelines and whether treatment variations occur due to existing co-morbidities among the hypertensive. METHODS: Our study surveyed 400 African Americans, aged ≥ 65 years, recruited from 16 predominantly African American churches located in South Los Angeles. The study used face-to-face interviews which documented type, frequency, and dosage of all medications used by participants. Label information of each drug was recorded. RESULTS: Our data indicate: 1) 29% were on one anti-hypertensive medication; 60% were taking 2-3 medications; and 9% were on four classes of anti-hypertensive medication; 2) among the elderly taking a combination of two or more drugs, ACE or ARB was used 76% in combination of agents, diuretics 60%, calcium channel blockers 63%, and beta-blocker 61%; and 3) 26% of the elderly were taking ≥ 3 medications including a diuretic. CONCLUSIONS: Treatment of hypertension appears to be inconsistent with the prevailing treatment guidelines for nearly one-third of the aged African Americans. Further investigation is needed to determine why a significant number of individuals from this under-served population are not receiving care based on established clinical guidelines.

Depression increases stroke hospitalization cost: an analysis of 17,010 stroke patients in 2008 by race and gender.

Objective. This analysis focuses on the effect of depression on the cost of hospitalization of stroke patients. Methods. Data on 17,010 stroke patients (primary diagnosis) were extracted from 2008 Tennessee Hospital Discharge Data System. Three groups of patients were compared: (1) stroke only (S(O), n = 7,850), (2) stroke + depression (S(+D), n = 3,965), and (3) stroke + other mental health diagnoses (S(+M), n = 5,195). Results. Of all adult patients, 4.3% were diagnosed with stroke. Stroke was more prevalent among blacks than whites (4.5% versus 4.2%, P < 0.001) and among males than females (5.1% versus 3.7%, P < 0.001). Nearly one-quarter of stroke patients (23.3%) were diagnosed with depression/anxiety. Hospital stroke cost was higher among depressed stroke patients (S(+D)) compared to stroke only (S(O)) patients ($77,864 versus $47,790, P < 0.001), and among S(+D), cost was higher for black males compared to white depressed males ($97,196 versus $88,115, P < 0.001). Similar racial trends in cost emerged among S(+D) females. Conclusion. Depression in stroke patients is associated with increased hospitalization costs. Higher stroke cost among blacks may reflect the impact of comorbidities and the delay in care of serious health conditions. Attention to early detection of depression in stroke patients might reduce inpatient healthcare costs.

Short-term trends in heart failure-related hospitalizations in a high-risk state.

OBJECTIVES: We sought to determine whether there are signs of improvement in the rates of heart failure (HF) hospitalizations given the recent reports of improvement in national trends. METHODS: HF admissions data from the Tennessee Hospital Discharge Data System were analyzed. RESULTS: Hospitalization for primary diagnosis of HF (HFPD) in adults (aged 20 years old or older) decreased from 4.5% in 2006 to 4.2% in 2008. Similarly, age-adjusted HF hospitalization (per 10,000 population) declined by 19.1% (from 45.5 in 2006 to 36.8 in 2008). The age-adjusted rates remain higher among blacks than whites and higher among men than women. Notably, the rate ratio of black-to-white men ages 20 to 34 years admitted with HFPD increased from 8.5 in 2006 to 11.1 in 2008; similarly, the adjusted odds ratios for HFPD were 4.75 (95% confidence interval 3.29-6.86) and 5.61 (95% confidence interval 3.70-8.49), respectively. There was, however, a significant improvement in odds ratio for HF rates among young black women, as evidenced by a decrease from 4.60 to 3.97 (aged 20-34 years) and 4.21 to 3.12 (aged 35-44 years) between 2006 and 2008, respectively. Among patients aged 20 to 34 and 35 to 44 years, hypertension was the strongest independent predictor for HF. Diabetes and myocardial infarction emerged as predictors for HF among patients aged 35 years and older. CONCLUSIONS: The overall rate of HF hospitalization declined during the period surveyed, but the persistent disproportionate involvement of blacks with evidence of worsening among younger black men, requires close attention.

United States counties with low black male mortality rates.

OBJECTIVE: In the United States, young and middle-aged black men have significantly higher total mortality than any other racial or ethnic group. We describe the characteristics of US counties with low non-Hispanic Black or African American male mortality (ages 25-64 years, 1999-2007). METHODS: Information was accessed through public data, the US Census, the US Compressed Mortality File, and the Native American Graves Repatriation Act military database. RESULTS: Of 1307 counties with black mortality rates classified as reliable by the National Center for Health Statistics (at least 20 deaths), 66 recorded lower mortality among black men than corresponding US whites. Most notable, 97% of the 66 counties were home to or adjacent a military installation versus 37% of comparable US counties (P<.001). Blacks in these counties had less poverty, higher percentages of elderly civilian veterans, and higher per capita income. Within these counties, national black:white disparities in mortality were eliminated for ischemic heart disease, accidents, diseases of the liver, chronic lower respiratory diseases, and mental disorder from psychoactive substance use. Application of age-, race-, ethnicity-, gender-, and urbanization-specific mortality rates from counties with relatively low mortality would reduce the black:white mortality rate ratio for black men aged 25 to 64 years from 1.67 to 1.20 nationally and to 1.00 in areas outside large central metropolitan areas. CONCLUSIONS: These descriptive data demonstrate a small number of communities with low mortality rates among young and middle-aged black/African American men. Their characteristics may provide clinical and public health insights to reduce these higher mortality rates in the US population. Analytic epidemiologic studies are necessary to test these hypotheses.

Race, sex, and age differences in heart failure-related hospitalizations in a southern state: implications for prevention.

BACKGROUND: Because heart failure (HF) is the final common pathway for most heart diseases, we examined its 10-year prevalence trend by race, sex, and age in Tennessee. METHODS AND RESULTS: HF hospitalization data from the Tennessee Hospital Discharge Data System were analyzed by race, sex, and age. Rates were directly age-adjusted using the Year 2000 standard population. Adult (age 20+ years) inpatient hospitalization for primary diagnosis of HF (HFPD) increased from 4.2% in 1997 to 4.5% in 2006. Age-adjusted hospitalization for HF (per 10 000 population) rose by 11.3% (from 29.3 in 1997 to 32.6 in 2006). Parallel changes in secondary HF admissions were also noted. Age-adjusted rates were higher among blacks than whites and higher among men than women. The ratios of black to white by sex admitted with HFPD in 2006 were highest (9:1) among the youngest age categories (20 to 34 and 35 to 44 years). Furthermore, for each age category of black men below 65 years, there were higher HF admission rates than for white men in the immediate older age category. In 2006, the adjusted rate ratios for HFPD in black to white men ages 20 to 34 and 35 to 44 years were odds ratio, 4.75; 95% confidence interval, 3.29 to 6.86 and odds ratio, 5.10; 95% confidence interval, 4.15 to 6.25, respectively. Hypertension was the independent predictor of HF admissions in black men ages 20 to 34 years. CONCLUSIONS: The higher occurrence of HF among young adults in general, particularly among young black men, highlights the need for prevention by identifying modifiable biological and social determinants to reduce cardiovascular health disparities in this vulnerable group.