Peer Support to Enhance Type 2 Diabetes Prevention Among African American and Latino Adults.

Social support occurs within complex social networks that are diffusely embedded within the social determinants of health. Social networks operate through five primary interconnected pathways: (1) provision of social support; (2) social influence; (3) social engagement; (4) social capital; and (5) social cohesion. Research has demonstrated that increased social support can have a beneficial impact on Type 2 Diabetes (T2DM) prevention and outcomes through culturally tailored Diabetes Prevention Programs in minority communities. Further research is needed to fully measure the impact of social network peer support on T2DM outcomes to better operationalize and scale up community specific interventions.

Cost-Related Access Barriers, Medical Debt, and Dissatisfaction with Care Among Privately Insured Americans.

BACKGROUND: Understanding experiences with private important to improving the quality of health care coverage. OBJECTIVE: To examine the association of health with cost-related access barriers, medical debt, and dissatisfaction with care among privately insured Americans. DESIGN: We classified Americans with private insurance by self-reported health status into five groups (excellent, very good, good, fair, and poor health). We examined self-reported difficulty seeing a doctor due to costs, not taking medications due to costs, medical debt, and dissatisfaction with care among individuals with differing health status. We used logistic regression to examine the association of health status with individuals' experiences after accounting for baseline characteristics. The analysis was repeated among individuals with different forms of private insurance. Odds ratios were converted to risk ratios to improve ease of interpretation of the results. SETTING: Behavioral Risk Factor Surveillance System of Americans in 17 states RESULTS: The sample included 82,494 US adults with private insurance. Following adjustment, compared to individuals with excellent health those in very good health, good health, fair health, and poor health reported increasingly higher risks of difficulty seeing a doctor due to costs with risk ratios of 1.02 (95% CI 1.01, 1.03), 1.07 (95% CI 1.06, 1.08), 1.18 (95% CI 1.17, 1.20), and 1.29 (95% CI 1.27, 1.31), respectively. Compared to individuals with excellent health, those in very good health, good health, fair health, and poor health reported increasingly higher risks of not taking medication due to costs, outstanding medical debt, and dissatisfaction with care. Similar relationships were seen across individually purchased and employer-sponsored insurance. CONCLUSION: Cost-related access barriers, medical debt, and dissatisfaction with care were common among individuals with private insurance and most pronounced among those with fair and poor health who likely need and use their health insurance the most.

Corrigendum to "Risk Factor Control Across the Spectrum of Cardiovascular Risk: Findings from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)" [American Journal of Preventive Cardiology, Volume 5, March 2021, 100147].

[This corrects the article DOI: 10.1016/j.ajpc.2021.100147.].

Characterization of Internal Medicine Chief Resident Administrative, Educational, and Clinical Experiences.

Importance: The internal medicine (IM) chief residency is a position of leadership and honor common in IM programs, but the goals, responsibilities, and experiences of those who undertake it can be highly variable. Studies assessing the experience and impressions of the chief resident (CR) position from the viewpoint of the IM CRs are lacking. Objective: To describe the structure, responsibilities, and perceptions of the IM CR role across IM residency programs. Design, Setting, and Participants: A cross-sectional, simple descriptive electronic survey for current CRs was administered between April and June 2018 across US IM residency programs accredited by US Accreditation Council for Graduate Medical Education. A 2-step nonrandom sampling approach was used: first, snowball sampling was performed using the authors' professional networks, and second, the survey was sent to the Association of Program Directors in Internal Medicine (APDIM) CR listserv. Data analysis was performed from June 2020 to August 2020. Exposures: Participation as a CR for an IM residency program in the 2017 to 2018 academic year. Main Outcomes and Measures: Descriptive CR personal and program characteristics and CR perceptions of administrative, clinical, and leadership experiences. Results: Among 169 unique responses, 77 participants (46%) were female and 89 (53%) were White. The response rate was 57% (70 of 122 surveys) in the snowball sample and 12% (99 of 842 surveys) in the APDIM listserv. The 2 sampled groups were combined for analysis. Most respondents (125 CRs [74%]) were from academic or university-based programs. Common across CR responses was responsibility for administrative tasks, clinical work, and educational efforts. Most CRs (111 of 157 respondents [71%]) reported being the primary schedulers for the residency program. Clinical work differed widely across respondents. Only 70 of 156 respondents (45%) reported having an academic title associated with the CR role. CRs reported inconsistent evaluation throughout the year, with high percentages reporting never receiving feedback on teaching (34 respondents [23%]), clinical abilities (67 respondents [45%]), or leadership abilities (60 respondents [40%]). Most CRs (107 respondents [69%]) agreed that they find work as a CR fulfilling and 117 (74%) agreed they would do chief residency again. Conclusions and Relevance: Despite its ubiquity in training programs across the US, the IM CR experience is very different across programs. Recommendations are provided to consider for improvement of the CR experience, including structured feedback opportunities, maximizing educational and clinical experiences, and standardizing policies.

Association of Social Determinants of Health and Their Cumulative Impact on Hospitalization Among a National Sample of Community-Dwelling US Adults.

IMPORTANCE: While the association between Social Determinants of Health (SDOH) and health outcomes is well known, few studies have explored the impact of SDOH on hospitalization. OBJECTIVE: Examine the independent association and cumulative effect of six SDOH domains on hospitalization. DESIGN: Using cross-sectional data from the 2016-2018 National Health Interview Surveys (NHIS), we used multivariable logistical regression models controlling for sociodemographics and comorbid conditions to assess the association of each SDOH and SDOH burden (i.e., cumulative number of SDOH) with hospitalization. SETTING: National survey of community-dwelling individuals in the US PARTICIPANTS: Adults ≥18 years who responded to the NHIS survey EXPOSURE: Six SDOH domains (economic instability, lack of community, educational deficits, food insecurity, social isolation, and inadequate access to medical care) MEASURES: Hospitalization within 1 year RESULTS: Among all 55,186 respondents, most were ≤50 years old (54.2%), female (51.7%, 95% CI 51.1-52.3), non-Hispanic (83.9%, 95% CI 82.4-84.5), identified as White (77.9%, 95% CI 76.8-79.1), and had health insurance (90%, 95% CI 88.9-91.9). Hospitalized individuals (n=5506; 8.7%) were more likely to be ≥50 years old (61.2%), female (60.7%, 95% CI 58.9-62.4), non-Hispanic (87%, 95% CI 86.2-88.4), and identify as White (78.5%, 95% CI 76.7-80.3), compared to those who were not hospitalized. Hospitalized individuals described poorer overall health, reporting higher incidence of having ≥5 comorbid conditions (38.9%, 95% CI 37.1-40.1) compared to those who did not report a hospitalization (15.9%, 95% CI 15.4-16.5). Hospitalized respondents reported higher rates of economic instability (33%), lack of community (14%), educational deficits (67%), food insecurity (14%), social isolation (34%), and less access to health care (6%) compared to non-hospitalized individuals. In adjusted analysis, food insecurity (OR: 1.36, 95% CI 1.22-1.52), social isolation (OR: 1.17, 95% CI 1.08-1.26), and lower educational attainment (OR: 1.12, 95% CI 1.02-1.25) were associated with hospitalization, while a higher SDOH burden was associated with increased odds of hospitalization (3-4 SDOH [OR: 1.25, 95% CI 1.06-1.49] and ≥5 SDOH [OR: 1.72, 95% CI 1.40-2.06]) compared to those who reported no SDOH. CONCLUSIONS: Among community-dwelling US adults, three SDOH domains: food insecurity, social isolation, and low educational attainment increase an individual's risk of hospitalization. Additionally, risk of hospitalization increases as SDOH burden increases.

Cardiovascular Impact of Race and Ethnicity in Patients With Diabetes and Obesity: JACC Focus Seminar 2/9.

Obesity and type 2 diabetes mellitus are highly prevalent and increasing in the United States among racial/ethnic minority groups. Type 2 diabetes mellitus, which is driven by many factors including elevated levels of adiposity, is an exemplar health disparities disease. Pervasive disparities exist at every level from risk factors through outcomes for U.S. racial/ethnic minority groups, including African American, Hispanic/LatinX American, and Asian American populations. Disparities in clinical care exist including hemoglobin A1c control, lower prescription rates of newer antihyperglycemic medications, along with greater rates of complications postbariatric surgery. Underpinning these disparities are the social determinants of health affecting provider-patient interactions, access to resources, and healthy built environments. We review the best practices to address cardiometabolic disparities in the current cardiovascular guidelines and describe recommendations for cross-cutting strategies to advance equity in obesity and type 2 diabetes across U.S. racial/ethnic groups.

Increasing Equity While Improving the Quality of Care: JACC Focus Seminar 9/9.

This review summarizes racial and ethnic disparities in the quality of cardiovascular care-a challenge given the fragmented nature of the health care delivery system and measurement. Health equity for all racial and ethnic groups will not be achieved without a substantially different approach to quality measurement and improvement. The authors adapt a tool frequently used in quality improvement work-the driver diagram-to chart likely areas for diagnosing root causes of disparities and developing and testing interventions. This approach prioritizes equity in quality improvement. The authors demonstrate how this approach can be used to create interventions that reduce systemic racism within the institutions and professions that deliver health care; attends more aggressively to social factors related to race and ethnicity that affect health outcomes; and examines how hospitals, health systems, and insurers can generate effective partnerships with the communities they serve to achieve equitable cardiovascular outcomes.

Risk factor control across the spectrum of cardiovascular risk: Findings from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

BACKGROUND: Presence of cardiovascular disease (CVD) risk factors (RFs) should prompt patients and their providers to work aggressively towards controlling those that are modifiable. The extent to which a greater CVD RF burden is related to CVD RF control in a contemporary and diverse Hispanic/Latino population is not well-understood. METHODS: Using multicenter community-based data from the Hispanic Community Health Study/Study of Latinos, we assessed the self-reported prevalence of hypertension, hypercholesterolemia, diabetes, and prevalent CVD (ischemic heart disease or stroke). We used contemporaneous guidelines to define RF control. Multivariable logistic regression for complex survey sampling was used to examine whether having more CVD RFs was associated with CVD RF control (adjusting for age, sex, Hispanic background group, education, and health insurance). RESULTS: Our sample included 8521 participants with at least one CVD RF or prevalent CVD. The mean age in HCHS/SOL target population was 49 (SE 0.3) years and 56% were women. Frequency of one, two, or three self-reported CVD RFs was 57%, 26%, 8%, respectively, and overall 9% of participants had prevalent CVD. After adjusting for sociodemographic factors, compared to those reporting one CVD RF, individuals with three CVD RFs were the least likely to have blood pressure, cholesterol, and glucose optimally controlled (odds ratio [OR]: 0.56; 95% confidence interval [CI]: 0.40-0.80). However, those with prevalent CVD were more likely to have all three risk factors controlled, (OR: 1.43; 95% CI: 1.01-2.01). CONCLUSION: Hispanic/Latino adults with three major CVD RFs represent a group with poor overall CVD RF control. Secondary CVD prevention fares better. The potential contributors to inadequate CVD RF control in this highly vulnerable group warrants further investigation.

The Hispanic paradox in the prevalence of obesity at the county-level.

OBJECTIVE: The percentage of Hispanics in a county has a negative association with prevalence of obesity. Because Hispanic individuals are unevenly distributed in the United States, this study examined whether this protective association persists when stratifying counties into quartiles based on the size of the Hispanic population and after adjusting for county-level demographic, socioeconomic, healthcare, and environmental factors. METHODS: Data were extracted from the 2018 Robert Wood Johnson Foundation County Health Rankings. Counties were categorized into quartiles based on their percentage of Hispanics, 0%-5% (n = 1794), 5%-20% (n = 962), 20%-50% (n = 283), and >50% (n = 99). For each quartile, univariate and multivariate regression models were used to evaluate the association between prevalence of obesity and demographic, socioeconomic, healthcare, and environmental factors. RESULTS: Counties with the top quartile of Hispanic individuals had the lowest prevalence of obesity compared to counties at the bottom quartile (28.4 ± 3.6% vs. 32.7 ± 4.0%). There was a negative association between county-level percentage of Hispanics and prevalence of obesity in unadjusted analyses that persisted after adjusting for all county-level factors. CONCLUSIONS: Counties with a higher percentage of Hispanics have lower levels of obesity, even after controlling for demographic, socioeconomic, healthcare, and environmental factors. More research is needed to elucidate why having more Hispanics in a county may be protective against county-level obesity.

Association of acculturation with cardiac structure and function among Hispanics/Latinos: a cross-sectional analysis of the echocardiographic study of Latinos.

OBJECTIVE: Hispanics/Latinos, the largest immigrant population in the USA, undergo the process of acculturation and have a large burden of heart failure risk. Few studies have examined the association of acculturation on cardiac structure and function. DESIGN: Cross-sectional. SETTING: The Echocardiographic Study of Latinos. PARTICIPANTS: 1818 Hispanic adult participants with baseline echocardiographic assessment and acculturation measured by the Short Acculturation Scale, nativity, age at immigration, length of US residence, generational status and language. PRIMARY AND SECONDARY OUTCOME MEASURES: Echocardiographic assessment of left atrial volume index (LAVI), left ventricular mass index (LVMI), early diastolic transmitral inflow and mitral annular velocities. RESULTS: The study population was predominantly Spanish-speaking and foreign-born with mean residence in the US of 22.7 years, mean age of 56.4 years; 50% had hypertension, 28% had diabetes and 44% had a body mass index >30 kg/m2. Multivariable analyses demonstrated higher LAVI with increasing years of US residence. Foreign-born and first-generation participants had higher E/e' but lower LAVI and e' velocities compared with the second generation. Higher acculturation and income >$20K were associated with higher LVMI, LAVI and E/e' but lower e' velocities. Preferential Spanish-speakers with an income <$20K had a higher E/e'. CONCLUSIONS: Acculturation was associated with abnormal cardiac structure and function, with some effect modification by socioeconomic status.

Examining the Utility of 30-day Readmission Rates and Hospital Profiling in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VA) reports hospital-specific 30-day risk-standardized readmission rates (RSRRs) using CMS-derived models. OBJECTIVE: The aim of this study was to examine and describe the interfacility variability of 30-day RSRRs for acute myocardial infarction (AMI), heart failure (HF), and pneumonia as a means to assess its utility for VA quality improvement and hospital comparison. RESEARCH DESIGN: A retrospective analysis of VA and Medicare claims data using one-year (2012) and three-year (2010-2012) data given their use for quality improvement or for hospital comparison, respectively. SUBJECTS: This study included 3,571 patients hospitalized for AMI at 56 hospitals, 10,609 patients hospitalized for HF at 102 hospitals, and 10,191 patients hospitalized for pneumonia at 106 hospitals. MEASURES: Hospital-specific 30-day RSRRs for AMI, HF, and pneumonia hospitalizations were calculated using hierarchical generalized linear models. RESULTS: Of 164 qualifying VA hospitals, 56 (34%), 102 (62%), and 106 (64%) qualified for analysis based on CMS criteria for AMI, HF, and pneumonia cohorts, respectively. Using 2012 data, we found that two hospitals (2%) had CHF RSRRs worse than the national average (+95% CI), whereas no hospital demonstrated worse-than-average risk-stratified readmission Rate (RSRR; +95% CI) for AMI or pneumonia. After increasing the number of facility admissions by combining three years of data, we found that four (range: 3.5%-5.3%) hospitals had RSRRs worse than the national average (+95% CI) for all three conditions. CONCLUSIONS: The Centers for Medicare and Medicaid Services-derived 30-day readmission measure may not be a useful measure to distinguish VA interfacility performance or drive quality improvement given the low facility-level volume of such readmissions.

Psychological Traits, Heart Rate Variability, and Risk of Coronary Heart Disease in Healthy Aging Women-The Women's Health Initiative.

OBJECTIVE: Psychological traits such as optimism and hostility affect coronary heart disease (CHD) risk, but mechanisms for this association are unclear. We hypothesized that optimism and hostility may affect CHD risk via changes in heart rate variability (HRV). METHODS: We conducted a longitudinal analysis using data from the Women's Health Initiative Myocardial Ischemia and Migraine Study. Participants underwent 24-hour ambulatory electrocardiogram monitoring 3 years after enrollment. Optimism (Life Orientation Test-Revised), cynical hostility (Cook-Medley), demographics, and coronary risk factors were assessed at baseline. HRV measures included standard deviation of average N-N intervals (SDNN); standard deviation of average N-N intervals for 5 minutes (SDANN); and average heart rate (HR). CHD was defined as the first occurrence of myocardial infarction, angina, coronary angioplasty, and bypass grafting. Linear and Cox regression models adjusted for CHD risk factors were used to examine, respectively, associations between optimism, hostility, and HRV and between HRV and CHD risk. RESULTS: Final analyses included 2655 women. Although optimism was not associated with HRV, hostility was inversely associated with HRV 3 years later (SDANN: adjusted ß = -0.54; 95% CI = -0.97 to -0.11; SDNN: -0.49; 95% CI = -0.93 to -0.05). HRV was inversely associated with CHD risk; for each 10-millisecond increase in SDNN or SDANN, there was a decrease in CHD risk of 9% (p = .023) and 12% (p = .006), respectively. CONCLUSIONS: HRV did not play a major role in explaining why more optimistic women seem to be somewhat protected from CHD risk. Although hostility was inversely associated with HRV, its role in explaining the association between hostility and CHD risk remains to be established.

Cardiovascular Risk Factors and Dehydroepiandrosterone Sulfate Among Latinos in the Boston Puerto Rican Health Study.

Low blood dehydroepiandrosterone sulfate (DHEAS) levels have strong positive associations with stroke and coronary heart disease. However, it is unclear whether DHEAS is independently associated with cardiovascular risk factors. Therefore, we examined the association between cardiovascular risk factors and DHEAS concentration among a high-risk population of Latinos (Puerto Ricans aged 45 to 75 years at baseline) in a cross-sectional analysis of the Boston Puerto Rican Health Study. Of eligible participants, 72% completed baseline interviews and provided blood samples. Complete data were available for 1355 participants. Associations between cardiovascular risk factors (age, sex, total cholesterol, high-density lipid cholesterol, triglycerides, and glucose) and log-transformed DHEAS (µg/dL) were assessed. In robust multivariable regression analyses, DHEAS was significantly inversely associated with age (ß = -12.4; 95% CI: -15.2, -9.7; per 5 years), being female (vs. male) (ß = -46; 95% CI: -55.3, -36.6), and plasma triglyceride concentration (ß = -0.2; 95% CI: -0.3, -0.1; per 10 mg/dL) and was positively associated with total cholesterol and plasma glucose levels (ß = 1.8; 95% CI: 0.6, 3 and ß = 0.2; 95% CI: 0.04, 0.3, respectively, per 10 mg/dL) after adjustment for smoking, alcohol, and physical activity and for postmenopausal hormone use in women. Estimates were unchanged after adjustment for measures of chronic disease and inflammation. Women exhibited a stronger age-related decline in DHEAS and a positive association with glucose in contrast to findings among men (P interaction < 0.05). In conclusion, in this large study of Latinos with a heavy cardiovascular risk factor burden, we observed significant associations between cardiovascular disease (CVD) risk factors and DHEAS, with variations by sex. These findings improve our understanding of the role DHEAS may play in CVD etiology.