Publications by authors named "Javier Valero-Elizondo"

58 Publications

Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018.

JAMA 2021 Aug;326(7):637-648

Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut.

Importance: The elimination of racial and ethnic differences in health status and health care access is a US goal, but it is unclear whether the country has made progress over the last 2 decades.

Objective: To determine 20-year trends in the racial and ethnic differences in self-reported measures of health status and health care access and affordability among adults in the US.

Design, Setting, And Participants: Serial cross-sectional study of National Health Interview Survey data, 1999-2018, that included 596 355 adults.

Exposures: Self-reported race, ethnicity, and income level.

Main Outcomes And Measures: Rates and racial and ethnic differences in self-reported health status and health care access and affordability.

Results: The study included 596 355 adults (mean [SE] age, 46.2 [0.07] years, 51.8% [SE, 0.10] women), of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively. Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018). Black individuals had a significantly higher estimated prevalence of poor or fair health status than White individuals in 1999, regardless of income strata (P < .001 for the overall and low-income groups; P = .03 for middle and high-income group). From 1999 to 2018, racial and ethnic gaps in poor or fair health status did not change significantly, with or without income stratification, except for a significant decrease in the difference between White and Black individuals with low income (-6.7 percentage points [95% CI, -11.3 to -2.0]; P = .005); the difference in 2018 was no longer statistically significant (P = .13). Black and White individuals had the highest levels of self-reported functional limitations, which increased significantly among all groups over time. There were significant reductions in the racial and ethnic differences in some self-reported measures of health care access, but not affordability, with and without income stratification.

Conclusions And Relevance: In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jama.2021.9907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8371573PMC
August 2021

Atherosclerotic Cardiovascular Disease, Cancer, and Financial Toxicity Among Adults in the United States.

JACC CardioOncol 2021 Jun 15;3(2):236-246. Epub 2021 Jun 15.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.

Background: Financial toxicity (FT) is a well-established side-effect of the high costs associated with cancer care. In recent years, studies have suggested that a significant proportion of those with atherosclerotic cardiovascular disease (ASCVD) experience FT and its consequences.

Objectives: This study aimed to compare FT for individuals with neither ASCVD nor cancer, ASCVD only, cancer only, and both ASCVD and cancer.

Methods: From the National Health Interview Survey, we identified adults with self-reported ASCVD and/or cancer between 2013 and 2018, stratifying results by nonelderly (age <65 years) and elderly (age ≥65 years). We defined FT if any of the following were present: any difficulty paying medical bills, high financial distress, cost-related medication nonadherence, food insecurity, and/or foregone/delayed care due to cost.

Results: The prevalence of FT was higher among those with ASCVD when compared with cancer (54% vs. 41%; p < 0.001). When studying the individual components of FT, in adjusted analyses, those with ASCVD had higher odds of any difficulty paying medical bills (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.09 to 1.36), inability to pay bills (OR: 1.25; 95% CI: 1.04 to 1.50), cost-related medication nonadherence (OR: 1.28; 95% CI: 1.08 to 1.51), food insecurity (OR: 1.39; 95% CI: 1.17 to 1.64), and foregone/delayed care due to cost (OR: 1.17; 95% CI: 1.01 to 1.36). The presence of ≥3 of these factors was significantly higher among those with ASCVD and those with both ASCVD and cancer when compared with those with cancer (23% vs. 30% vs. 13%, respectively; p < 0.001). These results remained similar in the elderly population.

Conclusions: Our study highlights that FT is greater among patients with ASCVD compared with those with cancer, with the highest burden among those with both conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaccao.2021.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8352280PMC
June 2021

Forgone Medical Care Associated With Increased Health Care Costs Among the U.S. Heart Failure Population.

JACC Heart Fail 2021 Aug 5. Epub 2021 Aug 5.

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA. Electronic address:

Objectives: The objective of this study was to describe the prevalence of patients with forgone/delayed care for heart failure (HF) and examine the associated demographic characteristics, health care utilization, and costs.

Background: HF is a leading cause of morbidity and mortality, with health care expenditures projected to increase 3-fold from 2012 to 2030. The proportion of HF patients with forgone/delayed medical care and the association with health care expenditures and utilization remain unknown.

Methods: Data on patients with HF were obtained from the Medical Expenditure Panel Survey to assess expenditures and health care utilization in the United States from 2004 to 2015. Patients with HF who reported forgone/delayed care, any missed or delayed medical treatment, were compared with those without care lapses.

Results: Overall, 16% of patients with HF reported forgone/delayed care, including 10% among the elderly (aged ≥65 years) and 27% among the nonelderly (age <65 years). Patients with HF who reported forgone/delayed care had annual health care expenses $8,027 (95% CI: $1,181-$14,872) higher than those who did not. Among the elderly, those reporting forgone/delayed care had more emergency department visits (43% vs 58%; P < 0.05), and had higher annual inpatient costs (+$7,548; 95% CI: $1,109-$13,988) and total health care costs (+$10,581; 95% CI: $1,754-$19,409). Sixty percent of nonelderly and 46% of elderly patients with HF reported deferring care due to financial barriers.

Conclusions: Nearly 1 in 6 patients with HF in the United States reported forgone/delayed medical care, with one-half attributing it to financial reasons, and this was associated with higher overall health care spending.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jchf.2021.05.010DOI Listing
August 2021

Scope and Social Determinants of Food Insecurity Among Adults With Atherosclerotic Cardiovascular Disease in the United States.

J Am Heart Assoc 2021 Aug 13;10(16):e020028. Epub 2021 Aug 13.

Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart and Vascular Center Houston TX.

Background Atherosclerotic cardiovascular disease (ASCVD) results in high out-of-pocket healthcare expenditures predisposing to food insecurity. However, the burden and determinants of food insecurity in this population are unknown. Methods and Results Using 2013 to 2018 National Health Interview Survey data, we evaluated the prevalence and sociodemographic determinants of food insecurity among adults with ASCVD in the United States. ASCVD was defined as self-reported diagnosis of coronary heart disease or stroke. Food security was measured using the 10-item US Adult Food Security Survey Module. Of the 190 113 study participants aged 18 years or older, 18 442 (adjusted prevalence 8.2%) had ASCVD, representing ≈20 million US adults annually. Among adults with ASCVD, 2968 or 14.6% (weighted ≈2.9 million US adults annually) reported food insecurity compared with 9.1% among those without ASCVD (<0.001). Individuals with ASCVD who were younger (odds ratio [OR], 4.0 [95% CI, 2.8-5.8]), women (OR, 1.2 [1.0-1.3]), non-Hispanic Black (OR, 2.3 [1.9-2.8]), or Hispanic (OR, 1.6 [1.2-2.0]), had private (OR, 1.8 [1.4-2.3]) or no insurance (OR, 2.3 [1.7-3.1]), were divorced/widowed/separated (OR, 1.2 [1.0-1.4]), and had low family income (OR, 4.7 [4.0-5.6]) were more likely to be food insecure. Among those with ASCVD and 6 of these high-risk characteristics, 53.7% reported food insecurity and they had 36-times (OR, 36.2 [22.6-57.9]) higher odds of being food insecure compared with those with ≤1 high-risk characteristic. Conclusion About 1 in 7 US adults with ASCVD experience food insecurity, with more than 1 in 2 adults reporting food insecurity among the most vulnerable sociodemographic subgroups. There is an urgent need to address the barriers related to food security in this population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.120.020028DOI Listing
August 2021

Prevalence of cardiovascular risk factors in a nationally representative adult population with inflammatory bowel disease without atherosclerotic cardiovascular disease.

Am J Prev Cardiol 2021 Jun 16;6:100171. Epub 2021 Mar 16.

Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, United States.

Background And Aims: Chronic inflammation is associated with premature atherosclerotic cardiovascular disease (ASCVD). We studied the prevalence of cardiovascular risk factors (CRFs) amongst individuals with IBD who have not developed ASCVD.

Methods: Our study population was derived from the 2015 - 2016 National Health Interview Survey. Those with ASCVD (defined as myocardial infarction, angina or stroke) were excluded. The prevalence of CRFs among individuals with IBD was compared with those without IBD. The odds CRFs among adults with IBD was assessed using logistic regression models.

Results: In our study population of 60,155 individuals, 786 (1.3%) had IBD. IBD was associated with increased odds hypertension (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.39-2.09), diabetes (OR 1.68, 95% CI 1.22-2.32), hypercholesterolemia (OR 1.62, 95% CI 1.32-2.99) and insufficient physical activity (OR 1.38, 95% CI 1.16-1.66).

Conclusion: IBD is associated with higher prevalence of CRFs. Early screening and risk mitigation strategies are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajpc.2021.100171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315477PMC
June 2021

Association of cardiovascular risk profile with healthcare expenditure and resource utilization in chronic obstructive pulmonary disease, with and without atherosclerotic cardiovascular disease.

Am J Prev Cardiol 2020 Sep 28;3:100084. Epub 2020 Aug 28.

Division of Cardiovascular Prevention & Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.

Objective: Atherosclerotic cardiovascular disease (ASCVD) and chronic obstructive pulmonary disease (COPD) are among the leading causes of morbidity, mortality, and economic burden in the United States (US). While previous reports have shown that an optimal cardiovascular risk factor (CRF) profile is associated with improved outcomes among COPD patients, the impact of ASCVD and CRF on healthcare costs and resource utilization is not well described.

Methods: The Medical Expenditure Panel Survey (MEPS) database was used from 2011 to 2016 to study healthcare expenditure for COPD patients with and without ASCVD and across CRF profiles in a nationally representative population of adults in the United States.

Results: The study population consisted of 14,807 adults with COPD, representing 28 million cases annually. Presence of ASCVD was associated with higher reported expenditure across the spectrum of CRF profiles among those with COPD. On average, after adjusting for confounders, presence of ASCVD represented a mean difference per capita of $5438 (95% CI $4121 - $6754; p ​< ​0.001). Mean per capita expenditures were significantly higher comparing poor vs optimal CRF profiles, with marginal expenditures of $8552 and $6531 among those with and without ASCVD, respectively. When comparing individuals with ASCVD and poor CRF profile versus individuals without ASCVD and optimal CRF profile, those in the latter group used 13% fewer prescription medications and required 24% fewer hospitalizations. Furthermore, an optimal CRF profile was associated with lower odds of most sources of healthcare utilization regardless of ASCVD status.

Conclusion: An absence of ASCVD and a favorable CRF profile was associated with lower healthcare expenditure and resource utilization among patients with COPD. These results provide robust estimates for potential healthcare savings as preemptive strategies continue to become integrated into new healthcare delivery models, for increased awareness and the need for improvement of CRF profiles among high-risk patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajpc.2020.100084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315593PMC
September 2020

Association of cardiovascular risk factor profile and financial hardship from medical bills among non-elderly adults in the United States.

Am J Prev Cardiol 2020 Jun 13;2:100034. Epub 2020 Jul 13.

Division of Cardiovascular Prevention & Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.

Background: While optimal cardiovascular risk factor (CRF) profile is associated with lower mortality, morbidity, and healthcare expenditures among individuals with atherosclerotic cardiovascular disease (ASCVD), less is known regarding its impact on financial hardship from medical bills. Therefore, we assessed whether an optimal CRF profile is associated with a lower burden of financial hardship from medical bills and a reduction in cost-related barriers to health.

Methods: We used a nationally representative sample of adults between 18 and 64 years from the National Health Interview Survey between 2013 and 2017. We assessed ASCVD status and the number of risk factors to categorize the study population into 4 mutually exclusive categories: ASCVD (irrespective of CRF profile) and non-ASCVD with poor, average, and optimal CRF profile. Adjusted logistic regression model was used to determine the association of ASCVD/CRF profile with financial hardship from medical bills and cost-related barriers to health (cost-related medication non-adherence (CRN), foregone/delayed care, and high financial distress).

Results: We included 119,388 non-elderly adults, representing 189 million individuals annually across the United States. Non-ASCVD/optimal CRF profile individuals had a lower prevalence of financial hardship and an inability paying medical bills when compared with individuals with ASCVD (24% vs 45% and 6% vs 19%, respectively). Among individuals without ASCVD and an optimal CRF profile, the prevalence of each cost-related barrier to health was <50% compared with individuals with ASCVD. Poor/low income and uninsured individuals within non-ASCVD/average CRF profile strata had a lower prevalence of financial hardship and an inability paying medical bills when compared with middle/high income and insured individuals with ASCVD. Non-ASCVD individuals with optimal CRF profile had the lowest odds of all barriers to health.

Conclusion: Optimal CRF profile is associated with a lower prevalence of financial hardship from medical bills and cost-related barriers to health despite lower income and lack of insurance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajpc.2020.100034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315456PMC
June 2020

Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity.

Curr Atheroscler Rep 2021 Jul 26;23(9):55. Epub 2021 Jul 26.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.

Purpose Of Review: We sought to examine the role of social and environmental conditions that determine an individual's behaviors and risk of disease-collectively known as social determinants of health (SDOH)-in shaping cardiovascular (CV) health of the population and giving rise to disparities in risk factors, outcomes, and clinical care for cardiovascular disease (CVD), the leading cause of death in the United States (US).

Recent Findings: Traditional CV risk factors have been extensively targeted in existing CVD prevention and management paradigms, often with little attention to SDOH. Limited evidence suggests an association between individual SDOH (e.g., income, education) and CVD. However, inequities in CVD care, risk factors, and outcomes have not been studied using a broad SDOH framework. We examined existing evidence of the association between SDOH-organized into 6 domains, including economic stability, education, food, neighborhood and physical environment, healthcare system, and community and social context-and CVD. Greater social adversity, defined by adverse SDOH, was linked to higher burden of CVD risk factors and poor outcomes, such as stroke, myocardial infarction (MI), coronary heart disease, heart failure, and mortality. Conversely, favorable social conditions had protective effects on CVD. Upstream SDOH interact across domains to produce cumulative downstream effects on CV health, via multiple physiologic and behavioral pathways. SDOH are major drivers of sociodemographic disparities in CVD, with a disproportionate impact on socially disadvantaged populations. Efforts to achieve health equity should take into account the structural, institutional, and environmental barriers to optimum CV health in marginalized populations. In this review, we highlight major knowledge gaps for each SDOH domain and propose a set of actionable recommendations to inform CVD care, ensure equitable distribution of healthcare resources, and reduce observed disparities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11883-021-00949-wDOI Listing
July 2021

Prevalence and predictors of cost-related medication nonadherence in individuals with cardiovascular disease: Results from the Behavioral Risk Factor Surveillance System (BRFSS) survey.

Prev Med 2021 Jul 7;153:106715. Epub 2021 Jul 7.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, United States of America; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America. Electronic address:

Medication nonadherence is highly prevalent among patients with chronic cardiovascular disease. Poor adherence has been associated with increased morbidity and mortality. Medication cost is a major driver for medication nonadherence. Utilizing data from the 2016 to 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey, we estimated the prevalence of cost-related medication nonadherence (CRMNA) among the overall population and among individuals who reported a history of diabetes, atherosclerotic cardiovascular disease (ASCVD), or hypertension. We then performed multivariable logistic regression to analyze sociodemographic factors associated with CRMNA. Our study population consisted of 142,577 individuals of whom 24% were older than 65 years, 47% were men, 66% were White, 17% Black, 35% had hypertension, 13% had diabetes mellitus, and 10% had ASCVD. CRMNA was reported in 10% of the overall population, 12% among those with hypertension, 17% among those with diabetes, and 17% among those with ASCVD. Age below 65 years, female gender, unemployment, lower income, lower educational attainment, having at least 1 comorbidity, and living in a state that did not expand Medicaid were independently associated with CRMNA. The prevalence of CRMNA increased with greater number of these high-risk sociodemographic factors. We conclude that the prevalence of CRMNA is 10% among U.S. adults overall and is higher among those with common chronic diseases. Risk factors associated with CRMNA should be addressed in order to improve adherence rates and health outcomes among high-risk individuals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ypmed.2021.106715DOI Listing
July 2021

Financial Hardship Among Nonelderly Adults With CKD in the United States.

Am J Kidney Dis 2021 Jun 16. Epub 2021 Jun 16.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas. Electronic address:

Rationale & Objective: The burden of financial hardship among individuals with chronic kidney disease (CKD) has not been extensively studied. Therefore, we describe the scope and determinants of financial hardship among a nationally representative sample of adults with CKD.

Study Design: Cross-sectional.

Setting & Participants: Nonelderly adults with CKD from the 2014-2018 National Health Interview Survey.

Exposure: Sociodemographic and clinical characteristics.

Outcome: Financial hardship based on medical bills and consequences of financial hardship (high financial distress, food insecurity, cost-related medication nonadherence, delayed/forgone care due to cost). Financial hardship was categorized into 3 levels: no financial hardship, financial hardship but able to pay bills, and unable to pay bills at all. Financial hardship was then modeled in 2 different ways: (1) any financial hardship (regardless of ability to pay) versus no financial hardship and (2) inability to pay bills versus no financial hardship and financial hardship but able to pay bills.

Analytical Approach: Nationally representative estimates of financial hardship from medical bills were computed. Multivariable logistic regression models were used to examine the associations of sociodemographic and clinical factors with the outcomes of financial hardship based on medical bills.

Results: A total 1,425 individuals, representing approximately 2.1 million Americans, reported a diagnosis of CKD within the past year, of whom 46.9% (95% CI, 43.7%-50.2%) reported experiencing financial hardship from medical bills; 20.9% (95% CI, 18.5%-23.6%) reported inability to pay medical bills at all. Lack of insurance was the strongest determinant of financial hardship in this population (odds ratio, 4.06 [95% CI, 2.18-7.56]).

Limitations: Self-reported nature of CKD diagnosis.

Conclusions: Approximately half the nonelderly US population with CKD experiences financial hardship from medical bills that is associated strongly with lack of insurance. Evidence-based clinical and policy interventions are needed to address these hardships.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.ajkd.2021.04.011DOI Listing
June 2021

Out-of-Pocket Annual Health Expenditures and Financial Toxicity From Healthcare Costs in Patients With Heart Failure in the United States.

J Am Heart Assoc 2021 Jul 16;10(14):e022164. Epub 2021 May 16.

Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.

Background Heart failure (HF) poses a major public health burden in the United States. We examined the burden of out-of-pocket healthcare costs on patients with HF and their families. Methods and Results In the Medical Expenditure Panel Survey, we identified all families with ≥1 adult member with HF during 2014 to 2018. Total out-of-pocket healthcare expenditures included yearly care-specific costs and insurance premiums. We evaluated 2 outcomes of financial toxicity: (1) high financial burden-total out-of-pocket healthcare expense to postsubsistence income ratio of >20%, and (2) catastrophic financial burden with the ratio of >40%-a bankrupting expense defined by the World Health Organization. There were 788 families in the Medical Expenditure Panel Survey with a member with HF representing 0.54% (95% CI, 0.48%-0.60%) of all families nationally. The overall mean annual out-of-pocket healthcare expenses were $4423 (95% CI, $3908-$4939), with medications and health insurance premiums representing the largest categories of cost. Overall, 14% (95% CI, 11%-18%) of families experienced a high burden and 5% (95% CI, 3%-6%) experienced a catastrophic burden. Among the two-fifths of families considered low income, 24% (95% CI, 18%-30%) experienced a high financial burden, whereas 10% (95% CI, 6%-14%) experienced a catastrophic burden. Low-income families had 4-fold greater risk-adjusted odds of high financial burden (odds ratio [OR] , 3.9; 95% CI, 2.3-6.6), and 14-fold greater risk-adjusted odds of catastrophic financial burden (OR, 14.2; 95% CI, 5.1-39.5) compared with middle/high-income families. Conclusions Patients with HF and their families experience large out-of-pocket healthcare expenses. A large proportion encounter financial toxicity, with a disproportionate effect on low-income families.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.121.022164DOI Listing
July 2021

Burden of cardiovascular risk factors and disease in five Asian groups in Catalonia: a disaggregated, population-based analysis of 121 000 first-generation Asian immigrants.

Eur J Prev Cardiol 2021 May 10. Epub 2021 May 10.

Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6565 Fannin St Brown Bldg. B5-019, Houston, TX 77030, USA.

Aims: To evaluate the burden of cardiovascular risk factors and disease (CVD) among five Asian groups living in Catalonia (Spain): Indian, Pakistani, Bangladeshi, Filipino, and Chinese.

Methods And Results: Retrospective cohort study using the Catalan Health Surveillance System database including 42 488 Pakistanis, 40 745 Chinese, 21 705 Indians, 9544 Filipinos, and 6907 Bangladeshis; and 5.3 million native individuals ('locals'). We estimated the age-adjusted prevalence (as of 31 December 2019) and incidence (during 2019) of diabetes, hypertension, hyperlipidaemia, obesity, tobacco use, coronary heart disease (CHD), cerebrovascular disease, atrial fibrillation, and heart failure (HF). Bangladeshis had the highest prevalence of diabetes (17.4% men, 22.6% women) followed by Pakistanis. Bangladeshis also had the highest prevalence of hyperlipidaemia (23.6% men, 18.3% women), hypertension among women (24%), and incident tobacco use among men. Pakistani women had the highest prevalence of obesity (28%). For CHD, Bangladeshi men had the highest prevalence (7.3%), followed by Pakistanis (6.3%); and Pakistanis had the highest prevalence among women (3.2%). For HF, the prevalence in Pakistani and Bangladeshi women was more than twice that of locals. Indians had the lowest prevalence of diabetes across South Asians, and of CHD across South Asian men, while the prevalence of CHD among Indian women was twice that of local women (2.6% vs. 1.3%). Filipinos had the highest prevalence of hypertension among men (21.8%). Chinese men and women had the lowest prevalence of risk factors and CVD.

Conclusions: In Catalonia, preventive interventions adapted to the risk profile of different Asian immigrant groups are needed, particularly for Bangladeshis and Pakistanis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/eurjpc/zwab074DOI Listing
May 2021

Social Determinants of Adherence to COVID-19 Risk Mitigation Measures Among Adults With Cardiovascular Disease.

Circ Cardiovasc Qual Outcomes 2021 06 6;14(6):e008118. Epub 2021 May 6.

Center for Outcomes Research, Houston Methodist, Houston, TX (K.K.H., Z.J., M.C.-A., F.S.V., I.A., B.K., K.N.).

Background: Social determinants of health (SDOH) may limit the practice of coronavirus disease 2019 (COVID-19) risk mitigation guidelines with health implications for individuals with underlying cardiovascular disease (CVD). Population-based evidence of the association between SDOH and practicing such mitigation strategies in adults with CVD is lacking. We used the National Opinion Research Center's COVID-19 Household Impact Survey conducted between April and June 2020 to evaluate sociodemographic disparities in adherence to COVID-19 risk mitigation measures in a sample of respondents with underlying CVD representing 18 geographic areas of the United States.

Methods: CVD status was ascertained by self-reported history of receiving heart disease, heart attack, or stroke diagnosis. We built de novo, a cumulative index of SDOH burden using education, insurance, economic stability, 30-day food security, urbanicity, neighborhood quality, and integration. We described the practice of measures under the broad strategies of personal protection (mask, hand hygiene, and physical distancing), social distancing (avoiding crowds, restaurants, social activities, and high-risk contact), and work flexibility (work from home, canceling/postponing work). We reported prevalence ratios and 95% CIs for the association between SDOH burden (quartiles of cumulative indices) and practicing these measures adjusting for age, sex, race/ethnicity, comorbidity, and interview wave.

Results: Two thousand thirty-six of 25 269 (7.0%) adults, representing 8.69 million in 18 geographic areas of the United States, reported underlying CVD. Compared with the least SDOH burden, fewer individuals with the greatest SDOH burden practiced all personal protection (75.6% versus 89.0%) and social distancing measures (41.9% versus 58.9%) and had any flexible work schedule (26.2% versus 41.4%). These associations remained statistically significant after full adjustment: personal protection (prevalence ratio, 0.83 [95% CI, 0.73-0.96]; =0.009), social distancing (prevalence ratio, 0.69 [95% CI, 0.51-0.94]; =0.018), and work flexibility (prevalence ratio, 0.53 [95% CI, 0.36-0.79]; =0.002).

Conclusions: SDOH burden is associated with lower COVID-19 risk mitigation practices in the CVD population. Identifying and prioritizing individuals whose medical vulnerability is compounded by social adversity may optimize emerging preventive efforts, including vaccination guidelines.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCOUTCOMES.121.008118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8204764PMC
June 2021

Disparities in cholesterol screening among a nationally representative sample of pregnant women in the United States.

Eur J Prev Cardiol 2020 Nov 25. Epub 2020 Nov 25.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin Street, Suite 1801, Houston, TX 77030, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/eurjpc/zwaa100DOI Listing
November 2020

Racial and Ethnic Disparities in Access to Health Care Among Adults in the United States: A 20-Year National Health Interview Survey Analysis, 1999-2018.

medRxiv 2020 Nov 4. Epub 2020 Nov 4.

Importance: Racial and ethnic disparities plague the US health care system despite efforts to eliminate them. To understand what has been achieved amid these efforts, a comprehensive study from the population perspective is needed.

Objectives: To determine trends in rates and racial/ethnic disparities of key access to care measures among adults in the US in the last two decades.

Design: Cross-sectional.

Setting: Data from the National Health Interview Survey, 1999-2018.

Participants: Individuals >18 years old.

Exposure: Race and ethnicity: non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, Hispanic.

Main Outcome And Measures: Rates of lack of insurance coverage, lack of a usual source of care, and foregone/delayed medical care due to cost. We also estimated the gap between non-Hispanic White and the other subgroups for these outcomes.

Results: We included 596,355 adults, of which 69.7% identified as White, 11.8% as Black, 4.7% as Asian, and 13.8% as Hispanic. The proportion uninsured and the rates of lacking a usual source of care remained stable across all 4 race/ethnicity subgroups up to 2009, while rates of foregone/delayed medical care due to cost increased. Between 2010 and 2015, the percentage of uninsured diminished for all, with the steepest reduction among Hispanics (-2.1% per year). In the same period, rates of no usual source of care declined only among Hispanics (-1.2% per year) while rates of foregone/delayed medical care due to cost decreased for all. No substantial changes were observed from 2016-2018 in any outcome across subgroups. Compared with 1999, in 2018 the rates of foregone/delayed medical care due to cost were higher for all (+3.1% among Whites, +3.1% among Blacks, +0.5% among Asians, and +2.2% among Hispanics) without significant change in gaps; rates of no usual source of care were not significantly different among Whites or Blacks but were lower among Hispanics (-4.9%) and Asians (-6.4%).

Conclusions And Relevance: Insurance coverage increased for all, but millions of individuals remained uninsured or underinsured with increasing rates of unmet medical needs due to cost. Those identifying as non-Hispanic Black and Hispanic continue to experience more barriers to health care services compared with non-Hispanic White individuals.

Key Points: In the last 2 decades, what has been achieved in reducing barriers to access to care and race/ethnicity-associated disparities? Using National Health Interview Survey data from 1999-2018, we found that insurance coverage increased across all 4 major race/ethnicity groups. However, rates of unmet medical needs due to cost increased without reducing the respective racial/ethnic disparities, and little-to-no change occurred in rates of individuals who have no usual source of care. Despite increased coverage, millions of Americans continued to experience barriers to access to care, which were disproportionately more prevalent among those identifying as Black or Hispanic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1101/2020.10.30.20223420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654899PMC
November 2020

Racial and Ethnic Disparities in Health of Adults in the United States: A 20-Year National Health Interview Survey Analysis, 1999-2018.

medRxiv 2020 Nov 4. Epub 2020 Nov 4.

Importance: Thirty-five years ago, the Heckler Report described health disparities among minority populations in the US. Since then, policies have been implemented to address these disparities. However, a recent evaluation of progress towards improving the health and health equity among US adults is lacking.

Objectives: To evaluate racial/ethnic disparities in the physical and mental health of US adults over the last 2 decades.

Design: Cross-sectional.

Setting: National Health Interview Survey data, years 1999-2018.

Participants: Adults aged 18-85 years.

Exposure: Race/ethnicity subgroups (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic).

Main Outcome And Measures: Proportion of adults reporting poor/fair health status, severe psychological distress, functional limitation, and insufficient sleep. We also estimated the gap between non-Hispanic White and the other subgroups for these four outcomes.

Results: We included 596,355 adults (mean age 46 years, 51.8% women), of which 69.7%, 13.8%, 11.8% and 4.7% identified as non-Hispanic White, Hispanic, non-Hispanic Black, and non-Hispanic Asian, respectively. Between 1999 and 2018, Black individuals fared worse on most measures of health, with 18.7% (95% CI 17.1-20.4) and 41.1% (95% CI 38.7-43.5) reporting poor/fair health and insufficient sleep in 2018 compared with 11.1% (95% CI 10.5- 11.7) and 31.2% (95% CI 30.3-32.1) among White individuals. Notably, between 1999-2018, there was no significant decrease in the gap in poor/fair health status between White individuals and Black (-0.07% per year, 95% CI -0.16-0.01) and Hispanic (-0.03% per year, 95% CI -0.07- 0.02) individuals, and an increase in the gap in sleep between White individuals and Black (+0.2% per year, 95% CI 0.1-0.4) and Hispanic (+0.3% per year, 95% CI 0.1-0.4) individuals. Additionally, there was no significant decrease in adults reporting poor/fair health status and an increase in adults reporting severe psychological distress, functional limitation, and insufficient sleep.

Conclusions And Relevance: The marked racial/ethnic disparities in health of US adults have not improved over the last 20 years. Moreover, the self-perceived health of US adults worsened during this time. These findings highlight the need to re-examine the initiatives seeking to promote health equity and improve health.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1101/2020.10.30.20223487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654876PMC
November 2020

Prevalence and Disparities in Influenza Vaccination Among Patients With COPD in the United States.

Chest 2021 04 28;159(4):1411-1414. Epub 2020 Oct 28.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX; Center for Outcomes Research, Houston Methodist Research Institute, Houston, TX. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.chest.2020.10.058DOI Listing
April 2021

Prevalence of and Sociodemographic Disparities in Influenza Vaccination Among Adults With Diabetes in the United States.

J Endocr Soc 2020 Nov 24;4(11):bvaa139. Epub 2020 Sep 24.

Center for Outcomes Research, Houston Methodist Research Institute, Houston Texas.

National estimates describing the overall prevalence of and disparities in influenza vaccination among patients with diabetes mellitus (DM) in United States are not well described. Therefore, we analyzed the prevalence of influenza vaccination among adults with DM, overall and by sociodemographic characteristics, using the Medical Expenditure Panel Survey database from 2008 to 2016. Associations between sociodemographic factors and lack of vaccination were examined using adjusted logistic regression. Among adults with DM, 36% lacked influenza vaccination. Independent predictors of lacking influenza vaccination included age 18 to 39 years (odds ratio [OR] 2.54; 95% confidence interval [CI], 2.14-3.00), Black race/ethnicity (OR 1.29; 95% CI, 1.14-1.46), uninsured status (OR 1.88; 95% CI, 1.59-2.21), and no usual source of care (OR 1.61; 95% CI, 1.39-1.85). Nearly 64% individuals with ≥ 4 higher-risk sociodemographic characteristics lacked influenza vaccination (OR 3.50; 95% CI 2.79-4.39). One-third of adults with DM in the United States lack influenza vaccination, with younger age, Black race, and lower socioeconomic status serving as strong predictors. These findings highlight the continued need for focused public health interventions to increase vaccine coverage and utilization among disadvantaged communities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1210/jendso/bvaa139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575128PMC
November 2020

Association Between Sociodemographic Determinants and Disparities in Stroke Symptom Awareness Among US Young Adults.

Stroke 2020 12 26;51(12):3552-3561. Epub 2020 Oct 26.

Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (R.M., J.L.). Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (S.M., H.M.K.). Section of Cardiovascular Medicine, Department of Internal Medicine (S.M., H.M.K.) and Department of Neurology (R.K.), Yale School of Medicine, New Haven, CT. Division of Cardiovascular Prevention and Wellness (J.V.-E., M.C.-A., K.N.) and Center for Outcomes Research (K.N.), Houston Methodist DeBakey Heart and Vascular Center, TX. Houston Methodist Research Institute, TX (T.Y.). University of Texas Southwestern Medical Center, Dallas (R.S.). Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD (G.R.G.). Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX (S.S.V.). Department of Medicine, West Virginia University School of Medicine, Morgantown (S.U.K.). Center for Outcomes Research, Houston Methodist Neurological Institute, TX (F.S.V.).

Background And Purpose: Despite declining stroke rates in the general population, stroke incidence and hospitalizations are rising among younger individuals. Awareness of and prompt response to stroke symptoms are crucial components of a timely diagnosis and disease management. We assessed awareness of stroke symptoms and response to a perceived stroke among young adults in the United States.

Methods: Using data from the 2017 National Health Interview Survey, we assessed awareness of 5 common stroke symptoms and the knowledge of planned response (ie, calling emergency medical services) among young adults (<45 years) across diverse sociodemographic groups. Common stroke symptoms included: (1) numbness of face/arm/leg, (2) confusion/trouble speaking, (3) difficulty walking/dizziness/loss of balance, (4) trouble seeing in one/both eyes, and (5) severe headache.

Results: Our study population included 24 769 adults, of which 9844 (39.7%) were young adults who were included in our primary analysis, and represented 107.2 million US young adults (mean age 31.3 [±7.5] years, 50.6% women, and 62.2% non-Hispanic White). Overall, 2718 young adults (28.9%) were not aware of all 5 stroke symptoms, whereas 242 individuals (2.7%; representing 2.9 million young adults in the United States) were not aware of a single symptom. After adjusting for confounders, Hispanic ethnicity (odds ratio, 1.96 [95% CI, 1.17-3.28]), non-US born immigration status (odds ratio, 2.02 [95% CI, 1.31-3.11]), and lower education level (odds ratio, 2.77 [95% CI, 1.76-4.35]), were significantly associated with lack of symptom awareness. Individuals with 5 high-risk characteristics (non-White, non-US born, low income, uninsured, and high school educated or lower) had nearly a 4-fold higher odds of not being aware of all symptoms (odds ratio, 3.70 [95% CI, 2.43-5.62]).

Conclusions: Based on data from the National Health Interview Survey, a large proportion of young adults may not be aware of stroke symptoms. Certain sociodemographic subgroups with decreased awareness may benefit from focused public health interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.120.031137DOI Listing
December 2020

Immunotyping of tumor-infiltrating lymphocytes in triple-negative breast cancer and genetic characterization.

Oncol Lett 2020 Nov 20;20(5):140. Epub 2020 Aug 20.

Breast Cancer Center, Hospital San José, TecSalud, Tecnológico de Monterrey, Monterrey, Nuevo León 64710, México.

Tumor-infiltrating lymphocytes (TILs) reflect the host immune response against cancer cells. Immunomodulators have been recently suggested as a novel therapeutic strategy against triple-negative breast cancer (TNBC). However, the TIL profile in TNBC has not been thoroughly investigated. In the present study, the percentage, immunophenotype and genetic profiles of TILs in pre-surgical tumor samples of patients with TNBC were evaluated prior to neoadjuvant chemotherapy (NAC). Patients diagnosed with breast cancer at Hospital San José TecSalud were consecutively and prospectively enrolled in the present study between August 2011 and August 2015. The pathological response to NAC was evaluated using the de Miller-Payne and MD Anderson Cancer Center system. TIL percentage (low, intermediate, and high) was evaluated using special hematoxylin-eosin staining on the core needle biopsies. The immunophenotype of TILs was assessed by immunohistochemistry (IHC) for CD3, CD4 and CD8. In addition, the gene expression profile of , forkhead box P3, interleukin 6, programmed cell death 1 and CD274 molecule was assessed in all patients. A total of 26 samples from patients with TNBC prior to NAC were included in the present study. TILs were low in 30.7%, intermediate in 38.4% and elevated in 30.7% of tumors. CD3 and CD4 counts were associated with the pathological response to NAC (P=0.04). Finally, an overexpression pattern of and genes was observed in patients with a partial or complete pathological response. The present results demonstrated that TILs may predict the pathological response to NAC in patients with TNBC. Furthermore, a more accurate association was identified between the high expression levels of and genes and partial and complete pathological response, compared with the association between high expression and IHC alone.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3892/ol.2020.12000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7471657PMC
November 2020

Financial Toxicity in Atherosclerotic Cardiovascular Disease in the United States: Current State and Future Directions.

J Am Heart Assoc 2020 10 13;9(19):e017793. Epub 2020 Sep 13.

Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine New Haven CT.

Atherosclerotic cardiovascular disease (ASCVD) has posed an increasing burden on Americans and the United States healthcare system for decades. In addition, ASCVD has had a substantial economic impact, with national expenditures for ASCVD projected to increase by over 2.5-fold from 2015 to 2035. This rapid increase in costs associated with health care for ASCVD has consequences for payers, healthcare providers, and patients. The issues to patients are particularly relevant in recent years, with a growing trend of shifting costs of treatment expenses to patients in various forms, such as high deductibles, copays, and coinsurance. Therefore, the issue of financial toxicity" of health care is gaining significant attention. The term encapsulates the deleterious impact of healthcare expenditures for patients. This includes the economic burden posed by healthcare costs, but also the unintended consequences it creates in form of barriers to necessary medical care, quality of life as well tradeoffs related to non-health-related necessities. While the societal impact of rising costs related to ASCVD management have been actively studied and debated in policy circles, there is lack of a comprehensive assessment of the current literature on the financial impact of cost sharing for ASCVD patients and their families. In this review we systematically describe the scope and domains of financial toxicity, the instruments that measure various facets of healthcare-related financial toxicity, and accentuating factors and consequences on patient health and well-being. We further identify avenues and potential solutions for clinicians to apply in medical practice to mitigate the burden and consequences of out-of-pocket costs for ASCVD patients and their families.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.120.017793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792407PMC
October 2020

Sociodemographic Disparities in Influenza Vaccination Among Adults With Atherosclerotic Cardiovascular Disease in the United States.

JAMA Cardiol 2021 Jan;6(1):87-91

Center for Outcomes Research, The Houston Methodist Research Institute, Houston, Texas.

Importance: Atherosclerotic cardiovascular disease (ASCVD) remains a leading cause of death and disability in the US and worldwide. Influenza vaccination has shown to decrease overall morbidity, mortality, severity of infection, and hospital readmissions among these individuals. However, national estimates of influenza vaccination among individuals with ASCVD in the US are not well studied.

Objective: To evaluate the prevalence of and sociodemographic disparities in influenza vaccination among a nationally representative sample of individuals with ASCVD.

Design, Setting, And Participants: Pooled Medical Expenditure Panel Survey data from 2008 to 2016 were used and included adults 40 years or older with ASCVD. Participants' ASCVD status was ascertained via self-report and/or International Classification of Diseases, Ninth Revision diagnosis of coronary heart disease, peripheral artery disease, and/or cerebrovascular disease. Analysis began April 2020.

Main Outcomes And Measures: Prevalence and characteristics of adults with ASCVD who lacked influenza vaccination during the past year. Covariates including age, sex, race/ethnicity, family income, insurance status, education level, and usual source of care were assessed.

Results: Of 131 881 adults, 19 793 (15.7%) had ASCVD, corresponding to 22.8 million US adults annually. A total of 7028 adults with ASCVD (32.7%), representing 7.4 million adults, lacked influenza vaccination. The highest odds of lacking vaccination were observed among individuals aged 40 to 64 years (odds ratio [OR], 2.32; 95% CI, 2.06-2.62), without a usual source of care (OR, 2.00; 95% CI, 1.71-2.33), without insurance (OR, 2.05; 95% CI, 1.63-2.58), with a lower education level (OR, 1. 25; 95% CI, 1.12-1.40), with a lower income level (OR, 1.14; 95% CI, 1.01-1.27), and of non-Hispanic Black race/ethnicity (OR, 1.24, 95% CI, 1.10-1.41). A stepwise increase was found in the prevalence and odds of lacking influenza vaccination among individuals with increase in high-risk characteristics. Overall, 1171 individuals (59.7%; 95% CI, 55.8%-63.5%) with 4 or more high-risk characteristics and ASCVD (representing 732 524 US adults annually) reported lack of influenza vaccination (OR, 6.06; 95% CI, 4.88-7.53).

Conclusion And Relevance: Despite current recommendations, a large proportion of US adults with established ASCVD lack influenza vaccination, with several sociodemographic subgroups having greater risk. Focused public health initiatives are needed to increase access to influenza vaccinations for high-risk and underserved populations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamacardio.2020.3978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489417PMC
January 2021

Financial Hardship After Traumatic Injury: Risk Factors and Drivers of Out-of-Pocket Health Expenses.

J Surg Res 2020 12 11;256:1-12. Epub 2020 Jul 11.

Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist, Houston, Texas.

Background: Trauma-related disorders rank among the top five most costly medical conditions to the health care system. However, the impact of out-of-pocket (OOP) health expenses for traumatic conditions is not known. In this cross-sectional study, we use nationally representative data to investigate whether patients with a traumatic injury experienced financial hardship from OOP health expenses.

Methods: Using data from the Medical Expenditure Panel Survey from 2010 to 2015, we analyzed the financial burden associated with a traumatic injury. Primary outcomes were excess financial burden (OOP>20% of annual income) and catastrophic medical expenses (OOP>40% of annual income). A multivariable logistic regression analysis evaluated whether these outcomes were associated with traumatic injury, adjusting for demographic, socioeconomic, and health care factors. We then completed a descriptive analysis to elucidate drivers of total OOP expenses.

Results: Of the 90,964 families in the cohort, 6434 families had a traumatic injury requiring a visit to the emergency room and 668 families had a traumatic injury requiring hospitalization. Overall 1 in 8 households with an injured family member requiring hospitalization experienced financial hardship. These families were more likely to experience excess financial burden (OR: 2.04, 95% CI: 1.13-3.64) and catastrophic medical expenses (OR: 3.08, 95% CI: 1.37-6.9). The largest burden of OOP expenses was due to prescription drug costs, with inpatient costs as a major driver of OOP expenses for those requiring hospitalization.

Conclusions: Households with an injured family member requiring hospitalization are significantly more vulnerable to financial hardship from OOP health expenses than the noninjured population. Prescription drug and inpatient costs were the most significant drivers of OOP health expenses.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2020.05.095DOI Listing
December 2020

Cumulative Burden of Financial Hardship From Medical Bills Across the Spectrum of Diabetes Mellitus and Atherosclerotic Cardiovascular Disease Among Non-Elderly Adults in the United States.

J Am Heart Assoc 2020 05 12;9(10):e015523. Epub 2020 May 12.

Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart and Vascular Center Houston TX.

Background Atherosclerotic cardiovascular disease (ASCVD) has a strong association with diabetes mellitus (DM), accounting for approximately two thirds of deaths in this patient population. Many individuals with ASCVD and DM are vulnerable to financial hardship associated with treatment-related expenses. Therefore, we examined the burden of financial hardship from medical bills across the spectrum of ASCVD status with and without DM. Methods and Results Using data from the National Health Interview Survey from 2013 to 2017, we used logistic regression analysis to examine the association of ASCVD and DM status with financial hardship and an inability to pay medical bills from a representative sample of non-elderly adults in the United States. Our study population consisted of 121 672 individuals. Approximately 3.1% of the weighted population had ASCVD, 5.6% had DM, and 1.3% had both ASCVD and DM. Nearly 50% of individuals with ASCVD and DM reported financial hardship from medical bills (23% being unable to pay medical bills at all), whereas ≈28% of those with neither ASCVD nor DM reported financial hardship from medical bills (8% being unable to pay medical bills at all). Individuals with concurrent ASCVD and DM had the highest relative odds of expressing an inability to pay at all when compared with those with neither condition (odds ratio, 2.69; 95% CI, 2.21-3.28). Conclusions Individuals with concurrent ASCVD and DM are at a disproportionately high risk of being unable to pay their medical bills. The findings provide strong evidence for developing more effective public health policies that protect vulnerable populations from financial hardship.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.119.015523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660844PMC
May 2020

Temporal Trends in E-Cigarette Use Among U.S. Adults: Behavioral Risk Factor Surveillance System, 2016 to 2018.

Am J Med 2020 09 25;133(9):e508-e511. Epub 2020 Mar 25.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.

Background: It is important to study the trends of e-cigarette use among various subgroups to understand which populations may be more susceptible to increased use and, therefore, are at risk for potential long-term health effects.

Methods: We used cross-sectional data from the 2016-2017 Behavioral Risk Factor Surveillance System, a nationally representative U.S. telephone-based survey of adults aged 18 years or older. The 2017 dataset also includes data from participant interviews that had been conducted in the year 2018. Current e-cigarette use was defined as use of e-cigarettes every day or on some days. We analyzed data using survey weights to ensure representativeness of the data to the US population.

Results: The study population consisted of 936,319 individuals, of whom 28,917 were current e-cigarette users, and corresponded to 10.8 million U.S. adults. Thirty percent were aged between 18 and 34 years. Forty-nine percent were men; 63% were white, 12% black, and 17% Hispanic. The overall prevalence of current e-cigarette use increased from 4.3% in 2016 to 4.8% in 2018. E-cigarette use significantly increased among middle-aged adults (from 3.9% to 5.2%; P = .004), women (from 3.3% to 4.3%; P <.001), and former smokers (from 5.2% to 7.9%; P = .02), but decreased among current smokers (from 14.5% to 13.8%; P = .02).

Conclusions: In a nationally representative sample, we found important trends in e-cigarette use in a relatively short time frame. A significantly increasing prevalence of e-cigarette use was noted among middle-age adults, women, and former smokers. Our study provides important information about e-cigarette trends that can be used by clinicians when counselling patients and by regulatory agencies to develop public policies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjmed.2019.12.020DOI Listing
September 2020

Burden and Consequences of Financial Hardship From Medical Bills Among Nonelderly Adults With Diabetes Mellitus in the United States.

Circ Cardiovasc Qual Outcomes 2020 02 6;13(2):e006139. Epub 2020 Feb 6.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX (J.V.-E., K.N.).

Background: The trend of increasing total and out-of-pocket expenditure among patients with diabetes mellitus represents a risk of financial hardship for Americans and a threat to medical and nonmedical needs. We aimed to describe the national scope and associated tradeoffs of financial hardship from medical bills among nonelderly individuals with diabetes mellitus.

Methods And Results: We used the National Health Interview Survey data from 2013 to 2017, including adults ≤64 years old with a self-reported diagnosis of diabetes mellitus. Among 164 696 surveyed individuals, 8967 adults ≤64 years old reported having diabetes mellitus, representing 13.1 million individuals annually across the United States. The mean age was 51.6 years (SD 10.3), and 49.1% were female. A total of 41.1% were part of families that reported having financial hardship from medical bills, with 15.6% reporting an inability to pay medical bills at all. In multivariate analyses, individuals who lacked insurance, were non-Hispanic black, had low income, or had high-comorbidity burden were at higher odds of being in families with financial hardship from medical bills. When comparing the graded categories of financial hardship, there was a stepwise increase in the prevalence of high financial distress, food insecurity, cost-related nonadherence, and foregone/delayed medical care, reaching 70.5%, 49.4%, 49.5%, and 74% among those unable to pay bills, respectively. Compared with those without diabetes mellitus, individuals with diabetes mellitus had higher odds of financial hardship from medical bills (adjusted odds ratio [aOR], 1.27 [95% CI, 1.18-1.36]) or any of its consequences, including high financial distress (aOR, 1.14 [95% CI, 1.05-1.24]), food insecurity (aOR, 1.27 [95% CI, 1.16-1.40]), cost-related medication nonadherence (aOR, 1.43 [95% CI, 1.30-1.57]), and foregone/delayed medical care (aOR, 1.30 [95% CI, 1.20-1.40]).

Conclusions: Nonelderly patients with diabetes mellitus have a high prevalence of financial hardship from medical bills, with deleterious consequences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCOUTCOMES.119.006139DOI Listing
February 2020

Variation and Disparities in Awareness of Myocardial Infarction Symptoms Among Adults in the United States.

JAMA Netw Open 2019 12 2;2(12):e1917885. Epub 2019 Dec 2.

Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.

Importance: Prompt recognition of myocardial infarction symptoms is critical for timely access to lifesaving emergency cardiac care. However, patients with myocardial infarction continue to have a delayed presentation to the hospital.

Objective: To understand the variation and disparities in awareness of myocardial infarction symptoms among adults in the United States.

Design, Setting, And Participants: This cross-sectional study used data from the 2017 National Health Interview Survey among adult residents of the United States, assessing awareness of the 5 following common myocardial infarction symptoms among different sociodemographic subgroups: (1) chest pain or discomfort, (2) shortness of breath, (3) pain or discomfort in arms or shoulders, (4) feeling weak, lightheaded, or faint, and (5) jaw, neck, or back pain. The response to a perceived myocardial infarction (ie, calling emergency medical services vs other) was also assessed.

Main Outcomes And Measures: Prevalence and characteristics of individuals who were unaware of myocardial infarction symptoms and/or chose not to call emergency medical services in response to these symptoms.

Results: Among 25 271 individuals (13 820 women [51.6%; 95% CI, 50.8%-52.4%]; 17 910 non-Hispanic white individuals [69.9%; 95% CI, 68.2%-71.6%]; and 21 826 individuals [82.7%; 95% CI, 81.5%-83.8%] born in the United States), 23 383 (91.8%; 95% CI, 91.0%-92.6%) considered chest pain or discomfort a symptom of myocardial infarction; 22 158 (87.0%; 95% CI, 86.1%-87.8%) considered shortness of breath a symptom; 22 064 (85.7%; 95% CI, 84.8%-86.5%) considered pain or discomfort in arm a symptom; 19 760 (77.0%; 95% CI, 76.1%-77.9%) considered feeling weak, lightheaded, or faint a symptom; and 16 567 (62.6%; 95% CI, 61.6%-63.7%) considered jaw, neck, or back pain a symptom. Overall, 14 075 adults (53.0%; 95% CI, 51.9%-54.1%) were aware of all 5 symptoms, whereas 4698 (20.3%; 95% CI, 19.4%-21.3%) were not aware of the 3 most common symptoms and 1295 (5.8%; 95% CI, 5.2%-6.4%) were not aware of any symptoms. Not being aware of any symptoms was associated with male sex (odds ratio [OR], 1.23; 95% CI, 1.05-1.44; P = .01), Hispanic ethnicity (OR, 1.89; 95% CI, 1.47-2.43; P < .001), not having been born in the United States (OR, 1.85; 95% CI, 1.47-2.33; P < .001), and having a lower education level (OR, 1.31; 95% CI, 1.09-1.58; P = .004). Among 294 non-Hispanic black or Hispanic individuals who were not born in the United States, belonged to the low-income or lowest-income subgroup, were uninsured, and had a lower education level, 61 (17.9%; 95% CI, 13.3%-23.6%) were not aware of any symptoms. This group had 6-fold higher odds of not being aware of any symptoms (OR, 6.34; 95% CI, 3.92-10.26; P < .001) compared with individuals without these characteristics. Overall, 1130 individuals (4.5%; 95% CI, 4.0%-5.0%) chose a different response than calling emergency medical services in response to a myocardial infarction.

Conclusions And Relevance: Many adults in the United States remain unaware of the symptoms of and appropriate response to a myocardial infarction. In this study, several sociodemographic subgroups were associated with a higher risk of not being aware. They may benefit the most from targeted public health initiatives.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2019.17885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991230PMC
December 2019

Cost-Related Medication Nonadherence in Adults With Atherosclerotic Cardiovascular Disease in the United States, 2013 to 2017.

Circulation 2019 12 25;140(25):2067-2075. Epub 2019 Nov 25.

Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart & Vascular Center & Center for Outcomes Research Houston Methodist, Houston, TX (K.N.).

Background: Medication nonadherence is associated with worse outcomes in patients with atherosclerotic cardiovascular disease (ASCVD), a group who requires long-term therapy for secondary prevention. It is important to understand to what extent drug costs, which are potentially actionable factors, contribute to medication nonadherence.

Methods: In a nationally representative survey of US adults in the National Health Interview Survey (2013-2017), we identified individuals ≥18 years with a reported history of ASCVD. Participants were considered to have experienced cost-related nonadherence (CRN) if in the preceding 12 months they reported skipping doses to save money, taking less medication to save money, or delaying filling a prescription to save money. We used survey analysis to obtain national estimates.

Results: Of the 14 279 surveyed individuals with ASCVD, a weighted 12.6% (or 2.2 million [95% CI, 2.1-2.4]) experienced CRN, including 8.6% or 1.5 million missing doses, 8.8% or 1.6 million taking lower than prescribed doses, and 10.5% or 1.9 million intentionally delaying a medication fill to save costs. Age <65 years, female sex, low family income, lack of health insurance, and high comorbidity burden were independently associated with CRN, with >1 in 5 reporting CRN in these subgroups. Survey respondents with CRN compared with those without CRN had 10.8-fold higher odds of requesting low-cost medications and 8.9-fold higher odds of using alternative, nonprescription, therapies.

Conclusions: One in 8 patients with ASCVD reports nonadherence to medications because of cost. The removal of financial barriers to accessing medications, particularly among vulnerable patient groups, may help improve adherence to essential therapy to reduce ASCVD morbidity and mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.119.041974DOI Listing
December 2019
-->