The study — presented at the American College of Cardiology’s Annual Scientific Session April 6–8 — also found men with a high intake of alcohol also had an increased risk of developing coronary heart disease. The research has yet to be published in a peer-reviewed journal.

Now, researchers from Kaiser Permanente Northern California have found that a woman’s chance of developing coronary heart disease can also increase depending on the amount of alcohol consumed.

Cisgender women are at a higher risk for developing coronary heart disease than men due to size and structural differences in the heart and hormonal changes that happen when a woman ages.

A type of cardiovascular disease, coronary heart disease occurs when cholesterol builds up on the inside of artery walls, forming plaques that make it difficult for blood to flow to the heart.

According to researchers, coronary heart disease is currently the third leading cause of death in the world and is linked to 17.8 million deaths each year.

“There has long been this idea that alcohol is good for the heart — but more and more evidence is challenging that notion. Also, past studies that compared people who drink alcohol with people who abstain from drinking alcohol could not completely account for bias due to ‘sick quitters’ or ‘healthy users.’ We felt it was important to explore the relationship between levels of alcohol use, including heavy episodic drinking or binge drinking , and the risk of coronary heart disease in women and men.”

“I think a lot more awareness is needed that alcohol use can be a factor in heart disease risk and that asking about alcohol use should be part of routine health assessments moving forward. At Kaiser Permanente Northern California, alcohol use is considered a vital sign, and we ask about it and record the response at every medical appointment, the same way we record someone’s blood pressure.”

“When we think about protection against heart disease, the first thing most people think of is: don’t smoke,” Dr. Rana told Medical News Today.

According to Dr. Jamal Rana , a cardiologist with The Permanente Medical Group, an adjunct investigator in the Division of Research at Kaiser Permanente Northern California, and the lead author of this study, more awareness is needed on how alcohol can affect heart health.

Scientists compared the relationship between alcohol intake levels reported by participants to coronary heart disease diagnoses received during the four years after.

Those who participated in binge drinking had five or more drinks per day in the past three months for men and four or more drinks per day in the past three months for women.

Additionally, researchers categorized study participants by whether they engaged in binge drinking or not.

Participants were placed in three alcohol intake levels — low (one to two drinks per week for both men and women), moderate (three to 14 drinks per week for men and three to seven drinks for women), and high (15 or more drinks per week for men and eight or more drinks per week for women).

Study participants ranged in age from 18 to 65 and had no prior heart disease at the start of the study.

For this study, Dr. Rana and his team analyzed alcohol use data from more than 430,000 people who received care at Kaiser Permanente Northern California.

The study also found that male participants with high alcohol intake and met the binge drinking category heightened their heart disease risk by 33% compared to those reporting moderate alcohol intake.

Males with a high alcohol intake who also met the criteria for binge drinking had a 33% increased risk of heart disease.

The study also found that male participants with high alcohol intake had a 15% higher risk of heart disease compared to those reporting moderate alcohol intake.

“Women process alcohol differently than men due to pharmacokinetic and physiologic differences. There has been an increasing prevalence of alcohol use among young and middle-aged women as women may feel they’re protected against heart disease until they’re older, but this study shows that even in that age group, women who drink more than the recommended amount of one drink per day or tend to binge drink, are at risk for coronary heart disease.”

“Our findings also underscore how important it is for healthcare providers to ask women not only how often they drink but if they binge drink.”

“These findings suggest that we need to be educating women about potential heart risks associated with binge drinking,” Dr. Rana said.

Scientists also discovered that women who fit the binge drinking category increased their heart disease risk by 68%.

Upon analysis, the researchers found that women who did not binge drink but reported high alcohol intake had a 45% increased chance of developing heart disease compared to female participants who reported moderate alcohol intake.

After reviewing this research, Dr. Jennifer Wong, a board certified cardiologist and medical director of Non-Invasive Cardiology at MemorialCare Heart and Vascular Institute at Orange Coast Medical Center in Fountain Valley, CA, told MNT she felt it was useful information about how alcohol might adversely affect the heart.

“It gives doctors additional evidence to present to patients when encouraging them to decrease their alcohol intake,” Dr. Wong explained.

“(For future research) it might be useful to see what the effects of cutting back would be in terms of cardiovascular outcomes, such as heart attack or myocardial infarction and deaths from cardiovascular causes.”

MNT also spoke with Monique Richard, a registered dietitian nutritionist and owner of Nutrition-In-Sight, who was not surprised by the study’s findings because while a little bit of a good thing can be beneficial, a lot of anything can be harmful.

“We know that excessive amounts of alcohol can contribute to an increase in blood pressure, dehydration, nutrient depletion, and displacement of, or an excess intake of, necessary and/or unnecessary calories,” Richard detailed.

Kaiser Permanente study suggests just 2 drinks a day can increase the risk of heart disease

Updated Feb. 11, 2025

Women who reported drinking 8 or more alcoholic beverages per week were significantly more likely to develop coronary heart disease than those who drank less, according to Kaiser Permanente research published in the American Journal of Preventive Cardiology. The findings were previously presented at the American College of Cardiology Annual Scientific Session.

“There has long been this idea that alcohol is good for the heart — but we are seeing growing evidence challenging that notion,” said lead author Jamal S. Rana, MD, PhD, a cardiologist with The Permanente Medical Group, and an adjunct investigator at the Kaiser Permanente Division of Research. “We felt it was important to leverage comprehensive data we have available at Kaiser Permanente to contribute to this conversation by exploring the relationship between levels of alcohol use, including heavy episodic or ‘binge’ drinking, and the risk of coronary heart disease in women and men.”

The study included 432,265 Kaiser Permanente Northern California (KPNC) members ages 18 to 65 who did not have a history of heart disease or stroke. All the participants were asked about their alcohol use during a primary care visit as part of KPNC’s “Alcohol as a Vital Sign” alcohol screening initiative in primary care, between 2014 to 2015. The research team identified which patients had a diagnosis of coronary heart disease in the following 4 years. Coronary heart disease occurs when the arteries that supply blood to the heart become narrowed, limiting blood flow.

There has long been this idea that alcohol is good for the heart — but we are seeing growing evidence challenging that notion. — Jamal Rana, MD, PhD

The researchers used federal standards to classify the participants’ overall alcohol intake as low (1 to 2 drinks per week for men and women); moderate (3 to 14 drinks per week for men and 3 to 7 drinks per week for women); or high (15 or more drinks per week for men and 8 or more drinks per week for women). Binge drinking was defined as more than 4 drinks for men or more than 3 drinks for women in a single day in the past 3 months.

The study found weekly alcohol intake above recommended limits was associated with an overall 26% higher risk of coronary heart disease. However, the risk was 19% higher in men and 43% higher in women.

Binge drinking increases risk

The highest risk was seen in women and men who reported heavy episodic or “binge” drinking. Women in this category were 68% more likely to develop heart disease compared with women reporting moderate intake. Men who reported binge drinking were 33% more likely to develop heart disease than men who drank a moderate amount of alcohol.

“Alcohol has been shown to raise blood pressure and lead to metabolic changes that are associated with inflammation and obesity, both of which increase the risk for heart disease,” said senior author Stacy A. Sterling, DrPH, MSW, a research scientist at the Division of Research. “Women also process alcohol differently than men due to biologic and physiologic differences, and this may contribute to the increased heart disease risk we found. It’s concerning because there has been an increasing prevalence of alcohol use among young and middle-aged women, including in the number of women who binge drink.”

Overall, 3,108 study participants were diagnosed with coronary heart disease during the 4-year follow-up period. Among women, those who reported high alcohol intake had a 45% higher risk of heart disease than those reporting low intake and a 29% higher risk than those who reporting moderate intake.

The study did not include people who said they did not drink alcohol. The researchers adjusted the data to account for age, physical activity, obesity, smoking, and other known cardiovascular risk factors.

“At Kaiser Permanente Northern California, alcohol use is considered a vital sign, and we ask all our patients how often they drink and how much they drink, and we record the response at every medical appointment, the same way we record someone’s blood pressure,” said Sterling.

Added Rana: “Our findings suggest that as doctors we need to be doing more to talk to our patients — especially our female patients — about the potential heart risks associated with excess and binge drinking.”

This study was funded by the National Institute on Alcohol Abuse and Alcoholism.

Co-authors include Felicia W. Chi, MPH, of the Division of Research, and Isaac Acquah, MD, MPH, MedStar Union Memorial Hospital.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.

Kaiser Permanente patient registry provides unique opportunity to study likelihood of rupture

An abdominal aortic aneurysm is often referred to as “a ticking time bomb.” That’s because if the aneurysm bursts, it is likely to result in a deadly torrent of internal bleeding.

These aneurysms — bulges that develop in the abdomen in the lower part of the aorta, the largest artery in the body — usually cause no symptoms. Most people don’t know they have one until it is identified on a CT scan ordered because of another health problem. But they aren’t uncommon. In the U.S., about 200,000 people are diagnosed with an abdominal aortic aneurysm every year and about 10,000 people die after an aneurysm ruptures, making it the 15th leading cause of death.

Doctors typically don’t recommend that a patient undergo surgery until the aneurysm has grown large enough to potentially rupture. For decades, the size threshold for surgery was 5.5 cm (2.2 in) for men and 5 cm (2 in) for women. But how likely is it that an abdominal aortic aneurysm that large will actually rupture? Robert Chang, MD, a vascular surgeon at The Permanente Medical Group and a physician researcher at the Kaiser Permanente Northern California Division of Research, is the senior author of the largest-ever study to answer that question. The findings, published in July in the Journal of Vascular Surgery, are expected to influence how physicians help patients decide if they should consider surgery to remove the blockage.

Chang discussed why it was important to study the natural history of large abdominal aortic aneurysms and how the Kaiser Permanente Northern California (KPNC) health care system made it possible.

Why did you decide to conduct this study?

Chang: Abdominal aortic aneurysms are still a leading cause of death in this country, due to rupture. The way we treat them is to repair them when they get to be a certain size, but the size threshold we have used has been based on information from studies that are quite old. We believed it was important to use contemporary data to identify a patient’s risk of an aneurysm rupturing. Before our research, no one had done this.

How did you use KPNC’s electronic medical records in your research?

Chang: We have an electronic registry of 15,000 patients with abdominal aortic aneurysms that we have used for surveillance for 18 years. We use that registry to monitor our patients, but it had never been used for research purposes. It took many steps for us to figure out how to use the registry to study these patients’ outcomes. We also had to develop a natural language processing tool that could examine the medical records and figure out which imaging studies showed an abdominal aortic aneurysm and also tell us the size of the aneurysm when it was first diagnosed and how much it grew over time. It would have taken us years to look through all those records. The software could do it in just a few hours.

What did you learn?

Chang: The obvious question was: Can we figure out whether the size threshold we use based on the older studies to counsel patients about surgery still makes sense? This type of study had never been done before because no one has had access to this kind of data set. So, we looked to see if there were patients in the registry who had large aneurysms that for whatever reason were not fixed right away. And then we looked to see what happened after the aneurysm reached the threshold where we would talk to a patient about surgery. Did their aneurysm rupture? Did they go on to have surgery later? Did they die?

It turned out we had over 3,000 patients who had a large aneurysm. About 40% had one at the threshold size — 5.5 cm in men, 5 cm in women — at the first imaging study, and the other 60% had small aneurysms that grew over time. What we found was that, essentially, the incidence of rupture is lower than we thought across the board for every starting size. We also learned the risk of rupture is not cumulative. The curve is much flatter, so there isn’t this huge increase in risk of rupture if you wait longer.

What we found was that, essentially, the incidence of rupture is lower than we thought across the board for every starting size.

Is this good news for patients?

Chang: It’s realistic, more accurate news. If I have a male patient with a 5.5 cm aneurysm, I need to be able to explain the risk of it rupturing today, the risk it could rupture in the next 5 years, and the risks associated with surgery. We had thought that if you have a 5.5 cm aneurysm, you have a 5% risk for rupture at 1 year, and that the risk is cumulative, meaning in 5 years it would be 25%. Now, I use the data from our study that shows the rupture risk at 1 year is only 1.3%, which is one-fifth of what I’d have told someone in the past. And they can then compare that risk to the risks associated with having surgery.

Did you find differences between women and men?

Chang: We demonstrated that women have a different risk of abdominal aortic aneurysm rupture, and that it could actually be higher than in men. Right now, we don’t really know why. But this is something we can explore because we have so many women in our cohort. Most studies have used databases that don’t have as many women as we do.

What’s next?

Chang: The next question we are asking will be focused on the patients with small aneurysms. We want to see if we can predict who will go on to need surgery. This information would help us to conduct surveillance and, potentially, to intervene at the appropriate time to prevent a patient from experiencing a catastrophic rupture. The goal in treating aneurysms is to prevent rupture, but you also don’t want to do unnecessary surgery.

Publications

Racial and Ethnic Differences in the Association Between Mean Glucose and Hemoglobin A1c Background: Studies have reported significantly higher hemoglobin A1c (A1C) in African American patients than in White patients with the same mean glucose, but less is known about other racial/ethnic groups. We evaluated racial/ethnic differences in the association between mean glucose, based on continuous glucose monitor (CGM) data, and A1C. Methods: Retrospective study among 1788 patients with diabetes from Kaiser Permanente Northern California (KPNC) who used CGM devices during 2016 to 2021. In this study population, there were 5264 A1C results; mean glucose was calculated from 124,388,901 CGM readings captured during the 90 days before each A1C result. Hierarchical mixed models were specified to estimate racial/ethnic differences in the association between mean glucose and A1C. Results: Mean A1C was 0.33 (95% confidence interval: 0.23-0.44; P 20% of participants were at risk of inadequate intake of ≥1 micronutrients, especially in some population subgroups. Pregnancy may be a window of opportunity to address disparities in micronutrient intake that could contribute to intergenerational health inequalities. Authors: Sauder, Katherine A; Avalos, Lyndsay A; Zhu, Yeyi; Breton, Carrie V; Program Collaborators for Environmental influences on Child Health Outcomes (ECHO),; et al. J Nutr. 2021 11 02;151(11):3555-3569. PubMed abstract

Disparities in Use of Video Telemedicine Among Patients With Limited English Proficiency During the COVID-19 Pandemic Authors: Hsueh, Loretta; Huang, Jie; Millman, Andrea K; Gopalan, Anjali; Parikh, Rahul K; Teran, Silvia; Reed, Mary E JAMA Netw Open. 2021 11 01;4(11):e2133129. Epub 2021-11-01. PubMed abstract

Opportunities to Integrate Mobile App-Based Interventions Into Mental Health and Substance Use Disorder Treatment Services in the Wake of COVID-19 The COVID-19 pandemic has heightened concerns about the impact of depression, anxiety, alcohol, and drug use on public health. Mobile apps to address these problems were increasingly popular even before the pandemic, and may help reach people who otherwise have limited treatment access. In this review, we describe pandemic-related substance use and mental health problems, the growing evidence for mobile app efficacy, how health systems can integrate apps into patient care, and future research directions. If equity in access and effective implementation can be addressed, mobile apps are likely to play an important role in mental health and substance use disorder treatment. Authors: Satre, Derek D; Meacham, Meredith C; Asarnow, Lauren D; Fisher, Weston S; Fortuna, Lisa R; Iturralde, Esti Am J Health Promot. 2021 11;35(8):1178-1183. Epub 2021-10-15. PubMed abstract

Attention-Deficit/Hyperactivity Disorder Medication Adherence in the Transition to Adulthood: Associated Adverse Outcomes for Females and Other Disparities The purpose of this study was to assess the association between attention-deficit/hyperactivity disorder (ADHD) medication adherence and adverse health outcomes in older adolescents transitioning to adulthood. In a cohort of 17-year-old adolescents with ADHD at Kaiser Permanente Northern California, we assessed medication adherence (medication possession ratio ≥70%) and any medication use and associations with adverse outcomes at 18 and 19 years of age. We conducted bivariate tests of association and multivariable logistic regression models. Adherence declined from 17 to 19 years of age (36.7%-19.1%, p 45 years: hazard ratio [HR], 1.21 [95% CI, 1.14-1.29]) and initiate PrEP (eg, age >45 years: HR, 1.09 [95% CI, 1.02-1.16]) and less likely to discontinue (eg, age >45 years: HR, 0.46 [95% CI, 0.42-0.52]). Compared with White patients, African American and Latinx individuals were less likely to receive a PrEP prescription (African American: HR, 0.74 [95% CI, 0.69-0.81]; Latinx: HR, 0.88 [95% CI, 0.84-0.93]) and initiate PrEP (African American: HR, 0.87 [95% CI, 0.80-0.95]; Latinx: HR, 0.90 [95% CI, 0.86-0.95]) and more likely to discontinue (African American: HR, 1.36 [95% CI, 1.17-1.57]; Latinx: 1.33 [95% CI, 1.22-1.46]). Similarly, women, individuals with lower neighborhood-level socioeconomic status (SES), and persons with a substance use disorder (SUD) were less likely to be prescribed (women: HR, 0.56 [95% CI, 0.50-0.62]; lowest SES: HR, 0.72 [95% CI, 0.68-0.76]; SUD: HR, 0.88 [95% CI, 0.82-0.94]) and initiate PrEP (women: HR, 0.71 [95% CI, 0.64-0.80]; lower SES: HR, 0.93 [95% CI, 0.87-.0.99]; SUD: HR, 0.88 [95% CI, 0.81-0.95]) and more likely to discontinue (women: HR, 1.99 [95% CI, 1.67-2.38]); lower SES: HR, 1.40 [95% CI, 1.26-1.57]; SUD: HR, 1.23 [95% CI, 1.09-1.39]). HIV incidence was highest among individuals who discontinued PrEP and did not reinitiate PrEP (1.28 [95% CI, 0.93-1.76] infections per 100 person-years). These findings suggest that gaps in the PrEP care continuum were concentrated in populations disproportionately impacted by HIV, including African American individuals, Latinx individuals, young adults (aged 18-25 years), and individuals with SUD. Comprehensive strategies to improve PrEP continuum outcomes are needed to maximize PrEP impact and equity. Authors: Hojilla, J Carlo; Hurley, Leo B; Marcus, Julia L; Silverberg, Michael J; Skarbinski, Jacek; Satre, Derek D; Volk, Jonathan E JAMA Netw Open. 2021 08 02;4(8):e2122692. Epub 2021-08-02. PubMed abstract

Sex Differences in Cardiovascular Outcomes in CKD: Findings From the CRIC Study Cardiovascular events are less common in women than men in general populations; however, studies in chronic kidney disease (CKD) are less conclusive. We evaluated sex-related differences in cardiovascular events and death in adults with CKD. Prospective cohort study. 1,778 women and 2,161 men enrolled in the Chronic Renal Insufficiency Cohort (CRIC). Sex (women vs men). Atherosclerotic composite outcome (myocardial infarction, stroke, or peripheral artery disease), incident heart failure, cardiovascular death, and all-cause death. Cox proportional hazards regression. During a median follow-up period of 9.6 years, we observed 698 atherosclerotic events (women, 264; men, 434), 762 heart failure events (women, 331; men, 431), 435 cardiovascular deaths (women, 163; men, 274), and 1,158 deaths from any cause (women, 449; men, 709). In analyses adjusted for sociodemographic, clinical, and metabolic parameters, women had a lower risk of atherosclerotic events (HR, 0.71 [95% CI, 0.57-0.88]), heart failure (HR, 0.76 [95% CI, 0.62-0.93]), cardiovascular death (HR, 0.55 [95% CI, 0.42-0.72]), and death from any cause (HR, 0.58 [95% CI, 0.49-0.69]) compared with men. These associations remained statistically significant after adjusting for cardiac and inflammation biomarkers. Assessment of sex hormones, which may play a role in cardiovascular risk, was not included. In a large, diverse cohort of adults with CKD, compared with men, women had lower risks of cardiovascular events, cardiovascular mortality, and mortality from any cause. These differences were not explained by measured cardiovascular risk factors. Authors: Toth-Manikowski, Stephanie M; Go, Alan S; Chronic Renal Insufficiency Cohort (CRIC) Study Investigators,; et al. Am J Kidney Dis. 2021 08;78(2):200-209.e1. Epub 2021-04-20. PubMed abstract

COVID-19 Vaccination Coverage Among Insured Persons Aged ≥16 Years, by Race/Ethnicity and Other Selected Characteristics – Eight Integrated Health Care Organizations, United States, December 14, 2020-May 15, 2021 COVID-19 vaccination is critical to ending the COVID-19 pandemic. Members of minority racial and ethnic groups have experienced disproportionate COVID-19-associated morbidity and mortality (1); however, COVID-19 vaccination coverage is lower in these groups (2). CDC used data from CDC’s Vaccine Safety Datalink (VSD)* to assess disparities in vaccination coverage among persons aged ≥16 years by race and ethnicity during December 14, 2020-May 15, 2021. Measures of coverage included receipt of ≥1 COVID-19 vaccine dose (i.e., receipt of the first dose of the Pfizer-BioNTech or Moderna COVID-19 vaccines or 1 dose of the Janssen COVID-19 vaccine [Johnson & Johnson]) and full vaccination (receipt of 2 doses of the Pfizer-BioNTech or Moderna COVID-19 vaccines or 1 dose of Janssen COVID-19 vaccine). Among 9.6 million persons aged ≥16 years enrolled in VSD during December 14, 2020-May 15, 2021, ≥1-dose coverage was 48.3%, and 38.3% were fully vaccinated. As of May 15, 2021, coverage with ≥1 dose was lower among non-Hispanic Black (Black) and Hispanic persons (40.7% and 41.1%, respectively) than it was among non-Hispanic White (White) persons (54.6%). Coverage was highest among non-Hispanic Asian (Asian) persons (57.4%). Coverage with ≥1 dose was higher among persons with certain medical conditions that place them at higher risk for severe COVID-19 (high-risk conditions) (63.8%) than it was among persons without such conditions (41.5%) and was higher among persons who had not had COVID-19 (48.8%) than it was among those who had (42.4%). Persons aged 18-24 years had the lowest ≥1-dose coverage (28.7%) among all age groups. Continued monitoring of vaccination coverage and efforts to improve equity in coverage are critical, especially among populations disproportionately affected by COVID-19. Authors: Pingali, Cassandra; Klein, Nicola P; Fireman, Bruce; Zerbo, Ousseny; Patel, Suchita A; et al. MMWR Morb Mortal Wkly Rep. 2021 Jul 16;70(28):985-990. Epub 2021-07-16. PubMed abstract

Engagement in perinatal depression treatment: a qualitative study of barriers across and within racial/ethnic groups To better understand previously observed racial/ethnic disparities in perinatal depression treatment rates we examined care engagement factors across and within race/ethnicity. Obstetric patients and women’s health clinician experts from a large healthcare system participated in this qualitative study. We conducted focus groups with 30 pregnant or postpartum women of Asian, Black, Latina, and White race/ethnicity with positive depression screens. Nine clinician experts in perinatal depression (obstetric, mental health, and primary care providers) were interviewed. A semi-structured format elicited treatment barriers, cultural factors, and helpful strategies. Discussion transcripts were coded using a general inductive approach with themes mapped to the Capability-Opportunity-Motivation-Behavior (COM-B) theoretical framework. Treatment barriers included social stigma, difficulties recognizing one’s own depression, low understanding of treatment options, and lack of time for treatment. Distinct factors emerged for non-White women including culturally specific messages discouraging treatment, low social support, trauma history, and difficulty taking time off from work for treatment. Clinician factors included knowledge and skill handling perinatal depression, cultural competencies, and language barriers. Participants recommended better integration of mental health treatment with obstetric care, greater treatment convenience (e.g., telemedicine), and programmatic attention to cultural factors and social determinants of health. Women from diverse backgrounds with perinatal depression encounter individual-level, social, and clinician-related barriers to treatment engagement, necessitating care strategies that reduce stigma, offer convenience, and attend to cultural and economic factors. Our findings suggest the importance of intervention and policy approaches effecting change at multiple levels to increase perinatal depression treatment engagement. Authors: Iturralde, Esti; Hsiao, Crystal A; Nkemere, Linda; Kubo, Ai; Sterling, Stacy A; Flanagan, Tracy; Avalos, Lyndsay A BMC Pregnancy Childbirth. 2021 Jul 16;21(1):512. Epub 2021-07-16. PubMed abstract

Equitably Allocating Resources During Crises: Racial Differences in Mortality Prediction Models Rationale: Crisis standards of care (CSCs) guide critical care resource allocation during crises. Most recommend ranking patients on the basis of their expected in-hospital mortality using the Sequential Organ Failure Assessment (SOFA) score, but it is unknown how SOFA or other acuity scores perform among patients of different races. Objectives: To test the prognostic accuracy of the SOFA score and version 2 of the Laboratory-based Acute Physiology Score (LAPS2) among Black and white patients. Methods: We included Black and white patients admitted for sepsis or acute respiratory failure at 27 hospitals. We calculated the discrimination and calibration for in-hospital mortality of SOFA, LAPS2, and modified versions of each, including categorical SOFA groups recommended in a popular CSC and a SOFA score without creatinine to reduce the influence of race. Measurements and Main Results: Of 113,158 patients, 27,644 (24.4%) identified as Black. The LAPS2 demonstrated higher discrimination (area under the receiver operating characteristic curve [AUC], 0.76; 95% confidence interval [CI], 0.76-0.77) than the SOFA score (AUC, 0.68; 95% CI, 0.68-0.69). The LAPS2 was also better calibrated than the SOFA score, but both underestimated in-hospital mortality for white patients and overestimated in-hospital mortality for Black patients. Thus, in a simulation using observed mortality, 81.6% of Black patients were included in lower-priority CSC categories, and 9.4% of all Black patients were erroneously excluded from receiving the highest prioritization. The SOFA score without creatinine reduced racial miscalibration. Conclusions: Using SOFA in CSCs may lead to racial disparities in resource allocation. More equitable mortality prediction scores are needed. Authors: Ashana, Deepshikha Charan; Anesi, George L; Liu, Vincent X; Escobar, Gabriel J; Chesley, Christopher; Eneanya, Nwamaka D; Weissman, Gary E; Miller, William Dwight; Harhay, Michael O; Halpern, Scott D Am J Respir Crit Care Med. 2021 07 15;204(2):178-186. PubMed abstract

Operationalizing Social Environments in Cognitive Aging and Dementia Research: A Scoping Review Social environments are a contributing determinant of health and disparities. This scoping review details how social environments have been operationalized in observational studies of cognitive aging and dementia. A systematic search in PubMed and Web of Science identified studies of social environment exposures and late-life cognition/dementia outcomes. Data were extracted on (1) study design; (2) population; (3) social environment(s); (4) cognitive outcome(s); (5) analytic approach; and (6) theorized causal pathways. Studies were organized using a 3-tiered social ecological model at interpersonal, community, or policy levels. Of 7802 non-duplicated articles, 123 studies met inclusion criteria. Eighty-four studies were longitudinal (range 1-28 years) and 16 examined time-varying social environments. When sorted into social ecological levels, 91 studies examined the interpersonal level; 37 examined the community/neighborhood level; 3 examined policy level social environments; and 7 studies examined more than one level. Most studies of social environments and cognitive aging and dementia examined interpersonal factors measured at a single point in time. Few assessed time-varying social environmental factors or considered multiple social ecological levels. Future studies can help clarify opportunities for intervention by delineating if, when, and how social environments shape late-life cognitive aging and dementia outcomes. Authors: Peterson, Rachel L; George, Kristen M; Tran, Duyen; Malladi, Pallavi; Gilsanz, Paola; Kind, Amy J H; Whitmer, Rachel A; Besser, Lilah M; Meyer, Oanh L Int J Environ Res Public Health. 2021 07 04;18(13). Epub 2021-07-04. PubMed abstract

The Role of Community-Based Organizations in Improving Chronic Care for Safety-Net Populations Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts. Varied qualitative inquiry methods – in-depth interviews, participant-led neighborhood tours, and clinic visit observations – involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco’s public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM). Several key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients’ self-management. Health service providers leveraged these resources to address patients’ social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated. The results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress. Authors: Nguyen, Kim Hanh; Fields, Jessica D; Cemballi, Anupama G; Desai, Riya; Gopalan, Anjali; Cruz, Tessa; Shah, Aekta; Akom, Antwi; Brown, William; Sarkar, Urmimala; Lyles, Courtney Rees J Am Board Fam Med. 2021 Jul-Aug;34(4):698-708. PubMed abstract

Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005-2015 To examine recent trends and differences in all-cause and cause-specific hospitalization rates by race, ethnicity, and gender among persons with HIV (PWH) in the United States and Canada. HIV clinical cohort consortium. We followed PWH at least 18 years old in care 2005-2015 in six clinical cohorts. We used modified Clinical Classifications Software to categorize hospital discharge diagnoses. Incidence rate ratios (IRR) were estimated using Poisson regression with robust variances to compare racial and ethnic groups, stratified by gender, adjusted for cohort, calendar year, injection drug use history, and annually updated age, CD4+, and HIV viral load. Among 27 085 patients (122 566 person-years), 80% were cisgender men, 1% transgender, 43% White, 33% Black, 17% Hispanic of any race, and 1% Indigenous. Unadjusted all-cause hospitalization rates were higher for Black [IRR 1.46, 95% confidence interval (CI) 1.32-1.61] and Indigenous (1.99, 1.44-2.74) versus White cisgender men, and for Indigenous versus White cisgender women (2.55, 1.68-3.89). Unadjusted AIDS-related hospitalization rates were also higher for Black, Hispanic, and Indigenous versus White cisgender men (all P < 0.05). Transgender patients had 1.50 times (1.05-2.14) and cisgender women 1.37 times (1.26-1.48) the unadjusted hospitalization rate of cisgender men. In adjusted analyses, among both cisgender men and women, Black patients had higher rates of cardiovascular and renal/genitourinary hospitalizations compared to Whites (all P 25 years’ follow-up. Probabilities of stage B LV abnormalities at ages 25 and 60 years were 10.5% (95% CI, 9.4%-11.8%) and 45.0% (95% CI, 42.0%-48.1%), with significant race-sex disparities (e.g., at age 60, black men 52.7% [95% CI, 44.9%-60.3%], black women 59.4% [95% CI, 53.6%-65.0%], white men 39.1% [95% CI, 33.4%-45.0%], and white women 39.1% [95% CI, 33.9%-44.6%]). Over 25 years, baseline LV end-systolic dimension indexed to height was associated with incident systolic dysfunction (adjusted odds ratio per 1 SD higher, 2.56; 95% CI, 1.87-3.52), eccentric hypertrophy (1.34; 95% CI, 1.02-1.75), concentric hypertrophy (0.69; 95% CI, 0.51-0.91), and concentric remodeling (0.68; 95% CI, 0.58-0.79); baseline LV mass indexed to height2.7 was associated with incident eccentric hypertrophy (1.70; 95% CI, 1.25-2.32]), concentric hypertrophy (1.63; 95% CI, 1.19-2.24), and diastolic dysfunction (1.24; 95% CI, 1.01-1.52). Among the entire cohort with baseline echocardiographic data available (n = 4,097; 72 HF events), LV end-systolic dimension indexed to height and LV mass indexed to height2.7 were significantly associated with incident clinical HF (adjusted hazard ratios per 1 SD higher, 1.56 [95% CI, 1.26-1.93] and 1.42 [95% CI, 1.14-1.75], respectively). Stage B LV abnormalities and related racial disparities were present in young adulthood, increased with age, and were associated with baseline variation in indexed LV end-systolic dimension and mass. Baseline indexed LV end-systolic dimension and mass were also associated with incident clinical HF. Efforts to prevent the LV abnormalities underlying clinical HF should start from a young age. Authors: Perak, Amanda M; Khan, Sadiya S; Colangelo, Laura A; Gidding, Samuel S; Armstrong, Anderson C; Lewis, Cora E; Reis, Jared P; Schreiner, Pamela J; Sidney, Stephen; Lima, Joao A C; Lloyd-Jones, Donald M J Am Soc Echocardiogr. 2021 04;34(4):388-400. Epub 2020-11-17. PubMed abstract

Do the Benefits of Educational Attainment for Late-life Cognition Differ by Racial/Ethnic Group?: Evidence for Heterogenous Treatment Effects in the Kaiser Healthy Aging and Diverse Life Experience (KHANDLE) Study Educational attainment is associated with late-life cognitive performance and dementia; few studies have examined diverse racial/ethnic groups to assess whether the association differs by race/ethnicity. We investigated whether the association between educational attainment and cognition differed between White, Black, Asian, and Latino participants in the Kaiser Healthy Aging and Diverse Life Experiences study (n=1348). Covariate-adjusted multivariable linear regression models examined domains of verbal episodic memory, semantic memory, and executive functioning. We observed significant effect heterogeneity by race/ethnicity only for verbal episodic memory (P=0.0198), for which any schooling between high school and college was beneficial for White, Asian, and Black participants, but not Latino participants. We found no evidence of heterogeneity for semantic memory or executive function. With the exception of Latino performance on verbal episodic memory, more education consistently predicted better cognitive scores to a similar extent across racial/ethnic groups, despite likely heterogenous educational and social experiences. Authors: Eng, Chloe W; Glymour, Medellena Maria; Gilsanz, Paola; Mungas, Dan M; Mayeda, Elizabeth R; Meyer, Oanh L; Whitmer, Rachel A Alzheimer Dis Assoc Disord. 2021 Apr-Jun 01;35(2):106-113. PubMed abstract

Disparities in Preventable Mortality from Colorectal Cancer: are they the result of structural racism? Authors: Doubeni, Chyke A; Selby, Kevin; Levin, Theodore R Gastroenterology. 2021 03;160(4):1022-1025. Epub 2021-01-05. PubMed abstract

Racial/ethnic disparities in survival after breast cancer diagnosis by estrogen and progesterone receptor status: A pooled analysis Limited studies have investigated racial/ethnic survival disparities for breast cancer defined by estrogen receptor (ER) and progesterone receptor (PR) status in a multiethnic population. Using multivariable Cox proportional hazards models, we assessed associations of race/ethnicity with ER/PR-specific breast cancer mortality in 10,366 California women diagnosed with breast cancer from 1993 to 2009. We evaluated joint associations of race/ethnicity, health care, sociodemographic, and lifestyle factors with mortality. Among women with ER/PR+ breast cancer, breast cancer-specific mortality was similar among Hispanic and Asian American women, but higher among African American women [HR, 1.31; 95% confidence interval (CI), 1.05-1.63] compared with non-Hispanic White (NHW) women. Breast cancer-specific mortality was modified by surgery type, hospital type, education, neighborhood socioeconomic status (SES), smoking history, and alcohol consumption. Among African American women, breast cancer-specific mortality was higher among those treated at nonaccredited hospitals (HR, 1.57; 95% CI, 1.21-2.04) and those from lower SES neighborhoods (HR, 1.48; 95% CI, 1.16-1.88) compared with NHW women without these characteristics. Breast cancer-specific mortality was higher among African American women with at least some college education (HR, 1.42; 95% CI, 1.11-1.82) compared with NHW women with similar education. For ER-/PR- disease, breast cancer-specific mortality did not differ by race/ethnicity and associations of race/ethnicity with breast cancer-specific mortality varied only by neighborhood SES among African American women. Racial/ethnic survival disparities are more striking for ER/PR+ than ER-/PR- breast cancer. Social determinants and lifestyle factors may explain some of the survival disparities for ER/PR+ breast cancer. Addressing these factors may help reduce the higher mortality of African American women with ER/PR+ breast cancer. Authors: John, Esther M; Kwan, Marilyn L; Wu, Anna H; et al. Cancer Epidemiol Biomarkers Prev. 2021 02;30(2):351-363. Epub 2020-12-18. PubMed abstract

Urban-Rural Disparities and Temporal Trends in Peptic Ulcer Disease Epidemiology, Treatment, and Outcomes in the United States The incidence of peptic ulcer disease (PUD) has been decreasing over time with Helicobacter pylori eradication and use of acid-suppressing therapies. However, PUD remains a common cause of hospitalization in the United States. We aimed to evaluate contemporary national trends in the incidence, treatment patterns, and outcomes for PUD-related hospitalizations and compare care delivery by hospital rurality. Data from the National Inpatient Sample were used to estimate weighted annual rates of PUD-related hospitalizations. Temporal trends were evaluated by joinpoint regression and expressed as annual percent change with 95% confidence intervals (CIs). We determined the proportion of hospitalizations requiring endoscopic and surgical interventions, stratified by clinical presentation and rurality. Multivariable logistic regression was used to assess independent predictors of in-hospital mortality and postoperative morbidity. There was a 25.8% reduction (P < 0.001) in PUD-related hospitalizations from 2005 to 2014, although the rate of decline decreased from -7.2% per year (95% CI: 13.2% to -0.7%) before 2008 to -2.1% per year (95% CI: 3.0% to -1.1%) after 2008. In-hospital mortality was 2.4% (95% CI: 2.4%-2.5%). Upper endoscopy (84.3% vs 78.4%, P < 0.001) and endoscopic hemostasis (26.1% vs 16.8%, P < 0.001) were more likely to be performed in urban hospitals, whereas surgery was performed less frequently (9.7% vs 10.5%, P < 0.001). In multivariable logistic regression, patients managed in urban hospitals were at higher risk for postoperative morbidity (odds ratio 1.16 [95% CI: 1.04-1.29]), but not death (odds ratio 1.11 [95% CI: 1.00-1.23]). The rate of decline in hospitalization rates for PUD has stabilized over time, although there remains significant heterogeneity in treatment patterns by hospital rurality. Authors: Guo, Howard; Ma, Christopher; Ma, Christopher; et al. Am J Gastroenterol. 2021 02 01;116(2):296-305. PubMed abstract

COVID-19 prevalence, symptoms, and sociodemographic disparities in infection among insured pregnant women in Northern California Research on COVID-19 during pregnancy has mainly focused on women hospitalized for COVID-19 or other reasons during their pregnancy. Little is known about COVID-19 in the general population of pregnant women. To describe the prevalence of COVID-19, symptoms, consequent healthcare use, and possible sources of COVID-19 exposure among a population-based sample of pregnant women residing in Northern California. We analyzed data from 19,458 members of Kaiser Permanente Northern California who were pregnant between January 2020 and April 2021 and responded to an online survey about COVID-19 testing, diagnosis, symptoms, and their experiences during the COVID-19 pandemic. Medical diagnosis of COVID-19 during pregnancy was defined separately by self-report and by documentation in electronic health records (EHR). We examined relationships of COVID-19 with sociodemographic factors, underlying comorbidities, and survey measures of COVID-19-like symptoms, consequent healthcare utilization, and possible COVID-19 exposures. Among 19,458 respondents, the crude prevalence of COVID-19 was 2.5% (n = 494) according to self-report and 1.4% (n = 276) according to EHR. After adjustment, the prevalence of self-reported COVID-19 was higher among women aged <25 years compared with women aged ≥35 years (prevalence ratio [PR], 1.75, 95% CI: 1.23, 2.49) and among Hispanic women compared with White women (PR, 1.91, 95% CI: 1.53, 2.37). Prevalence of self-reported COVID-19 was higher among women affected by personal or partner job loss during the pandemic (PR, 1.23, 95% CI: 1.02, 1.47) and among women living in areas of high vs. low neighborhood deprivation (PR, 1.74, 95% CI: 1.33, 2.27). We did not observe differences in self-reported COVID-19 between women with and without underlying comorbidities. Results were similar for EHR-documented COVID-19. Loss of smell or taste was a unique and common symptom reported among women with COVID-19 (42.3% in self-reported; 54.0% in EHR-documented). Among women with symptomatic COVID-19, approximately 2% were hospitalized, 71% had a telehealth visit, and 75% quarantined at home. Over a third of women with COVID-19 reported no known exposure to someone with COVID-19. Observed COVID-19 prevalence differences by sociodemographic and socioeconomic factors underscore social and health inequities among reproductive-aged women. Women with COVID-19 reported unique symptoms and low frequency of hospitalization. Many were not aware of an exposure to someone with COVID-19. Authors: Ames, Jennifer L; Ferrara, Assiamira; Avalos, Lyndsay A; Badon, Sylvia E; Greenberg, Mara B; Hedderson, Monique M; Kuzniewicz, Michael W; Young-Wolff, Kelly C; Zerbo, Ousseny; Zhu, Yeyi; Croen, Lisa A; et al. PLoS One. 2021;16(9):e0256891. Epub 2021-09-03. PubMed abstract

Trans-ancestry genome-wide association meta-analysis of prostate cancer identifies new susceptibility loci and informs genetic risk prediction Prostate cancer is a highly heritable disease with large disparities in incidence rates across ancestry populations. We conducted a multiancestry meta-analysis of prostate cancer genome-wide association studies (107,247 cases and 127,006 controls) and identified 86 new genetic risk variants independently associated with prostate cancer risk, bringing the total to 269 known risk variants. The top genetic risk score (GRS) decile was associated with odds ratios that ranged from 5.06 (95% confidence interval (CI), 4.84-5.29) for men of European ancestry to 3.74 (95% CI, 3.36-4.17) for men of African ancestry. Men of African ancestry were estimated to have a mean GRS that was 2.18-times higher (95% CI, 2.14-2.22), and men of East Asian ancestry 0.73-times lower (95% CI, 0.71-0.76), than men of European ancestry. These findings support the role of germline variation contributing to population differences in prostate cancer risk, with the GRS offering an approach for personalized risk prediction. Authors: Conti, David V; Van Den Eeden, Stephen K; Haiman, Christopher A; et al. Nat Genet. 2021 01;53(1):65-75. Epub 2021-01-04. PubMed abstract

Community Health Behaviors and Geographic Variation in Early-Onset Colorectal Cancer Survival Among Women Despite overall reductions in colorectal cancer (CRC) morbidity and mortality, survival disparities by sex persist among young patients (age <50 years). Our study sought to quantify variance in early-onset CRC survival accounted for by individual/community-level characteristics among a population-based cohort of US women. Geographic hot spots-counties with high early-onset CRC mortality rates among women-were derived using 3 geospatial autocorrelation approaches with Centers for Disease Control and Prevention national mortality data. We identified women (age: 15-49 years) diagnosed with CRC from 1999 to 2016 in the National Institutes of Health/National Cancer Institute's Surveillance, Epidemiology, and End Results program. Patterns of community health behaviors by hot spot classification were assessed by Spearman correlation (ρ). Generalized R values were used to evaluate variance in survival attributed to individual/community-level features. Approximately 1 in every 16 contiguous US counties identified as hot spots (191 of 3,108), and 52.9% of hot spot counties (n = 101) were located in the South. Among 28,790 women with early-onset CRC, 13.7% of cases (n = 3,954) resided in hot spot counties. Physical inactivity and fertility were community health behaviors that modestly correlated with hot spot residence among women with early-onset CRC (ρ = 0.21 and ρ = -0.23, respectively; P = $1000), receipt of benefits from the California AIDS Drug Assistance Program (ADAP), demographic factors, and three-year patterns of health service utilization (primary care, psychiatry, substance treatment, emergency, inpatient) and HIV outcomes (CD4 counts; viral suppression at HIV RNA < 75 copies/mL). Health care use was greatest immediately after enrollment and decreased over 3 years. Those with high deductibles were less likely to use primary care (OR = 0.64, 95% CI = 0.49-0.84, p < 0.01) or psychiatry OR = 0.59, 95% CI = 0.37, 0.94, p = 0.03) than those with no deductible. Enrollment via the Exchange was associated with fewer psychiatry visits (rate ratio [RR] = 0.40, 95% CI = 0.18-0.86; p = 0.02), but ADAP was associated with more psychiatry visits (RR = 2.22, 95% CI = 1.24-4.71; p = 0.01). Those with high deductibles were less likely to have viral suppression (OR = 0.65, 95% CI = 0.42-1.00; p = 0.05), but ADAP enrollment was associated with viral suppression (OR = 2.20, 95% CI = 1.32-3.66, p < 0.01). Black (OR = 0.35, 95% CI = 0.21-0.58, p < 0.01) and Hispanic (OR = 0.50, 95% CI = 0.29-0.85, p = 0.01) PWH were less likely to be virally suppressed. In this sample of PWH newly enrolled in an integrated health care system in California, findings suggest that enrollment via the Exchange and higher deductibles were negatively associated with some aspects of service utilization, high deductibles were associated with worse HIV outcomes, but support from ADAP appeared to help patients achieve viral suppression. Race/ethnic disparities remain important to address even among those with access to insurance coverage. Authors: Satre, Derek D; Parthasarathy, Sujaya; Silverberg, Michael J; Horberg, Michael; Young-Wolff, Kelly C; Williams, Emily C; Volberding, Paul; Campbell, Cynthia I BMC Health Serv Res. 2020 Nov 11;20(1):1030. Epub 2020-11-11. PubMed abstract

Interventions Targeting Racial/Ethnic Disparities in Stroke Prevention and Treatment Systemic racism is a public health crisis. Systemic racism and racial/ethnic injustice produce racial/ethnic disparities in health care and health. Substantial racial/ethnic disparities in stroke care and health exist and result predominantly from unequal treatment. This special report aims to summarize selected interventions to reduce racial/ethnic disparities in stroke prevention and treatment. It reviews the social determinants of health and the determinants of racial/ethnic disparities in care. It provides a focused summary of selected interventions aimed at reducing stroke risk factors, increasing awareness of stroke symptoms, and improving access to care for stroke because these interventions hold the promise of reducing racial/ethnic disparities in stroke death rates. It also discusses knowledge gaps and future directions. Authors: Levine, Deborah A; Duncan, Pamela W; Nguyen-Huynh, Mai N; Ogedegbe, Olugbenga G Stroke. 2020 11;51(11):3425-3432. Epub 2020-10-26. PubMed abstract

Long-term follow-up of a racially and ethnically diverse population of men with localized prostate cancer who did not undergo initial active treatment There is limited research on the racial/ethnic differences in long-term outcomes for men with untreated, localized prostate cancer. Men diagnosed with localized, Gleason ≤7 prostate cancer who were not treated within 1 year of diagnosis from 1997-2007 were identified. Cumulative incidence rates of the following events were calculated; treatment initiation, metastasis, death due to prostate cancer and all-cause mortality, accounting for competing risks. The Cox model of all-cause mortality and Fine-Gray sub distribution model to account for competing risks were used to test for racial/ethnic differences in outcomes adjusted for clinical factors. There were 3925 men in the study, 749 Hispanic, 2415 non-Hispanic white, 559 non-Hispanic African American, and 202 non-Hispanic Asian/Pacific Islander (API). Median follow-up was 9.3 years. At 19 years, overall cumulative incidence of treatment, metastasis, death due to prostate cancer, and all-cause mortality was 25.0%, 14.7%, 11.7%, and 67.8%, respectively. In adjusted models compared to non-Hispanic whites, African Americans had higher rates of treatment (HR = 1.39, 95% CI = 1.15-1.68); they had an increased risk of metastasis beyond 10 years after diagnosis (HR = 4.70, 95% CI = 2.30-9.61); API and Hispanic had lower rates of all-cause mortality (HR = 0.66, 95% CI = 0.52-0.84, and HR = 0.72, 95% CI = 0.62-0.85, respectively), and API had lower rates of prostate cancer mortality in the first 10 years after diagnosis (HR = 0.29, 95% CI = 0.09-0.90) and elevated risks beyond 10 years (HR = 5.41, 95% CI = 1.39-21.11). Significant risks of metastasis and prostate cancer mortality exist in untreated men beyond 10 years after diagnosis, but are not equally distributed among racial/ethnic groups. Authors: Slezak, Jeff M; Van Den Eeden, Stephen K; Cannavale, Kimberly L; Chien, Gary W; Jacobsen, Steven J; Chao, Chun R Cancer Med. 2020 11;9(22):8530-8539. Epub 2020-09-23. PubMed abstract

Understanding Racial/Ethnic Disparities in Physical Performance in Mid-Life Women: Findings from SWAN (Study of Women’s Health Across the Nation) Evaluate degree to which racial/ethnic differences in physical performance are mediated by sociodemographic, health, behavioral, and psychosocial factors. Physical performance was evaluated using a decile score derived from grip strength, timed 4 m walk, and timed repeat chair stand in 1,855 African American, Caucasian, Chinese, Hispanic, and Japanese women, mean age = 61.8 (SD = 2.7) in the Study of Women’s Health Across the Nation. Mediators included education, financial strain, comorbidities, pain, body mass index (BMI), physical activity, and perceived stress. Structural equation models provided estimates of the total difference in physical performance between Caucasians and each race/ethnic groups and differences due to direct effects of race/ethnicity and indirect effects through mediators. The mean decile score for Caucasian women was 16.9 (SD = 5.6), 1.8, 2.6, and 2.1 points higher than the model-estimated scores in African Americans, Hispanics and Chinese, respectively, and 1.3 points lower than the Japanese. Differences between Caucasians and the Chinese and Japanese were direct effects of race/ethnicity whereas in African Americans and Hispanics 75% or more of that disparity was through mediators, particularly education, financial strain, BMI, physical activity, and pain. Addressing issues of poverty, racial inequality, pain, and obesity could reduce some racial/ethnic disparity in functional limitations as women age. Authors: Sternfeld B; Colvin A; Stewart A; Appelhans BM; Cauley JA; Dugan SA; El Khoudary SR; Greendale GA; Strotmeyer E; Karvonen-Gutierrez C J Gerontol B Psychol Sci Soc Sci. 2020 10 16;75(9):1961-1971. PubMed abstract

Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described. Authors: Rivera, M Patricia; Sakoda, Lori C; Aldrich, Melinda C; et al. Am J Respir Crit Care Med. 2020 10 01;202(7):e95-e112. PubMed abstract

Body mass index versus bioelectrical impedance analysis for classifying physical function impairment in a racially diverse cohort of midlife women: the Study of Women’s Health Across the Nation (SWAN) Body composition strongly influences physical function in older adults. Bioelectrical impedance analysis (BIA) differentiates fat mass from skeletal muscle mass, and may be more useful than body mass index (BMI) for classifying women on their likelihood of physical function impairment. This study tested whether BIA-derived estimates of percentage body fat (%BF) and height-normalized skeletal muscle mass (skeletal muscle mass index; SMI) enhance classification of physical function impairment relative to BMI. Black, White, Chinese, and Japanese midlife women (N = 1482) in the Study of Women’s Health Across the Nation (SWAN) completed performance-based measures of physical function. BMI (kg/m2) was calculated. %BF and SMI were derived through BIA. Receiver-operating characteristic (ROC) curve analysis, conducted in the overall sample and stratified by racial group, evaluated optimal cutpoints of BMI, %BF, and SMI for classifying women on moderate-severe physical function impairment. In the overall sample, a BMI cutpoint of ≥ 30.1 kg/m2 correctly classified 71.1% of women on physical function impairment, and optimal cutpoints for %BF (≥ 43.4%) and SMI (≥ 8.1 kg/m2) correctly classified 69% and 62% of women, respectively. SMI did not meaningfully enhanced classification relative to BMI (change in area under the ROC curve = 0.002; net reclassification improvement = 0.021; integrated discrimination improvement = – 0.003). Optimal cutpoints for BMI, %BF, and SMI varied substantially across race. Among Black women, a %BF cutpoint of 43.9% performed somewhat better than BMI (change in area under the ROC curve = 0.017; sensitivity = 0.69, specificity = 0.64). Some race-specific BMI and %BF cutpoints have moderate utility for identifying impaired physical function among midlife women. Authors: Appelhans BM; Lange-Maia BS; Pettee Gabriel K; Karvonen-Gutierrez C; Karavolos K; Dugan SA; Greendale GA; Avery EF; Sternfeld B; Janssen I; Kravitz HM Aging Clin Exp Res. 2020 Sep;32(9):1739-1747. Epub 2019-10-04. PubMed abstract

Heterogeneous trends in burden of heart disease mortality by subtypes in the United States, 1999-2018: observational analysis of vital statistics To describe trends in the burden of mortality due to subtypes of heart disease from 1999 to 2018 to inform targeted prevention strategies and reduce disparities. Serial cross sectional analysis of cause specific heart disease mortality rates using national death certificate data in the overall population as well as stratified by race-sex, age, and geography. United States, 1999-2018. 12.9 million decedents from total heart disease (49% women, 12% black, and 19% <65 years old). Age adjusted mortality rates (AAM

The Framingham risk score and other assessments used to evaluate an individual’s risk of cardiovascular disease perform poorly in people living with HIV, according to US research presented to the 23rd International AIDS Conference (AIDS 2020: Virtual). The investigators tested the performance of three separate diagnostic tools developed for use in the general population and found that all under-estimated the risk of cardiovascular disease in people living with HIV.

Moreover, the researchers, led by Dr Virginia Triant of Harvard University, also showed that the performance of the risk estimates differed according to healthcare system – public hospital compared to insurance-based – and also between men and women.

“The results underscore the need for both HIV-specific and sex-specific functions to ensure equity in the delivery of preventative care,” comment Dr Triant and colleagues.

Glossary cardiovascular Relating to the heart and blood vessels. cardiovascular disease Disease of the heart or blood vessels, such as heart attack (myocardial infarction) and stroke. lipid Fat or fat-like substances found in the blood and body tissues. Lipids serve as building blocks for cells and as a source of energy for the body. Cholesterol and triglycerides are types of lipids. stroke An interruption of blood flow to the brain, caused by a broken or blocked blood vessel. A stroke results in sudden loss of brain function, such as loss of consciousness, paralysis, or changes in speech. Stroke is a medical emergency and can be life-threatening. person years In a study “100 person years of follow-up” could mean that information was collected on 100 people for one year, or on 50 people for two years each, or on ten people over ten years. In practice, each person’s duration of follow-up is likely to be different.

Cardiovascular disease is now a leading cause of serious illness and death in people living with HIV. There are several reasons for this, including ageing (people with HIV now have an excellent chance of living well into old age), lifestyle factors such as smoking and diet, damage caused by untreated HIV infection and also the side effects of some antiretroviral drugs.

The prevention of cardiovascular disease is a priority in routine HIV care. A person’s risk is usually assessed using tools developed using information obtained from the general population. These assessments take into account factors such as age, sex, blood lipids, blood pressure, weight and smoking.

But there’s long been concern that the additional risk factors associated with living with HIV mean that these assessments under-estimate cardiovascular risk in people with HIV. Dr Triant and colleagues already showed this was the case for men receiving care at Massachusetts General Hospital and the Brigham and Women’s Hospital in Boston.

The investigators wanted to take this research further. They therefore teamed up with doctors from Kaiser Permanente Northern California, a major provider of health insurance-based HIV care in the San Francisco Bay Area.

The investigators examined rates of serious cardiovascular disease – heart attack, stroke or cardiovascular death – among people who received HIV care between 2000 and 2020.

They also looked at the ability of three prediction tools that are widely used in the general population to predict risk in individuals with HIV.

The tools were:

American College of Cardiology/American Heart Association risk estimator for atherosclerotic cardiovascular disease: myocardial infarction, stroke or coronary death.

Framingham Heart Study function for ‘hard’ coronary heart disease: myocardial infarction or coronary death.

Framingham Heart Study function for all forms of cardiovascular disease, adjusted to take into account American College of Cardiology/American Heart Association outcomes.

Dr Triant and colleagues also compared the performance of the assessments between the Boston and Californian cohorts: individuals in the Boston hospitals have higher rates of poverty and social exclusion than individuals in the Kaiser Permanente Cohort. Comparison was also conducted according to sex.

Analysis was limited to people aged between 30 and 79 years who had not experienced a cardiovascular event prior to follow-up (the date of first lipid test). The follow-up period was limited to five years for each person.

The total study population consisted of over 10,000 people (2185 in Boston; 7938 in California).

A quarter of individuals in the Boston cohort were female compared to 10% of those in Northern California. There were also racial differences: the Boston patients more likely to be Black compared to the Californian cohort (27% vs 15%).

In terms of cardiovascular risk factors, cholesterol, blood pressure and medication for high blood pressure were broadly comparable between the two cohorts. However, rates of smoking and diabetes were higher in Boston than California (44% vs 21%; 8% vs 6%).

Use of antiretroviral therapy was comparable between the two cohorts at approximately 80%. Nevertheless, only 48% of people in Boston had an undetectable viral load compared to three-quarters of individuals in the Californian cohort.

“In both cohorts, the predictive accuracy of the tools was especially poor in women.”

The incidence of serious cardiovascular outcomes was markedly higher in the Boston cohort compared to the Californian group, regardless of the outcomes assessed (rates between 10 and 28 per 1000 person-years compared to incidence between 1 and 6 per 1000 person-years)

In almost every case, all three assessment tools under-estimated the risk of a serious cardiovascular event in the people with HIV.

This was especially the case for the Boston cohort, with risk generally under-estimated by approximately a third. Accuracy was somewhat better, though still sub-optimal, among the group receiving care from Kaiser Permanente, with risk underestimated by up to a quarter.

In both cohorts, the predictive accuracy of the tools was especially poor in women.

These findings will have important implications for HIV care. “Cardiovascular risk prediction functions developed for the general population are not uniformly transportable to people living with HIV,” the researchers concluded.