Publications

BACKGROUND

Insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of healthcare reform in Massachusetts on use of coronary revascularization procedures and in-hospital and 1-year mortality by race/ethnicity, education, and sex.

METHODS AND RESULTS

Using hospital claims data, we compared differences in coronary revascularization rates (coronary artery bypass grafting or percutaneous coronary intervention) and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents aged 21 to 64 years hospitalized with a principal discharge diagnosis of ischemic heart disease before (November 1, 2004, to July 31, 2006) and after (December 1, 2006, to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted logistic regression assessed 24 216 discharges before reform and 20 721 discharges after reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the prereform period. Compared with whites in the postreform period, blacks (odds ratio=0.73; 95% confidence interval, 0.63-0.84) and Hispanics (odds ratio= 0.84; 95% confidence interval, 0.74-0.97) were less likely and Asians (odds ratio=1.29; 95% confidence interval, 1.01-1.65) were more likely to receive coronary revascularization. Patients living in more educated communities, men, and persons with private insurance were more likely to receive coronary revascularization before and after reform. Compared with the prereform period, the adjusted odds of in-hospital mortality were higher in patients living in less-educated communities in the postreform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed before or after reform.

CONCLUSIONS

Reducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated preexisting demographic and educational disparities in access to these procedures.

INTRODUCTION

To describe the characteristics associated with patterns of daily and dual tobacco use among U.S. Air Force (USAF) personnel transitioning from basic military training to technical training.

METHODS

Cross-sectional survey of USAF personnel in Technical Training School at Lackland Air Force Base (N = 8,956, response rate: 73%). Logistic regression analyzed the association of predictor variables between daily smokers, daily smokeless tobacco (ST) users, daily smokers who used ST nondaily, daily ST users who smoked cigarettes nondaily, and daily users of both cigarettes and ST.

RESULTS

Compared to daily smokers, participants who were daily smokers/nondaily ST users were more likely to be male, would use ST and multiple forms of tobacco in the future, reported more friends using ST and cigarettes, and were more susceptible to tobacco advertising. Compared to daily ST users, daily ST users/nondaily cigarette users were more likely to live in the Midwest, would use multiple forms of tobacco in the future, reported more friends smoked cigarettes and used ST, and were more likely to try a product that claimed to be safer than cigarettes. Daily users of both cigarettes and ST were significantly more likely to be nicotine dependent than daily smokers/nondaily ST users and daily ST users/nondaily smokers.

CONCLUSIONS

Dual users are heterogeneous groups of tobacco users who are at high risk for continued tobacco use. Daily users of both cigarettes and ST have higher levels of nicotine dependence, even when compared to other dual users. Specific interventions targeted at dual users are needed in this increasingly prevalent and high-risk population.

African Americans face higher risk of AKI than Caucasians. The extent to which this increased risk is because of differences in clinical, socioeconomic, or genetic risk factors is unknown. We evaluated 10,588 African-American and Caucasian participants in the Atherosclerosis Risk in Communities study, a community-based prospective cohort of middle-aged individuals. Participants were followed from baseline study visit (1996-1999) to first hospitalization for AKI (defined by billing code), ESRD, death, or December 31, 2010. African-American participants were slightly younger (61.7 versus 63.1 years, P<0.001), were more often women (64.5% versus 53.2%, P<0.001), and had higher baseline eGFR compared with Caucasians. Annual family income, education level, and prevalence of health insurance were lower among African Americans than Caucasians. The unadjusted incidence of hospitalized AKI was 7.4 cases per 1000 person-years among African Americans and 5.8 cases per 1000 person-years among Caucasians (P=0.002). The elevated risk of AKI among African Americans persisted after adjustment for demographics, cardiovascular risk factors, kidney markers, and time-varying number of hospitalizations (adjusted hazard ratio, 1.20; 95% confidence interval [95% CI], 1.01 to 1.43; P=0.04); however, accounting for differences in income and/or insurance by race attenuated the association (P>0.05). High-risk APOL1 variants did not associate with AKI among African Americans (demographic-adjusted hazard ratio, 1.07; 95% CI, 0.69 to 1.65; P=0.77). In summary, the higher risk of AKI among African Americans may be related to disparities in socioeconomic status.

OBJECTIVE

Male-to-female transgender women (transwomen) have a disproportionate burden of HIV. We sought to estimate HIV treatment cascade indicators among transwomen in San Francisco.

METHODS

We conducted a respondent driven sampling (RDS) study of 314 transwomen from August to December 2010. The study tested participants for HIV and collected self-reported data on linkage and access to care, viral load and antiretroviral treatment (ART). We derived population-based estimates and 95% CIs of cascade indicators using sampling weights based on established RDS methods. We conducted RDS-weighted logistic regression analyses to evaluate correlates of being on ART and being virologically suppressed (viral load ≤ 200 copies/mL).

RESULTS

The RDS-weighted population-based estimate of HIV prevalence was 39% (95% CI 32% to 48%) among transwomen tested for HIV. Among HIV-positive transwomen, 77% (95% CI 70% to 93%) reported being linked to care within 3 months of diagnosis and 87% (95% CI 76% to 98%) accessed care in the past 6 months. In addition, 65% (95% CI 54% to 75%) were on ART, and less than half (44%; 95% CI 21% to 58%) were virologically suppressed. Housing instability was associated with lower odds of being on ART and being virologically suppressed.

CONCLUSIONS

We observed a high prevalence of HIV in our population-based estimates of transwomen in San Francisco, coupled with modest ART use and low virological suppression rates, indicating high potential for forward transmission. Poor HIV treatment outcomes were consistently associated with housing instability. These data suggest that multi-level efforts, including efforts to address housing insecurity, are urgently needed to ameliorate disparities in HIV clinical outcomes among transwomen and reduce secondary HIV transmission to their partners.