Race, education, and weight change in a biracial sample of women at midlife

BACKGROUND: Overall rates of obesity have increased dramatically in the United States, yet African American women remain disproportionately represented among the overweight and obese. The excess weight observed in African American women is primarily considered a result of low socioeconomic status, but recent cross-sectional findings suggest otherwise. METHODS: We examined the interactive effects of race and 3 levels of education (low [high school or less]; moderate [some college]; and high [college degree or more]) on body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) and changes in BMI over 4 years in 2019 middle-aged African American and white women from the Study of Women's Health Across the Nation (SWAN). Data were analyzed with mixed effects regression models. RESULTS: At baseline, we observed a significant race x education interaction (estimate, -3.7; 95% confidence interval, -5.3 to -2.1; P<.001) on BMI. Compared with whites, African Americans had higher BMIs, but only at the moderate (means, 32.1 and 29.2) and highest (means, 31.5 and 27.8) level of education. At the lowest level of education, African American and white women were similar in BMI (means, 31.1 [African American] and 31.2 [white]). Body mass index increased significantly for all women over follow-up (estimate, 0.22; 95% confidence interval, 0.17 to 0.26; P<.001), but increases did not differ by race, education, or race x education. Results were unchanged after adjustment for potential confounding variables. CONCLUSIONS: For middle-aged women, racial disparities in BMI are largely patterned by education, with the greatest disparities observed at higher levels of education. The absence of significant longitudinal effects suggests that these race-education patterns are set in place and well established before midlife.     

Race, medical researcher distrust, perceived harm, and willingness to participate in cardiovascular prevention trials

Minority underrepresentation exists in medical research including cardiovascular clinical trials, but the hypothesis that this relates to distrust in medical researchers is unproven. Therefore, we examined whether African American persons differ from white persons in perceptions of the risks/benefits of trial participation and distrust toward medical researchers, and whether these factors influence willingness to participate (WTP) in a clinical drug trial. Participants were self-administered a survey regarding WTP in a cardiovascular drug trial given to 1440 randomly selected patients from 13 Maryland outpatient cardiology and general medicine clinics. Patients reported their WTP, rated their perceived chances of experiencing health benefit and harm, and rated their distrust toward researchers. Of eligible participants, 70% responded, and 717 individuals were included: 36% African American and 64% white.African American participants possessed lower WTP than white participants (27% vs. 39%, p = 0.001) and had higher mean distrust scores than whites (p < 0.0001). African American participants more frequently reported that doctors would less fully explain research participation to them (24% vs. 13%, p < 0.001), use them as guinea pigs without their consent (72% vs. 49%, p < 0.001), prescribe medication as a way of experimenting on people without their knowledge (35% vs. 16%, p < 0.001), and ask them to participate in research even if it could harm them (24% vs. 15%, p = 0.002). African American participants also more often believed they could less freely ask their doctor questions (8% vs. 2%, p < 0.001) and that doctors had previously experimented on them without their consent (58% vs. 25%, p < 0.001). African American participants expressed lesser WTP than white participants after controlling for racial differences in age, sex, socioeconomic status and cardiovascular disease risk profiles (multivariable odds ratio [OR], 0.57; 95% confidence interval [CI], 0.39-0.85). The impact of race was attenuated and nonsignificant after adjustment for potential mediating factors of racial differences in medical researcher distrust and perceived risk of harm (explanatory model OR, 0.84; 95% CI 0.54-1.30). In summary, African American participants expressed markedly greater concerns about experiencing harm from participation in clinical trials and distrust toward medical researchers than white participants. These factors, in turn, appear to explain much of the resistance among African American persons to participate in clinical trials compared to white persons.     

Combined hyperlipidemia in relation to race/ethnicity, obesity, and insulin resistance in the Multi-Ethnic Study of Atherosclerosis

We have asked whether the prevalence of combined hyperlipidemia (CHL) differs by race/ethnicity, obesity, and insulin resistance in a contemporary, multiethnic, US cohort. We determined the prevalence and adjusted odds of CHL in a cohort of 5923 men and women free of clinically recognized cardiovascular disease and diabetes according to race/ethnicity (white, Chinese, African American, and Hispanic), obesity, and insulin resistance. Untreated lipid values were imputed for those on lipid-lowering therapy. Combined hyperlipidemia was defined using age- and sex-specific greater than or equal to 75th percentile cut points for low-density lipoprotein cholesterol and triglycerides obtained from a predominantly white North American population study. Compared with whites, adjusted odds ratios for CHL were 0.48 in African Americans (95% confidence interval [CI], 0.30-0.75), 1.33 in Hispanics (95% CI, 0.93-1.91), and 1.06 in Asians (95% CI, 0.62-1.82). Within the entire population, the adjusted odds of CHL were over 2-fold higher in overweight and obese participants compared with normal-weight participants and more than 4-fold higher in quartiles 2 through 4 of insulin resistance compared with quartile 1. African Americans had lower odds for CHL than whites despite higher body mass index and abdominal adiposity. Hispanics had a nonsignificantly higher trend, and Asians had no significantly different odds than whites. Modest increases in weight and insulin resistance were associated with significantly higher odds of CHL in a multiethnic US population. Further research is needed to determine the most efficacious diet, exercise, and drug management to decrease the risk of CHL and coronary heart disease among racial/ethnic groups in the United States.     

Race and Association With Disease Manifestations and Mortality in Scleroderma: A 20-Year Experience at the Johns Hopkins Scleroderma Center and Review of the Literature

Experience suggests that African Americans may express autoimmune disease differently than other racial groups. In the context of systemic sclerosis (scleroderma), we sought to determine whether race was related to a more adverse expression of disease. Between January 1, 1990, and December 31, 2009, a total of 409 African American and 1808 white patients with scleroderma were evaluated at a single university medical center. While the distribution by sex was virtually identical in both groups, at 82% female, African American patients presented to the center at a younger mean age than white patients (47 vs. 53 yr; p < 0.001). Two-thirds of white patients manifested the limited cutaneous subset of disease, whereas the majority of African American patients manifested the diffuse cutaneous subset (p < 0.001). The proportion seropositive for anticentromere antibody was nearly 3-fold greater among white patients, at 34%, compared to African American patients (12%; p < 0.001). Nearly a third of African American (31%) patients had autoantibodies to topoisomerase, compared to 19% of white patients (p = 0.001). Notably, African American patients experienced an increase in prevalence of cardiac (adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3–2.2), renal (OR, 1.6; 95% CI, 1.2–2.1), digital ischemia (OR, 1.5; 95% CI, 1.4–2.2), muscle (OR, 1.7; 95% CI, 1.3–2.3), and restrictive lung (OR, 6.9; 95% CI, 5.1–9.4) disease. Overall, 700 (32%) patients died (159 African American; 541 white). The cumulative incidence of mortality at 10 years was 43% among African American patients compared to 35% among white patients (log-rank p = 0.0011). Compared to white patients, African American patients experienced an 80% increase in risk of mortality (relative risk [RR], 1.8; 95% CI, 1.4–2.2), after adjustment for age at disease onset and disease duration. Further adjustment by sex, disease subtype, and scleroderma-specific autoantibody status, and for the socioeconomic measures of educational attainment and health insurance status, diminished these risk estimates (RR, 1.3; 95% CI, 1.0–1.6). The heightened risk of mortality persisted in strata defined by age at disease onset, diffuse cutaneous disease, anticentromere seropositivity, decade of care at the center, and among women. These findings support the notion that race is related to a distinct phenotypic profile in scleroderma, and a more unfavorable prognosis among African Americans, warranting heightened diagnostic evaluation and vigilant care of these patients. Further, we provide a chronologic review of the literature regarding race, organ system involvement, and mortality in scleroderma; we furnish synopses of relevant reports, and summarize findings.     

Racial/ethnic differences in hypertension and hypertension treatment and control in the multi-ethnic study of atherosclerosis (MESA)

BACKGROUND: Most previous studies investigating the association between ethnicity and hypertension focused on differences between African Americans and whites and did not include other racial/ethnic groups such as Chinese or Hispanics. METHODS: We used data from the Multi-Ethnic Study of Atherosclerosis (MESA), a population-based study of 6814 adults without clinical cardiovascular disease, to examine the association between ethnicity and hypertension and hypertension treatment among white, African American, Chinese, and Hispanic ethnic groups. RESULTS: The prevalence of hypertension, defined as systolic blood pressure (BP) <140 mm Hg and diastolic BP <90 mm Hg or self-reported treatment for hypertension, was significantly higher in African Americans compared to whites (60% v 38%; P < .0001), whereas prevalence in Hispanic (42%) and Chinese participants (39%) did not differ significantly from that in whites. After adjustment for age, body mass index, prevalence of diabetes mellitus, and smoking, African American (odds ratio [OR] 2.21; 95% confidence interval [95% CI] 1.91-2.56) and Chinese (OR 1.30; 95% CI 1.07-1.56) ethnicity were significantly associated with hypertension compared to whites. Among hypertensive MESA participants, the percentage of treated but uncontrolled hypertension in whites (24%) was significantly lower than in African Americans (35%, P < .0001), Chinese (33%, P = .003), and Hispanics (32%, P = .0005), but only African-American race/ethnicity remained significantly associated with treated but uncontrolled hypertension after controlling for socioeconomic factors (OR 1.35; 95% CI 1.07-1.71). Diuretic use was lowest in the Chinese (22%) and Hispanic participants (32%) and was significantly lower in these groups compared with white participants (47%; P < .0001 for both comparisons). CONCLUSIONS: Programs to improve hypertension treatment and control should focus on a better understanding of differences in the prevalence of hypertension and hypertension control among minority groups in the United States, especially African Americans, compared with whites, and on techniques to prevent hypertension and improve control in high-risk groups.     

Falls in African American and white community-dwelling elderly residents

BACKGROUND: Few studies have examined the relationship of race to falls. This study evaluated the association between potential risk factors and falls in a representative sample of 1049 African American and 1947 white participants of the second in-person wave of the Duke Established Populations for Epidemiologic Studies of the Elderly. METHODS: Information about sociodemographic characteristics, health-related behaviors, health status, visual function, and drug use was determined during baseline in-home interviews. Three years later, falls in the previous 12 months were assessed by self-report. RESULTS: One or more falls occurred in 22.2% of the participants. Nearly half the fallers reported more than one fall. Multivariable analysis revealed that African Americans were less likely than whites to have any fall (adjusted odds ratio [OR] 0.77, 95% confidence interval [CI] 0.62-0.94). Increased age and education, arthritis, diabetes, and history of broken bones were also significant (p <.05) independent risk factors for any fall. In multivariable analyses comparing those with two or more falls to those with none, again, increased age and education, arthritis, and diabetes were significant (p <.05) independent risk factors while smoking was protective. Race was not a significant predictor of multiple falls (adjusted OR 0.90, 95% CI 0.64-1.26). CONCLUSIONS: Similar sociodemographic characteristics and health problems appear to be important risk factors for any and multiple falls in community-dwelling African American and white elderly residents, with white elders at greater risk of one-time falls.     

Variation in perceptions of treatment and self-care practices in elderly with osteoarthritis: a comparison between African American and white patients

OBJECTIVE: To compare elderly African American and white patients with osteoarthritis of the knee or hip with respect to their perceptions of the efficacy of traditional and complementary treatments and their self-care practices. METHODS: An observational, cross-sectional study design using structured questionnaires was employed. RESULTS: The sample consisted of 593 patients (44% African American and 56% white). The 2 groups were comparable with respect to age, disease severity or functional status, and comorbidities. African Americans were more likely than whites to report lower educational level and household income. African Americans were also more likely than whites to perceive various traditional and complementary care modalities as efficacious. However, they were less likely than whites to perceive joint replacement therapy as efficacious (odds ratio 0.52, 95% confidence interval 0.28-0.98). African American patients were more likely than white patients to rely on self-care measures for their arthritis. CONCLUSION: African American and white patients with osteoarthritis of the knee or hip differ with respect to their perceptions of traditional and complementary treatments for arthritis and their self-care practices.     

Self-reported osteoarthritis, ethnicity, body mass index, and other associated risk factors in postmenopausal women-results from the Women's Health Initiative

The objective of this analysis was to assess risk factors for self-reported osteoarthritis (OA) in an ethnically diverse cohort of women. The participants were postmenopausal women aged 50 to 79 (n=146,494) participating in the clinical trial and observational study of the Women's Health Initiative (WHI). Baseline OA and risk factors were collected from WHI questionnaires. Logistic regression was used to find the association between the risk factors and OA. Risk factor distribution and ethnicity interaction terms were used to assess ethnic differences in OA risk. Forty-four percent of the participants reported OA. Older age (odds ratio (OR)(70-79 vs 50-59)=2.69, 95% confidence interval (CI)=2.60-2.78) and higher body mass index (BMI) (OR(BMI>or=40.0 vs <24.9)=2.80, 95% CI=2.63-2.99) were found to be the strongest risk factors associated with self-reported OA. The prevalence of obesity (BMI>or=30.0) was 57.9% in African Americans, 51.0% in American Indians, 41.9% in Hispanic whites, and 32.9% in non-Hispanic whites. The prevalence of other major OA risk factors was higher in African-American, American-Indian, and Hispanic white women than in non-Hispanic white women. Non-Hispanic white women who were in the extreme obese category (BMI>or=40.0 kg/m(2)) had a 2.80 times (95% CI=2.63, 2.99) greater odds of self-reported OA. The odds were even higher in American-Indian (OR=4.22, 95% CI=1.82, 9.77) and African-American (OR=3.31, 95% CI=2.79, 3.91) women, indicating a significant interactive effect of BMI and ethnicity on odds of OA. In conclusion, OA is a highly prevalent condition in postmenopausal women, and there are differential effects according to ethnicity.     

Genetic ancestry and lower extremity peripheral artery disease in the Multi-Ethnic Study of Atherosclerosis

Using self-report of race/ethnicity, African Americans consistently have a higher prevalence of peripheral artery disease (PAD) compared to other ethnic groups. We aimed to determine the associations between estimated genetic admixture and PAD among African and Hispanic Americans. We studied the association between genetic ancestry and PAD among 1417 African and Hispanic American participants in the Multi-Ethnic Study of Atherosclerosis who were genotyped for ancestry informative markers (AIMs). PAD was defined as an ankle-brachial index (ABI) < 0.90. The overall prevalence of PAD among the 712 self-identified African American subjects was 15.2% and 4.6% among the 705 self-identified Hispanic Americans. A one standard deviation increment in European ancestry was associated with non-significant reductions in the odds for PAD among African (OR: 0.96 [95% CI: 0.78-1.18]) and Hispanic Americans (0.84 [0.58-1.23]), while the same increment in Native American ancestry was significantly associated with a lower odds of PAD in Hispanic Americans (0.56 [0.36-0.96]). Adjustment for demographic variables, field center, cardiovascular disease (CVD) risk factors and inflammatory markers strengthened the odds for European ancestry among African (0.85 [0.66-1.10]) and Hispanic Americans (0.68 [0.41-1.11]). The magnitude of the association for Native American ancestry among Hispanic Americans did not materially change (0.56 [0.29-1.09]). In conclusion, a higher percent Native American ancestry in Hispanics is associated with a lower odds of PAD while in both Hispanics and African Americans, greater European ancestry does not appear to be associated with lower odds for PAD.     

Racial disparities in receipt of hip and knee joint replacements are not explained by need: the Health and Retirement Study 1998-2004

BACKGROUND: Hip and knee joint replacement rates vary by demographic group. This article describes the epidemiology of need for joint replacement, and of subsequent receipt of a joint replacement by those in need. METHODS: Data from the Health and Retirement Study were used to assess need for hip or knee joint replacement in a total of 14,807 adults aged 60 years or older in 1998, 2000, and 2002 and receipt of needed surgery 2 years later. "Need" classification was based on difficulty walking, joint pain, stiffness, or swelling and receipt of treatment for arthritis, without contraindications to surgery. RESULTS: Need in 2002 was greater in participants who were older than 74 years (vs 60-64: adjusted odds ratio 2.06; 95% confidence interval, 1.68-2.53), women (vs men: 1.81; 1.53-2.14), less educated (vs college educated: 1.27; 1.06-1.52), in the poorest third (vs richest: 2.20; 1.78-2.72), or obese (vs nonobese: 2.39; 2.02-2.81). One hundred sixty-eight participants in need received a joint replacement, with lower receipt in black or African American participants (vs white: 0.47; 0.26-0.83) or less educated (vs college educated: 0.65; 0.44-0.96). These differences were not explained by current employment, access to medical care, family responsibilities, disability, living alone, comorbidity, or exclusion of those younger than Medicare eligibility age. CONCLUSIONS: After taking variations in need into consideration, being black or African American or lacking a college education appears to be a barrier to receiving surgery, whereas age, sex, relative poverty, and obesity do not. These disparities maintain disproportionately high levels of pain and disability in disadvantaged groups.     

The prevalence and severity of coronary artery calcification on coronary artery computed tomography in black and white subjects

OBJECTIVES: We studied the relationship between coronary artery calcium (CAC) and race in asymptomatic, active-duty personnel in the Prospective Army Coronary Calcium (PACC) project. BACKGROUND: Valid cardiovascular risk assessments in black Americans using coronary artery computed tomography (coronary CT) require the generalizability of population-based CAC score distributions derived from primarily white patient populations. METHODS: Among 1,000 consecutive participants (mean age, 42 +/- 2 years; range, 40 to 45 years), 999 participants underwent coronary CT and indicated a specific racial affiliation. This included white, non-Hispanic in 699 (69.9%) participants and black, non-Hispanic in 194 (19.4%) participants. Univariate associations between race and cardiovascular risk variables were entered into a logistic regression model for CAC that also controlled for socioeconomic status and education. RESULTS: Coronary artery calcium was nearly twice as prevalent in white (19.2%) than in black participants (10.3%) (p = 0.004). Black individuals had a threefold greater prevalence of hypertension, left ventricular hypertrophy, ST-T-wave abnormalities, and current cigarette smoking. Black subjects also had significantly greater blood pressure, high-density lipoprotein cholesterol, glycosylated hemoglobin, lipoprotein(a) and fibrinogen levels, and lower triglyceride levels and waist girth than white subjects. After adjustment for these differences, and socioeconomic adjusters, black individuals were 39% as likely to have any CAC present (odds ratio, 0.39; 95% confidence interval, 0.20 to 0.78; p = 0.007). CONCLUSIONS: Despite a worse cardiovascular risk profile, black Americans have significantly less CAC than white Americans. The use of coronary CT as an accurate risk prediction tool in black Americans will require ethnic-specific data on the presence and severity of CAC.     

The cardiac access longitudinal study. A study of access to invasive cardiology among African American and white patients

OBJECTIVES: We sought to identify factors contributing to racial disparity in the receipt of coronary angiography (CA). BACKGROUND: Numerous studies have demonstrated that African American patients are less likely to receive needed diagnostic and therapeutic coronary procedures than white patients. This report summarizes the methods and findings of a study linking medical records with patient and physician interviews to address racial disparities in the utilization of CA. METHODS: This is a retrospective, cross-sectional study conducted in three urban hospitals in Maryland. A total of 9,275 medical records were reviewed, representing all 7,058 cardiac patients admitted in a two-year period. We identified 2,623 patients who, according to American College of Cardiology guidelines, were candidates for receiving CA. A total of 1,669 patients (721 African Americans and 948 whites) and 74% of their physicians were successfully interviewed. Multivariate and hierarchical multivariate logistic regression were used to construct a model of receipt of CA within one year of the hospitalization. RESULTS: The unadjusted odds of white patients receiving CA was three times greater than the odds for African American patients (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.4 to 3.7). Adjusting for patients' clinical and social characteristics resulted in a 13% reduction in the OR for race. Adjusting for physician and health care system characteristics reduced the OR by 43%, to 1.7 (95% CI 1.3 to 2.4). CONCLUSIONS: Racial disparity in the utilization of CA is a function of differences in the health care system "context" in which African American and white patients obtain care, combined with differences in the specific clinical characteristics of patients.     

Racial and ethnic disparities in sarcoidosis: from genetics to socioeconomics

Sarcoidosis is a multisystem granulomatous disease of unknown cause that occurs worldwide. The clinical expression of sarcoidosis varies by race. These racial differences may be the result of genetic and socioeconomic factors. Many of these genetic associations are race-specific in that they are found in either African Americans or whites but not both. Socioeconomic differences may also explain the racial disparities between African American and white patients with sarcoidosis. Finally, the phenotypic differences be-tween races may relate to an interaction between genetics and socioeconomic factors.The influences of genetics and socioeconomic status on the development and phenotypic expression of sarcoidosis will be better understood as the mechanisms of disease development are uncovered.     

Acculturation is associated with hypertension in a multiethnic sample

BACKGROUND: Hypertension varies in prevalence among race/ethnic groups in the United States. Within-ethnic group differences associated with acculturation have been less frequently examined. We studied the association of three measures of acculturation (language spoken at home, place of birth, and years living in the US) with hypertension in a population sample of 2619 white, 1898 African American, 1,494 Hispanic, and 803 Chinese participants in the Multiethnic Study of Atherosclerosis. METHODS: Multivariate Poisson regression was used to estimate the association between the acculturation variables and hypertension. RESULTS: Birthplace outside the US and speaking a non-English language at home were each associated with a lower prevalence of hypertension after adjustment for age, gender, and socioeconomic status (prevalence ratio [95% confidence intervals] 0.82 (0.77-0.87) for non-US born versus US born and 0.80 (0.74-0.85) for those not speaking English at home versus speakers of English at home, both P < .001). For participants born outside of the US, each 10-year increment of years in the US was associated with a higher prevalence of hypertension after adjustment for age, gender, and socioeconomic status (P for trend < .01). The associations between acculturation variables and hypertension were weakened after adjustment for race/ethnic category and risk factors for hypertension. Compared to US-born Hispanics, those born in Mexico or South America had lower prevalence of hypertension, but those born in the Caribbean and Central America had higher prevalence of hypertension. CONCLUSIONS: Acculturation and place of birth are associated with hypertension in a multiethnic sample.     

Understanding ethnic disparities in the use of total joint arthroplasty: application of the health belief model

OBJECTIVE: The Health Belief Model holds promise in understanding patient-related factors that may explain disparities in the use of total joint arthroplasty (TJA). We examined whether patients' health beliefs differ between African Americans and whites. METHODS: In a primary care clinic setting, 691 African Americans and whites with at least a moderately severe degree of osteoarthritis (OA) completed the Arthritis-related Health Belief Instrument. The instrument has 4 scales: perceived benefits of TJA, perceived barriers to obtaining TJA, perceived severity of arthritis, and perceived susceptibility of arthritis to worsen. RESULTS: The sample (40% women) consisted of 263 (38%) African Americans and 428 (62%) whites who were similar with respect to education, amount of insurance coverage, number of comorbidities, and self-report OA severity score. The African American group was younger, had less men, had more participants who reported an annual income<$15,000, and had a higher body mass index than whites. After controlling for confounders, African Americans were almost 50% (odds ratio [OR] 0.60, 95% confidence interval [95% CI] 0.42-0.86, P=0.005) as likely as whites to perceive that TJA is beneficial or helpful for their arthritis. Furthermore, African Americans were 70% (OR 1.7, 95% CI 1.18-2.44, P=0.004) more likely than whites to recognize barriers (e.g., risky, etc.) to TJA. Race was not associated with either the perceived severity or the perceived susceptibility of arthritis to worsen. CONCLUSION: Among patients with at least moderately severe OA, African Americans were significantly less likely than whites to perceive the benefits of TJA and more likely to recognize barriers to TJA.     

Role of age, sex, and obesity in the higher prevalence of arthritis among lower socioeconomic groups: a population-based survey

OBJECTIVE: To compare the prevalence of arthritis among population groups based on demographic, socioeconomic, and body mass index (BMI) characteristics; to investigate the combined influence of these factors on arthritis; and to assess the relationship between self-reported health and psychological distress and arthritis. METHODS: Data from the Victorian Population Health Survey (n = 7,500) were used in the study. Psychological distress was assessed using the Kessler Psychological Distress scale, and self-reported health was assessed by a single item. Multiple logistic regression was used to investigate the combined influence of demographic and socioeconomic factors and BMI on arthritis. RESULTS: Overall, 23% of Victorian adults (20% men and 26% women) reported having arthritis. The presence of arthritis was associated with high psychological distress (odds ratio [OR] 1.2; 95% confidence interval [95% CI] 1.1-1.4) and poor self-reported health (OR 1.9; 95% CI 1.7-2.1). Increased prevalence of arthritis was found in older age groups, lower education and income groups, and in people who were overweight or obese. Women had higher risk of arthritis, even after adjustment for age, residence, education, occupation, income, and BMI. Age and BMI independently predicted arthritis for men and women. For men, higher risk of arthritis was also associated with lower income. CONCLUSION: Arthritis is a highly prevalent condition associated with poor health and high psychological distress. Prevalence of arthritis is disproportionately high among women and individuals from lower socioeconomic backgrounds. As the prevalence of arthritis is predicted to increase, careful consideration of causal factors, and setting priorities for resource allocation for the treatment and prevention of arthritis are required.     

Racial differences in foot disorders and foot type

Objective

To describe racial differences in the frequency of structural foot disorders and pes planus and pes cavus foot types in a large cohort of African American and white men and women ages ≥50 years.

Methods

Of 1,695 Johnston County Osteoarthritis Project participants evaluated for foot disorders/types in 2006–2010, 4 with lower extremity amputation were excluded, leaving 1,691 available for analyses (mean age 69 years, mean body mass index [BMI] 31.5 kg/m², 68% women, 31% African American). The most common foot disorders/types were identified using a validated foot examination. Each foot disorder/type was compared by race using logistic regression, controlling for age, BMI, and sex. Effect modification between race (African American versus white) and age, BMI (categorized as ≥30 kg/m² [obese] or <30 kg/m² [nonobese]), sex, and education was examined.

Results

Hallux valgus (64%), hammer toes (35%), overlapping toes (34%), and pes planus (23%) were common. Compared to whites, African Americans were almost 3 times more likely to have pes planus and were nearly 5 times less likely to have Tailor's bunions or pes cavus. Among the nonobese, African Americans were more likely than whites to have hallux valgus (adjusted odds ratio [OR_adj] 2.01, 95% confidence interval [95% CI] 1.39–2.92), hammer toes (OR_adj 2.64, 95% CI 1.88–3.70), and overlapping toes (OR_adj 1.53, 95% CI 1.09–2.13).

Conclusion

Foot disorders are common among adults ages ≥50 years and differ by race. Future research is needed to determine the etiology of foot problems, especially those with racial differences, in order to inform prevention approaches.     

Racial differences in hospice revocation to pursue aggressive care

BACKGROUND: Hospice provides supportive care to terminally ill patients at the end of life. However, some enrollees leave hospice before death in search of therapies that may prolong survival. Because of a greater preference for life-sustaining therapies at the end of life, African American patients may be more likely than white patients to withdraw from hospice to seek life-prolonging therapies. METHODS: In a secondary data analysis of African American and white patients discharged from VITAS hospice programs between January 1, 1999, and December 31, 2003, we used logistic regression to examine the association between race and discharge disposition defined as hospice revocation to pursue aggressive care (eg, emergency medical care, chemotherapy, or invasive medical intervention) vs all other discharges. We used a Cox proportional hazards model to examine survival at 1 year after hospice revocation in a subgroup of enrollees from Florida hospice programs. RESULTS: Of the 166 197 enrollees, 2.8% revoked hospice to pursue aggressive care, and African American patients were more likely than white patients to do so (4.5% vs 2.5%; P< .001). In multivariate analysis, African American patients had a 70% higher odds of leaving hospice to pursue life-prolonging therapies (odds ratio, 1.70; 95% confidence interval, 1.57-1.84). In the subgroup analysis, 48.4% of the enrollees who revoked hospice to pursue life-prolonging therapies were still alive at 1 year. CONCLUSIONS: African American patients were more likely than white patients to revoke hospice to pursue life-prolonging therapies. Models of health care that couple curative and palliative therapies may be more attractive to African American patients and more effective at maximizing continuity throughout life-limiting illness.     

Patient Difficulty Using Tablet Computers to Screen in Primary Care

Background Patient-administered computerized questionnaires represent a novel tool to assist primary care physicians in the delivery of preventive health care. Objective The aim of this study was to assess patient-reported ease of use with a self-administered tablet computer-based questionnaire in routine clinical care. Design All patients seen in a university-based primary care practice were asked to provide routine screening information using a touch-screen tablet computer-based questionnaire. Patients reported difficulty using the tablet computer after completion of their first questionnaire. Patients Ten thousand nine hundred ninety-nine patients completed the questionnaire between January 2004 and January 2006. Measurements We calculated rates of reporting difficulty (no difficulty, some difficulty, or a lot of difficulty) using the tablet computers based on patient age, sex, race, educational attainment, marital status, and number of comorbid medical conditions. We constructed multivariable ordered logistic models to identify predictors of increased self-reported difficulty using the computer. Results The majority of patients (84%) reported no difficulty using the tablet computers to complete the questionnaire, with only 3% reporting a lot of difficulty. Significant predictors of reporting more difficulty included increasing age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.05–1.05)]; Asian race (OR 2.3, 95% CI 1.8–2.9); African American race (OR 1.4, 95% CI 1.2–1.6); less than a high school education (OR 3.0, 95% CI 2.6–3.4); and the presence of comorbid medical conditions (1–2: OR 1.3, 95% CI 1.2–1.5; ≥3: OR 1.7 95% CI 1.5–2.1). Conclusions The majority of primary care patients reported no difficulty using a self-administered tablet computer-based questionnaire. While computerized questionnaires present opportunities to collect routine screening information from patients, attention must be paid to vulnerable groups.