Cheryl Nelson

Trends in Antihypertensive Drug Therapy of Ambulatory Patients by US Office-Based Physicians

This study assessed trends from 1980 to 1995 in ambulatory patients’ antihypertensive drug therapy by US office-based physicians for visits in which hypertension was the principal diagnosis and compared these trends with the respective guidelines given in 5 Joint National Committee (JNC) Reports on Detection, Evaluation, and Treatment of High Blood Pressure published around the same time period. Data from the National Center for Health Statistics’ National Ambulatory Medical Care Surveys for 1980, 1985, 1990, and 1995 were used. From 1980 to 1995, there was no significant trend in the percentage of hypertension visits that did not mention any antihypertensive drug (20% to 27%). Further analyses focused on those hypertension visits in which at least 1 antihypertensive drug was used. Across the years, antihypertensive drug visits mentioning calcium channel blockers or ACE inhibitors significantly increased; those noting diuretics significantly decreased. However, in 1995, antihypertensive drug visits that included a diuretic and/or a &bgr;-adrenergic blocker equalled 53%; these are the antihypertensive drug classes preferred by the JNC V. Physician antihypertensive drug prescribing was generally consistent with the basic antihypertensive drug guidelines of the JNC reports.

Developing a Research Agenda for Cardiovascular Disease Prevention in High-Risk Rural Communities

The National Institutes of Health convened a workshop to engage researchers and practitioners in dialogue on research issues viewed as either unique or of particular relevance to rural areas, key content areas needed to inform policy and practice in rural settings, and ways rural contexts may influence study design, implementation, assessment of outcomes, and dissemination. Our purpose was to develop a research agenda to address the disproportionate burden of cardiovascular disease (CVD) and related risk factors among populations living in rural areas. Complementary presentations used theoretical and methodological principles to describe research and practice examples from rural settings. Participants created a comprehensive CVD research agenda that identified themes and challenges, and provided 21 recommendations to guide research, practice, and programs in rural areas.

Treatment of Hypertension Among African Americans: The Jackson Heart Study

Hypertension treatment regimens used by African American adults in the Jackson Heart Study were evaluated at the first two clinical examinations (2415 treated hypertensive persons at examination I [exam I], 2000–2004; 2577 at examination II [exam II], 2005–2008). Blood pressure (BP) was below 140/90 mm Hg for 66% and 70% of treated participants at exam I and exam II, respectively. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure treatment targets were met for 56% and 61% at exam I and exam II, respectively. Persons with diabetes or chronic kidney disease were less likely to have BP at target, as were men compared with women. Thiazide diuretics were the most commonly used antihypertensive medication, and persons taking a thiazide were more likely to have their BP controlled than persons not taking them; thiazides were used significantly less among men than women. Although calcium channel blockers are often considered to be effective monotherapy for African Americans, persons using calcium channel blocker monotherapy were significantly less likely to be at target BP than persons using thiazide monotherapy.

Neighborhood Disadvantage, Poor Social Conditions, and Cardiovascular Disease Incidence Among African American Adults in the Jackson Heart Study

OBJECTIVES To examine the impact of neighborhood conditions resulting from racial residential segregation on cardiovascular disease (CVD) risk in a socioeconomically diverse African American sample. METHODS The study included 4096 African American women (n = 2652) and men (n = 1444) aged 21 to 93 years from the Jackson Heart Study (Jackson, Mississippi; 2000-2011). We assessed neighborhood disadvantage with a composite measure of 8 indicators from the 2000 US Census. We assessed neighborhood-level social conditions, including social cohesion, violence, and disorder, with self-reported, validated scales. RESULTS Among African American women, each standard deviation increase in neighborhood disadvantage was associated with a 25% increased risk of CVD after covariate adjustment (hazard ratio = 1.25; 95% confidence interval = 1.05, 1.49). Risk also increased as levels of neighborhood violence and physical disorder increased after covariate adjustment. We observed no statistically significant associations among African American men in adjusted models. CONCLUSIONS Worse neighborhood economic and social conditions may contribute to increased risk of CVD among African American women. Policies directly addressing these issues may alleviate the burden of CVD in this group.

Multilevel Interventions Targeting Obesity: Research Recommendations for Vulnerable Populations

INTRODUCTION The origins of obesity are complex and multifaceted. To be successful, an intervention aiming to prevent or treat obesity may need to address multiple layers of biological, social, and environmental influences. METHODS NIH recognizes the importance of identifying effective strategies to combat obesity, particularly in high-risk and disadvantaged populations with heightened susceptibility to obesity and subsequent metabolic sequelae. To move this work forward, the National Heart, Lung, and Blood Institute, in collaboration with the NIH Office of Behavioral and Social Science Research and NIH Office of Disease Prevention convened a working group to inform research on multilevel obesity interventions in vulnerable populations. The working group reviewed relevant aspects of intervention planning, recruitment, retention, implementation, evaluation, and analysis, and then made recommendations. RESULTS Recruitment and retention techniques used in multilevel research must be culturally appropriate and suited to both individuals and organizations. Adequate time and resources for preliminary work are essential. Collaborative projects can benefit from complementary areas of expertise and shared investigations rigorously pretesting specific aspects of approaches. Study designs need to accommodate the social and environmental levels under study, and include appropriate attention given to statistical power. Projects should monitor implementation in the multiple venues and include a priori estimation of the magnitude of change expected within and across levels. CONCLUSIONS The complexity and challenges of delivering interventions at several levels of the social-ecologic model require careful planning and implementation, but hold promise for successful reduction of obesity in vulnerable populations.

Impact of National Heart, Lung, and Blood Institute–Supported Cardiovascular Epidemiology Research, 1998 to 2012

In a recent article, Alberts et al1 warned that the US-based biomedical science enterprise is flawed in its assumption that the enterprise will constantly expand, and it cannot expect a persistently expanding National Institutes of Health (NIH) biomedical research budget in the future. In fact, as noted by multiple observers, the NIH budget has been declining in constant dollars since 2003, and the pay lines for grants are at historic lows.1–4 Such realizations have led to calls for a reexamination of the policies and programs of the NIH and its individual institutes and centers.1,2 Some have questioned the appropriateness of the allocation of research budgets between discovery science and translational science.1,2,5 Others have argued for better methods to make funding decisions, suggesting that peer review is too conservative and limits innovation,1,2,4,6,7 or simply does not demonstrate the ability to prioritize research proposals on their potential to yield high impact.8,9 Evidence that scientists spend too much time writing and rewriting grant applications, stay too long in training programs, and achieve their first tenure track position or first NIH grant in their late thirties and early forties, respectively, suggest there is a mismatch in the supply and demand for scientists that must be addressed.1,5,7 Editorial see p 1949 Efforts at the NIH to conduct evaluation and self-examination have already begun. Institutes and centers within the NIH have taken multiple approaches. The National Cancer Institute conducted a workshop to make recommendations on how the National Cancer Institute can transform itself for the 21st century to address criticisms of excess expense, repudiated findings, small incremental gains in knowledge, inability to innovate at reasonable cost, and …

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.

Implementation Research to Address the United States Health Disadvantage: Report of a National Heart, Lung, and Blood Institute Workshop.

Four decades ago, U.S. life expectancy was within the same range as other high-income peer countries. However, during the past decades, the United States has fared worse in many key health domains resulting in shorter life expectancy and poorer health-a health disadvantage. The National Heart, Lung, and Blood Institute convened a panel of national and international health experts and stakeholders for a Think Tank meeting to explore the U.S. health disadvantage and to seek specific recommendations for implementation research opportunities for heart, lung, blood, and sleep disorders. Recommendations for National Heart, Lung, and Blood Institute consideration were made in several areas including understanding the drivers of the disadvantage, identifying potential solutions, creating strategic partnerships with common goals, and finally enhancing and fostering a research workforce for implementation research. Key recommendations included exploring why the United States is doing better for health indicators in a few areas compared with peer countries; targeting populations across the entire socioeconomic spectrum with interventions at all levels in order to prevent missing a substantial proportion of the disadvantage; assuring partnership have high-level goals that can create systemic change through collective impact; and finally, increasing opportunities for implementation research training to meet the current needs. Connecting with the research community at large and building on ongoing research efforts will be an important strategy. Broad partnerships and collaboration across the social, political, economic, and private sectors and all civil society will be critical-not only for implementation research but also for implementing the findings to have the desired population impact. Developing the relevant knowledge to tackle the U.S. health disadvantage is the necessary first step to improve U.S. health outcomes.

Relation of Carotid Intima-Media Thickness to Cardiovascular Events in Black Americans (From the Jackson Heart Study)

Although several prospective studies have reported independent relations between carotid intima-media thickness (CIMT) and risk of incident cardiovascular diseases (CVD) in primarily non-African-American (AA) cohorts, the utility of CIMT values for the prediction of incident coronary heart disease and stroke events in blacks remain unclear. At the baseline examination (2000 to 2004) of the Jackson Heart Study, AA adults 21 to 94 years of age (mean 54) underwent bilateral far-wall CIMT measurement (mean 0.76 mm). Incident CVD events were then assessed over 7 to 11 years of follow-up (2000 to 2011) from samples of 2,463 women (107 CVD events) and 1,338 men (64 CVD events) who were free of clinical CVD at baseline. Each 0.2-mm increase in CIMT was associated with age-adjusted incident CVD hazard ratios of 1.4 (95% confidence interval 1.2, 1.5) for women and 1.3 (1.1, 1.6) for men. Classification accuracy improved only slightly when comparing multivariable models that used traditional risk factors alone with models that added CIMT: C-statistics 0.837 (0.794, 0.881) versus 0.842 (0.798, 0.886) in women and 0.754 (0.683, 0.826) versus 0.763 (0.701, 0.825) in men. Similarly, risk reclassification was only mildly improved by adding CIMT: Net Reclassification Index 0.13 (p = 0.05) and 0.05 (p = 0.50) for women and men, respectively; Integrated Discrimination Improvement 0.02 (p = 0.02) and 0.01 (p = 0.26) for women and men, respectively. In conclusion, CIMT was associated with incident CVD but provided modest incremental improvement in risk reclassification beyond traditional risk factors in a community-based AA cohort.

Capacity-Building for Career Paths in Public Health and Biomedical Research for Undergraduate Minority Students: A Jackson Heart Study Success Model

OBJECTIVE This article chronicles the building of individual student capacity as well as faculty and institutional capacity, within the context of a population-based, longitudinal study of African Americans and cardiovascular disease. The purpose of this article is to present preliminary data documenting the results of this approach. DESIGN The JHS Scholars program is designed, under the organizational structure of the Natural Sciences Division at Tougaloo College, to provide solid preparation in quantitative skills through: good preparation in mathematics and the sciences; a high level of reading comprehension; hands-on learning experiences; and mentoring and counseling to sustain the motivation of the students to pursue further studies. SETTING This program is on the campus of a private Historically Black College in Mississippi. PARTICIPANTS The participants in the program are undergraduate students. MAIN OUTCOME MEASURES Data, which included information on major area of study, institution attended, degrees earned and position in the workforce, were analyzed using STATA 14. RESULTS Of 167 scholars, 46 are currently enrolled, while 118 have graduated. One half have completed graduate or professional programs, including; medicine, public health, pharmacy, nursing, and biomedical science; approximately one-fourth (25.4 %) are enrolled in graduate or professional programs; and nearly one tenth (9.3%) completed graduate degrees in law, education, business or English. CONCLUSIONS These data could assist other institutions in understanding the career development process that helps underrepresented minority students in higher education to make career choices on a path toward public health, health professions, biomedical research, and related careers.