Group 1 Abstracts: Charting the course to eliminate disparities for heart disease and stroke

Preventive Medicine 39 (2004) S3 – S27 www.elsevier.com/locate/ypmed

Abstract

Group 1 Abstracts: Charting the course to eliminate disparities for heart disease and stroke 1 PREVALENCE OF SELF-REPORTED RISK FACTORS AMONG BLACK AND WHITE WOMEN WITH HISTORY OF PREMATURE HEART DISEASE-BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS), 2001. A. Sundaram, C. Ayala, K. Greenlund, G. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Heart disease continues to be a leading cause of disability and death among both black and white women in the US. An understanding of self-reported CHD risk factors among younger women (< 65 years) with prior history of heart disease by race and age can facilitate the planning a nd implementation of prevention programs. Objective: To assess the prevalence of selected CHD risk factors present among black and white women with a history of heart disease by race and age. Methods: Prevalence data are from the Behavioral Risk Factor Surveillance System (BRFSS), a state based telephone survey of US adults. In 2001, 36049 women in 20 states reported physical inactivity status, and whether they had ever been told by a healthcare provider that they had high blood pressure, high cholesterol, or coronary heart disease. Overweight status (body mass index > 25) was determined by self-reported height and weight. Data were weighted to each state’s population. Results: Of 28, 271 younger women (less than age 65), 739 white women and 118 black women reported having heart disease. Black women with heart disease had a greater self-reported proportion of hypertension (86% vs. 57%), overweight (63% vs. 33%), and sedentary lifestyle (50% vs. 40%) and a lower prevalence of high cholesterol (53% vs. 56%) compared to white women. Among those with a prior history of heart disease, 63% of white women and 80% of black women less than 65 years of age had two or more risk factors for CHD. Conclusion: CHD risk factors are highly prevalent among younger women with reported heart disease. Although comprehensive risk reduction is necessary for all women, aggressive programs may also provide tailored messages for women at earlier ages by ethnicity and age based on selected risk factor profiles. doi:10.1016/j.ypmed.2004.06.019

2 TRENDS IN CARDIOVASCULAR DISEASE (CVD) AND RISK FACTORS AMONG AMERICAN INDIANS IN MONTANA. C. Oser, T. Harwell, C. Strasheim, C. Fogle, L. Blades, D. Gohdes, S. Helgerson. Montana Department of Public Health and Human Services, Helena, Montana, Billings Area Indian Health Service, Billings, Montana. Objective: To assess trends in cardiovascular disease (CVD) and CVD-related risk factors among American Indians in Montana from 1999 to 2003. Methods: Adult American Indians living on or near the seven reservations in Montana were interviewed through an adapted Behavior Risk Factor Surveillance Survey (BRFSS) telephone survey in 1999, 2001 and 2003. Each year the survey included approximately 1000 individuals age 18 years and over. Results: From 1999 to 2003, the proportion of American Indian adults reporting diabetes (12% to 16%), high blood pressure (26% to 34%), high cholesterol (23% to 30%), and obesity (34% to 39%) increased significantly. After adjusting for age, sex and survey year (1999 vs. 2003), the increases in high blood pressure (AOR 1.29, 95% CI: 1.05– 1.58), high cholesterol (AOR 1.31, 95% CI: 1.02 –1.68) and obesity (AOR 1.23, 95% CI: 1.02 – 1.49) remained significant. During the 5-year period, the prevalence of cardiovascular disease (history of myocardial infarction, angina, or stroke) (10% in 1999; 11% in 2003) and smoking rates (38% in 1999; 36% in 2003) remained stable. Conclusion: The prevalence of cardiovascular disease risk factors among American Indians in Montana is high, and for many of the risk factors, alarmingly increasing.

3 SELF-REPORTED HIGH BLOOD PRESSURE AWARENESS AND TREATMENT AMONG HISPANICS –UNITED STATES, 2001. J.A. Minaya, C. Ayala, K.J. Greenlund, C.H. Denny, J.B. Croft, G.A. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Objective: To assess the prevalences of self-reported high blood pressure and treatment among Hispanics compared to other population groups in 2001. Methods: Using data from

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184,296 respondents of the 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey aged > 20 years, the prevalences and odds ratios for self-reported high blood pressure and treatment were estimated among Hispanics, Non-Hispanic Whites (NHW), and Non-Hispanic Blacks (NHB). Data were analyzed using SAS and SUDAAN software. Results: Overall, Hispanics had the lowest prevalence of reported high blood pressure (24.1%) and the lowest treatment (52.6%) prevalence. Hispanics were more likely to be younger, less educated, less likely to have health insurance, and more likely to have diabetes. After adjusting for gender, age, education, marital status, health insurance, and diabetes, Hispanics were 0.8 (0.8, 0.9) times as likely as NHW to report being told that they had high blood pressure; whereas, NHB were 1.8 (1.7, 1.9) times more likely than NHW to report that they were told that they had high blood pressure. Also, Hispanics were 0.8 (0.7, 0.9) times as likely to report treatment for high blood pressure, while NHB were 1.5 (1.3, 1.6) times more likely than NHW to be treated for high blood pressure. Conclusion: Hispanics are less likely to report being treated for high blood pressure than their Non-Hispanic counterparts. In order to better tailor high blood pressure prevention interventions in Hispanic communities, health officials should be cognizant of the differences in high blood pressure treatment among Hispanics.

4 INCREASING HYPERTENSION-RELATED MORTALITY AMONG HISPANIC SUBGROUPS – UNITED STATES, 1995 – 2000. M. Moreno, C. Ayala, J. Minaya, J. Croft, R. Zambrana, G. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Objective: To assess national trends from 1995 to 2000 in HRM among Hispanic subgroups were assessed in the U.S. Methods: National vital statistics multiple cause mortality files from 1995 – 2000 were analyzed for HRM among Mexican Americans (MA), Puerto Rican Americans (PRA), Cuban Americans (CA), and Central and South Americans (CSA) ages > 20 years with hypertension listed as one of up to 20 conditions resulting in death. Trends (2-year intervals) were examined using relative percent change for age-standardized death rates (ASDR per 100,000) for HRM. Results: In 1995 –1996, the ASDR for HRM were highest among OHA (84.0) followed by PRA (72.2), MA (68.0), CA (58.8), and CSA (53.3). In 1999 – 2000, PRA and MA had the highest ASDR for HRM among all Hispanics, 148.9 and 97.1, respectively. However, the greatest relative percent increase from 1995 – 96 to 1999 – 00 was 106.2% (p < 0.01). among PRA, followed by 42.8% (p < 0.01) among MA; 22.1% (p < 0.01) among CSA; and 16.8% (p < 0.01) among PRA. Conclusions: ASDR for HRM are highest among PRA and MA. Future research is needed to examine the variation in health issues, specifically hypertension

among these individual subgroups to better identify risks and properly implement interventions. Since control rates for the general population are unacceptably low; moreover MA has the lowest control rates. Thus, program and systems changes to increase treatment and control rates for the general populations, particularly for high-risk Hispanic subgroups must be a high national public health priority. 5 HYPERTENSION-RELATED MORTALITY INCREASED AMONG ADULT HISPANICS – U.S., 1995– 2000. J. Minaya, C. Ayala, M. Moreno, J. Croft, G. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: Nationwide, hypertension control rates are the lowest among Hispanics. However, national trends in hypertension-related mortality (HRM) death rates among Hispanic decedents have not been assessed. This study examines national trends in HRM death rates among adult Hispanic Blacks (HB) and Hispanic Whites (HW) in the U.S. from 1995 – 2000. Methods: National vital statistics multiple cause mortality files from 1995– 2000 were analyzed for all adult Hispanic decedents with hypertension listed as one of up to 20 conditions resulting in death. Trends (2-year intervals) were examined using relative percent change for agestandardized and age-specific death rates (per 100,000) of HRM. Results: In 1999– 2000 death rates for HRM increased to 35.0 for HB with a relative percent increase (RPI) of 34.5% (p < 0.01) and 91.4 for HW (RPI = 39.4%, p < 0.01). Agespecific death rates increased for all age groups. Among HB decedents, the highest increase in age-specific death rates was among those aged 20 – 44 years (RPI = 151.5%, p < 0.01) and the lowest increase was among those aged 45-64 years (RPI = 25.9%, p < 0.01). Among HW decedents, the highest increases in age-specific death rates were among those aged 20-44 years (RPI = 52.6%, p < 0.01) and > 85 years (RPI = 52.6%, p < 0.01). Death rates increased the least for those aged 45 – 64 years (RPI = 27.1%, p < 0.01). Conclusions: Age-standardized and age-specific death rates of HRM increased significantly for adult Hispanic Whites and Blacks from 1995 –2000. The highest increase was among young Hispanic Blacks aged 20– 44 years. Aggressive efforts in the prevention and control of hypertension in high-risk populations, such as young adult Hispanic Blacks, are warranted. 6 COMMUNITY WELLNESS ADVOCATES: BUILDING HEALTHY HEARTS IN ALASKA NATIVE VILLAGES. H. Davis. Chugachmiut, Alaska. Providing health services in rural and remote Alaskan villages is a difficult task. Many health related services

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are delivered by itinerant providers who do not live in the communities they serve and are in the community for a specific task and time period. Through the use of Community Wellness Advocates (CWAs), trained communitybased public health promotion paraprofessionals, villages in the Chugach region of Alaska have worked to address the problem of increasing rates of cardiovascular disease. In 1998, heart disease was the third leading cause of death for Alaska Native men, and the second leading cause of death for Alaska Native women. Community Wellness Advocates are members of the communities they serve. They have been educated on how to successfully implement culturally competent health promotion and health education activities through an accessible and academically sound distance-delivered certificate program. Working in conjunction with a cardiovascular disease prevention program, Community Wellness Advocates have developed and implemented awareness of cardiovascular disease by promoting health behavior changes in their communities. Cardiovascular disease awareness activities vary in each community of the 15,000 square mile region served, but include cardiovascular disease education as well as promoting healthy lifestyles through exercise programs, nutrition information, tobacco cessation, stress reduction, and any other ideas community members are interested in. By having Community Wellness Advocates actively working in Chugach region Alaska Native villages, many community members have become more aware of cardiovascular disease and have started to adopt healthy lifestyle changes to reduce the risk of cardiovascular problems. Community Wellness Advocates are truly a community-based intervention to help eliminate heart disease and stroke disparities.

7 ATLAS OF HEART DISEASE AND STROKE AMONG AMERICAN INDIANS AND ALASKA NATIVES. J. Coolidge, M. Casper, C. Denny, I. Williams, J. Galloway, N. Cobb. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background-Objectives: Evidence highlights the serious burden of heart disease and stroke among American Indians and Alaska Natives (AI/ANs). In this atlas we examine geographic patterns in the prevalence of risk factors for heart disease and stroke and the rate of heart disease and stroke mortality among AI/ANs. Methods: Mortality data were obtained for stroke (1991 – 1998) and heart disease (1996 –2000) through the National Center for Health Statistics. Heart disease and stroke death rates were calculated by county for ages 35 and older. Risk factor data were drawn from the 1995– 2000 BRFSS, a telephone survey of U.S. adults ages 18 and older. Age-adjusted prevalences of self-reported high blood pressure, cholesterol screening, high cholesterol, cigarette smoking, physical activity, poor

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health, obesity and diabetes were calculated by region, state and gender. Results: Substantial geographic disparities were observed in this atlas. Stroke mortality rates among AI/ANs were highest in counties of the northwestern states and Alaska, while the heart disease death rates were highest in the northern plains states. For several of the risk factors, states with the highest prevalences are located in the northern parts of the US. However, the patterns varied substantially among the risk factors. Comparisons of risk factor prevalence estimates with other racial/ethnic groups in the U.S. indicate that AI/ANs have higher prevalences of some risk factors and lower prevalences of others. Conclusions: The geographic disparities in heart disease and stroke observed in this atlas highlight the importance of tailoring programs, policies and interventions among AI/ ANs to specific states and counties.

8 USING STATE DATA FOR HEART DISEASE AND STROKE PREVENTION PROGRAMS. C.H. Denny, K.J. Greenlund, J.B. Croft, G.A. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: CDC funds State Heart Disease and Stroke Prevention Programs in 32 states and the District of Columbia. The Behavioral Risk Factor Surveillance System (BRFSS), a state-based telephone survey, is an important source of population-based data for monitoring and evaluating state program progress. Objective: To describe how the BRFSS is used to measure progress at meeting national and state program objectives related to preventing heart disease and stroke. Methods: A literature review of BRFSS reports of risk factors and outcomes of interest to State Heart Disease and Stroke Prevention Programs and summarization of national program objectives. Results: BRFSS questions have been implemented to measure progress on hypertension awareness, cholesterol screening and awareness, secondary preventive practices, and awareness of the signs and symptoms of heart attack and stroke. For example, the percentage of respondents reporting that they had high blood pressure increased slightly from 22.9% in 1991 to 24.9% in 1999. Also, among 17 states and the Virgin Islands in 2001, the percentage of respondents who knew all major stroke symptoms and to call 911 ranged from 5.9% to 21.7%. Beginning in 2005, data will be collected that measure actions to control high blood pressure. Conclusions: As CDC’s Heart Disease and Stroke Prevention Program develops, the need for state data will become more important to measure the burden of disease and program impact. State Heart Disease and Stroke Prevention Programs are encouraged to work closely with state BRFSS coordinators to obtain vital information to measure the burden of heart disease and stroke in their state.

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9 CHARACTERISTICS OF ‘‘ILL-DEFINED’’ STROKE DIAGNOSIS AT HOSPITAL DISCHARGE AMONG OLDER ADULTS-MEDICARE, 2000. H. McGruder, J.B. Croft, C. Ayala, K. Greenlund, A.M. Malarcher, Z.J. Zheng, G.A. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Objective: Rapid and accurate diagnosis of stroke subtypes are crucial for optimal treatment and outcomes. However, a substantial proportion of strokes receive an ill-defined stroke (IDS) diagnosis. We assessed the likelihood of an IDS diagnosis among all Medicare patients hospitalized with stroke. Methods: Medicare hospital claims for 2000 were used to examine the distribution of stroke subtypes and characteristics related to an IDS diagnosis. Stroke subtypes included a principal diagnosis (ICD-9 code) of hemorrhagic stroke (430 –432), ischemic stroke (433 – 434), IDS (436 – 437), and late effects of cerebrovascular disease (438). Results: Among 445,452 hospital claims for stroke, 65.3% were ischemic, 20.9% were IDS, 11.9% were hemorrhagic, and 1.9% were late effects of cerebrovascular disease. After controlling for age, women (OR = 1.30; 95%CI = 1.28, 1.32), blacks (OR = 1.31; 95%CI = 1.28, 1.33) and Hispanics (OR = 1.27; 95%CI = 1.20, 1.34) were more likely to receive a discharge diagnosis of IDS compared to men and whites, respectively. IDS at discharge was associated with IDS admitting diagnosis (p < 0.05) and discharge to a skilled nursing facility or other facility (p < 0.05), but was less likely for hospital deaths (p < 0.05). Persons with an IDS were less likely to receive arteriography, diagnostic ultrasound, or magnetic resonance imaging of the brain (p < 0.05). States varied in the proportion of IDS (range = 4.4% – 34.8%). Conclusion: The high proportion of IDS demonstrates a need for more accurate diagnoses of stroke subtypes during the hospital stay. A public health effort to promote hospital stroke policies and professional education is critical because evaluation to diagnose the type of stroke is essential to target treatment and improve clinical outcomes.

10 TIME TREND AND COHORT ANALYSIS OF CARDIOVASCULAR DISEASE MORTALITY IN MISSISSIPPI: PROJECTIONS TO 2010. A. Penman. Mississippi State Department of Health. Objectives: To analyze time trends in cardiovascular disease (CVD) mortality in Mississippi over the period 1980-2001 by age, sex, and race; determine any cohort effects; and project rates to 2010. Methods: Age-group specific and age adjusted CVD mortality rates were obtained from CDC WONDER. Estimated annual percent change (EAPC) was calculated by fitting a regression line to the natural logarithm of the rates using calendar year as a regressor. Projections to

2010 were made using two methods: extrapolation of the EAPC and simple linear regression. Poisson regression was used to calculate age-group specific mortality rate ratios. Graphs of age-group specific rates by central year of birth were examined to detect cohort effects. Results: Between 1980 and 2001, CVD mortality rates for African-American women declined by only 12% (0.4% per year), compared to 20% (1% per year) for white women, 25% (0.5% per year) for African-American men, and 33% (1.7% per year) for white men. No cohort effect was seen for women, but African-American men 45 years of age and older born before the period 1918 –1924 had lower CVD mortality rates than white men; those born after this period had higher rates than white men. The CVD mortality rate trend line for AfricanAmerican women will cross the trend line for white men around 2004 and the trend line for African-American men around 2008. Conclusions: African-American women will soon have the highest CVD mortality rate in the state.

11 EFFECTIVENESS OF THE FAST PROGRAM ON KNOWLEDGE OF STROKE IN A RURAL POPULATION. P. Stewart Fahs, M.A. Baron, A. Dura, T. Folks, A. Fronczek, L.T. Kasey, L.L. Morgan, F. Srnka-Debnar, M. Sutherland. Binghamton University, New York. The purpose of this study was to measure the effectiveness of the Facts for Action to Stroke Treatment program on knowledge and early recognition of the symptoms of stroke with emphasis on the medically urgency of the situation among a population of adult rural dwellers. Stroke remains a problem as a leading cause of death in the US and 42% of the population is unable to identify the most common signs of stroke. The prospective quasi-experimental design utilized a convenience sample from the FAST presentations hosted by community groups in a rural county of upstate New York. Participants where given a pretest, attended a 30 minute slide presentation on stroke utilizing the Cincinnati PreHospital Stroke Scale with information on when to seek emergency treatment, took a posttest and two months later were asked to complete a follow-up instrument. Analysis to date is based on 84 subjects attending 5 programs in Fall 2003 with ongoing data collection during 2004. To date, mean sample age was 55 years (range 18 to 88 years). Seventy-four percent (74%) of the sample were female. Ninety-three (93%) percent self-identified as rural dwellers. Dependent t-tests with Bonferroni correction indicated a significant increase in knowledge at posttest (p < .01) and knowledge held at the 2 month follow-up. The ability to recognize stroke signs and symptoms and respond appropriately is essential to reduce delay time when immediate medical attention and treatment is required. The FAST program was effective in increasing knowledge of stroke recognition in a rural sample.

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12 CARDIOVASCULAR DISEASE RISK FACTORS AMONG AMERICAN INDIAN ADULTS IN NORTH CAROLINA. S. Huston, Z. Gizlice. Heart Disease and Stroke Prevention Branch, North Carolina Division of Public Health. North Carolina (NC) has the 8th largest American Indian population among U.S. states, but the prevalence of cardiovascular disease (CVD) risk factors in this population has been largely unknown. We sought to determine the prevalence of CVD risk factors among a statewide sample of NC American Indian adults. Beginning in 2002, the NC Behavioral Risk Factor Surveillance System sample was expanded, including 285 American Indians in 2002 and 230 in 2003. Age-adjusted prevalence rates of CVD risk factors among NC American Indians in 2002– 2003 were compared with those of NC whites and African Americans. NC American Indians had higher age-adjusted prevalence rates of high blood pressure (40.0% vs. 26.6%), obesity (32.9% vs. 20.9%), and diabetes (14.1% vs. 6.8%) than whites. American Indians were less likely to engage in any leisure-time physical activity (67.6% vs. 76.3%) and in the recommended amount of physical activity (28.5% vs. 39.8%), and slightly less likely to consume five or more servings of fruits and vegetables daily (19.3% vs. 25.2%) than whites. Smoking and high cholesterol prevalence rates were similar between American Indians and whites. Prevalence rates of all CVD risk factors were similar between American Indians and African Americans. NC American Indians had higher age-adjusted prevalence rates of most CVD risk factors than NC whites and similar rates as NC African Americans, known to be at high risk for CVD. CVD prevention programs must continue to build collaborations with American Indian organizations and provide culturally appropriate interventions addressing this population’s high prevalence of risk factors.

13 PROGRESS CHECK: A LOGIC MODEL APPROACH TO EVALUATING CHANGES IN CARDIOVASCULAR HEALTH POLICIES AND PRACTICES. Abha Varma. North Carolina Division of Public Health. Ongoing evaluation is an often undervalued component of public health. While research-oriented evaluations are expensive and may not yield information that can be used in program planning, evaluation systems with a primarily applied focus may lack the scientific rigor required to validate theoretical frameworks. Our objective was to develop an evaluation system for tracking environmental and policy changes that was based on good science and yet was capable of yielding useful information for program planning and improvement. Progress Check is based on a logic model

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illustrating the development of a program from groundwork to final achievements and accomplishments. The two activities central to Progressu¨Check are the process of assigning an event code to a program activity and linking the activity to one or more pre-stated objectives. In addition, Progress Check gathers other relevant data, such as demographic information, funding source, risk factors, and collaborations. Progress Check tracks local efforts directed towards initiating policy and environmental changes that promote cardiovascular health. It documents success stories that can be shared with a broader audience, helps health departments make data-based decisions about their programs, and provides accountability for funding. The strength of Progress Check lies in its unique ability to yield consistent, valid and reliable data that has relevance for both, scientific research and program planning and development. Currently in its second revision, this flexible evaluation system enables local health coordinators to document activities linked with their action plan objectives and export their data to state staff for tracking and analysis.

14 AGING AND PUBLIC HEALTH: RELEVANCE TO STATE-BASED CARDIOVASCULAR HEALTH PROGRAMS. J. Lang, W. Benson, L. Anderson. Health Care and Aging Studies Branch, Centers for Disease Control and Prevention. State cardiovascular health programs face a growing and not often recognized challenge-the aging of the American population. Older adults have the highest rate of heart disease compared to any other age group. All states will experience a dramatic rise in the number of older adults during this century. By 2030, some 20 percent of Americans will be over the age of 65. This poster presentation describes 1) the structure of the public health and aging services networks, 2) select results and recommendations from the Aging States Project, and 3) examples of ongoing CDC aging activities relevant to cardiovascular health programs. Although state health departments (SHDs) and state units on aging (SUAs) bring different resources, approaches, and partners to address older adult health, many of these elements are complementary. The Aging States survey was designed to assess the barriers to and benefits of enhancing coordination between the two networks. Based on a survey of SHDs (n = 43, 68% response rate) and SUAs (n = 39, 75% response rate), the most common health concern was cardiovascular disease (57% of SHDs and 55% of SUAs). Fewer than half of the respondents reported having cardiovascular health programs directed at older adults (37% of SHDs and 40% for SUAs). Examples of resultant activities based on recommendations are provided, including data for action, strategic partnerships, and capacity building. These examples provide models and potential opportunities for current and future state cardiovascular health programs

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wanting to enhance the reach of health promotion activities for older adult heart health. 15 ESTABLISHING PUBLIC HEALTH INFORMATION NETWORK (PHIN) COMPATIBLE DATA ELEMENTS FOR AN EMERGENCY DEPARTMENT-BASED HYPERTENSION REGISTRY. C. Ayala, D. Cline, A. Lekiachvili, H. Saeed, G. Mensah, C. Ferrario, D. Goff, A. Tracy, F. Russell. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: National hypertension (HTN) control rates remain suboptimal, particularly among uninsured. Data from the National Ambulatory Medical Care Survey demonstrate that emergency departments (ED) are used increasingly as a primary source of health care for many patients. Objective: To establish data elements for an ED-based HTN Registry that will be applicable for the individual site as well as be compatible in the future with the Public Health Information Network (PHIN). Setting: A university hospital with 65,000 annual emergency patient visits; Of these, 44% are racial/ ethnic minorities and 29% were uninsured. Methods: All patients z 18 years presenting to the emergency department were triaged for HTN. Data abstraction (from week to week in 2003-2004) included ED triage nurses’ assessment form; electronic Chart (RT-System); ED course medications, laboratory results, subsequent blood pressures, diagnoses, admission status, discharge diagnosis and counseling; and discharge recommendations follow-up. Results: Data elements were categorized to include patient-level information organized in domains that reflect the entire timeframe of a newly or previously diagnosed hypertensive from ED visit to follow-up clinic. Quality assurance was estimated by data element checks and by default and set parameters within the system. Automated reports were developed. Conclusion: An ED-based HTN registry provides important information regarding patients at risk for complications of HTN, particularly among the uninsured with no usual source of health care. An ED-based HTN registry may be valuable, especially if it can be PHIN-compatible and expanded to more than one site. A successful ED-based HTN registry could contribute to the elimination of HTN-related health disparities. 16 TRENDS IN THE INCIDENCE OF PREGNANCY-INDUCED HYPERTENSION IN THE U.S., 1993-2000. C. Ayala, W. Nembhard, R. Donehoo, A. Miles. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Objective: One of the leading causes of maternal mortality in the U.S. is pregnancy-induced hypertension (PIH). Pre-

eclampsia and eclampsia are serious conditions due to PIH and common complications associated with adverse maternal and fetal outcomes. We examined national trends in PIH, pre-eclampsia, and eclampsia. Methods: National Hospital Discharge Survey (NHDS) files from 1993 – 2000 were analyzed for women ages 15 –54 years who delivered a live-born or stillborn infant and whose pregnancies were complicated by PIH including pre-eclampsia codes (mild 642.40 – 642.44, severe 642.50 – 642.54) and eclampsia (codes 642.60 –642.64). Age-standardized and age-specific PIH incidence and age-standardized incidence of preeclampsia and eclampsia (per 1,000 deliveries) were estimated. Results: Overall, the age-standardized incidence for PIH doubled from 43.0 in 1993 to 87.1 in 2000 (p < 0.05). From 1993 to 2000, age-specific PIH incidence significantly (p < 0.05) increased 60% for ages 25 –34 years, 70% for 35– 44 years, 80% for 15 –24 years, and 1174% for 45– 54 years. Age-standardized incidence tripled for pre-eclampsia and increased 50% for eclampsia. Conclusion: The increase in PIH incidence among all ages of pregnant women in the U.S. since 1993 is of serious concern. Aggressive management of pre-eclampsia and eclampsia remains crucial in order to reduce maternal complications, premature births, and fetal deaths. Research is needed to identify PIH determinants so public health intervention and prevention programs can be developed.

17 ETHNIC AND RACIAL DISPARITIES IN THE INCIDENCE OF RISK FACTORS FOR UNCONTROLLED HYPERTENSION IN EMERGENCY DEPARTMENT PATIENTS. David M. Cline, Carlos Ferrario, Carma Ayala, Akaki Lekiachvili, George A. Mensah, Aimee Tracy, Jennifer Escojido. Wake Forest University, North Carolina. Background: Lack of a primary care physician (PCP) and absence of health care coverage (HCCov) have been identified as risk factors for poor blood pressure control. Objective: To assess the frequency of risk factors for uncontrolled hypertension in emergency department patients. Setting: A university hospital with 65,000 annual emergency patient visits. Methods: Prospective screening of all patients presenting to the emergency department aged 18 years or older for hypertension, race, sex, and history of hypertension. The ED charts of all patients with a blood pressure over 130/85 mm Hg, a history of hypertension, or currently on antihypertensives are retrospectively reviewed. Results: 5073 patients with blood pressure greater than 130/90 were screened for this assessment. Minority patients in general had significantly greater frequency of no PCP (34% vs. 28%, p < 0.001), and no HCCov (30% vs. 19%, p < 0.001). Seventy-two percent of Hispanics had no PCP compared to 45% of Asians, 31% of African Americans, and 28% of Caucasians. Hispanics also were most likely to be without

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HCCov at 65%, compared to 32% of Asians, 28% of African Americans, and 19 percent of Caucasians. Conclusion: In this setting of hypertensive emergency patients, minorities in general and Hispanics in particular are at greater risk for poor control of blood pressure due to higher frequency of no health care coverage and no primary care physician.

18 TOBACCO USE PREVENTION AMONG YOUTH. A. Vance, T. Williams, J. Lee. The Greater Cleveland Health Education and Service Council, Ohio. Tobacco Teen Summit objectives were: 1) Provide an environment outside of their school that would enable them to focus on the hazards of tobacco. 2) Train students to become anti-tobacco advocates in their schools. 3) Collect data on their knowledge about the health hazards of tobacco. African American Tobacco Control Coalition (AATCC) and Cleveland Municipal School District (CMSD) collaborated to select 160 minority students from four middle schools. AATCC members worked to create a culturally specific antitobacco program, which included two sessions. The morning sessions consisted of presenters that educated students on the hazards of tobacco and its relation to health issues. ‘‘Youth Empowerment’’ sessions provided students with a chance to become advocates in their schools by developing messages with the information they learned from the morning session. Results were measured through pre-test and post-test. Youth completed a questionnaire before they attended a workshop describing the dangers of cigarette smoking, and they were administered a questionnaire after the workshop. 30% of the youth has tried smoking cigarettes. 70% of these youths had someone in his or her household who smokes. Key measures in the post-test showed very little change in orientation and attitudes by youth. A specific question was asked. How many smoke mini-cigars, i.e. Black and Milds, Blunts, Swisher Sweets? 75% of students indicated the use of these products. Students did not know mini-cigars are as harmful as cigarettes. Conclusion: Students were able to return to their schools and make presentations. Workshops Objectives were met and deemed successful.

19 VALIDATION OF CORONARY HEART DISEASE (CHD) DEATHS IN NEW YORK CITY (NYC), 2003. Maleeka J. Glover, Lorna Thorpe, Henraya McGruder, Ann Malarcher, Jennifer Leng, Akaki Lekiachvili, Michele Casper, Jason Hsia, Steven Schwartz, Wayne Rosamond. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Objective: New York City mortality data show a pattern of high CHD and very low stroke rates over the past decade.

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This pattern occurs within all age, gender, and racial/ethnic groups. Analyses of vital statistics data comparing NYC and the U.S. could not explain this disparity by differences in place of death or in the coding of ill-defined causes. The current study investigates whether the disparity is due to misclassification of CHD on NYC death certificates. Methods: A random sample of death certificates from NYC residents who died between January and June, 2003 was selected within neighborhoods defined by level of CHD mortality (low < 185/100,000, medium 185– 371/ 100,000, and high > 371/100,000). Using Atherosclerotic Risk in Communities methodology, death certificates were limited to those with CHD, or selected non-CHD causes likely to involve CHD as the underlying cause of death. Medical charts, discharge summaries and EKGs of inhospital or dead on arrival deaths were abstracted to determine if the death was caused by CHD. Results: As of May 1, 2004, data were abstracted from 409 of 491 deaths (83%). Forty-five of 58 (77%) hospitals/institutions have been visited. Two independent cardiologists will determine whether each death was definite CHD, probable CHD or non-CHD. Conclusions: Study results will assist the NYC Health Department in determining the level of misclassification of CHD on death certificates. Future public health programs can use this data to increase education on proper completion of cause of death on death certificates or to target CHD prevention programs to neighborhoods with high CHD rates.

20 USING HOSPITAL DISCHARGE DATA TO IDENTIFY TRENDS IN CARDIAC DEATHS. C. Alo, J. Smith. Texas Department of Health, Texas. Objectives: Diseases of the heart mortality have shown a declining trend, however, determinfsants of the decline have not really been made clear. Analysis of the epidemiologic features of these deaths by location could provide important insight into these determinants. Methods: Inhospital deaths (IHDs) due to diseases of the heart were defined as those deaths occurring in acute-care or long-term care hospitals. Out-of-hospital deaths (OHDs) were categorized into those occurring in emergency departments or were dead on arrival (ED/DOA), those occurring in private homes/public places and those occurring in nursing homes. Three-year average location-specific deaths rates were calculated and standardized to the 2000 US population. Results: Of the 130,941 deaths due to diseases of the heart that occurred during the study period, 60 percent were OHDs. Of these, 28 percent occurred in an ED/DOA, 30 percent occurred in the nursing home, and 42 percent occurred in private homes/public places. Females had higher total number of deaths due to diseases of the heart and deaths occurring in the nursing home while males had higher proportion of deaths that occurred in ED/DOA and

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private homes/public places. OHD to IHD rate ratios were highest among those aged 35 to 64 years of age during the study period. Conclusion: OHDs will persist as a major public health problem unless efforts to improve primary and secondary prevention strategies, public education on signs and symptoms of heart disease and timely access to emergency care are fulfilled.

21 DOES GENDER DISPARITY EXIST IN CARDIAC REHABILITATION? S. Kamath, V. Burt, L. Thomas, J. Sewell. University Hospital, Georgia. Objective: To determine if there is disparity in the outcomes between men and women in our cardiac rehabilitation program. Methods: Outcomes were studied in patients that completed our 12 week cardiac rehabilitation program in a community hospital during 2002 and 2003 for the diagnoses of CABG (Coronary artery bypass graft), MI (Myocardial infarction), PTCA (Percutaneus Transluminal Coronary Angioplasty) and CHF (Congestive Heart Failure). Patients were assessed using the six minute walk test and the QOWB SF-36 (Quality of Well Being Short Form 36). Results: Out of the 670 patients that were enrolled in our program complete data were gathered on 306 patients for the SF-36 and 486 for the six-minute walk test. 65% of the patients were male, 35% were female. This ratio is consistent with the statistics for patients admitted in the hospital for the same cardiac events. The results will be summarized in the poster presentation. Conclusion: Since none of the variables showed a statistically significant difference between the gains made by men and women in the outcomes, we conclude that there is no disparity in our cardiac rehabilitation program.

22 GEOGRAPHIC CLUSTERING OF HYPERTENSION. D. Schlundt, C. Larson. Vanderbilt University, Tennessee. Background: Improving the treatment and prevention of hypertension and CVD involves community-based efforts to modify behavioral and environmental risk factors. Objective: To describe and map the spatial clustering of hypertension and its risk factors in Nashville, TN. Methods: Data from two random community phone surveys (Nashville REACH 2010, Nashville Health Department BRFSS) were combined into a single data set with 7,913 respondents (61.4% female, 34.5% African American) Data included those who provided heights and weights and whose address could be geocoded. Data were aggregated by census tract and those tracts with 10 or more interviews (129 of 144, 7,606 cases) were included. Results: Hypertension prevalence in the 129 census tracts ranged from 10% to 70%

(mean 29 +/ 11) and showed geographic clustering when mapped using GIS software. Correlation coefficients were used to summarize the degree to which risk factors cluster with hypertension and obesity prevalence by measuring similarity of variables across the 129 census tracts. A pattern of similarity (r’s between 0.15 and 0.50) was observed between the prevalence hypertension, diabetes, obesity, and measures of health access, health behavior, neighborhood safety, demographics, and socioeconomic status. Census variables like per capita income and age of housing stock also correlated with the prevalence of hypertension and obesity. Conclusions: Geographic analysis can be used to identify high-risk neighborhoods. Detailed analysis of associations between neighborhood characteristics, health behaviors, and health outcomes may also lead to better targeted intervention strategies.

23 ELIMINATING HEALTH DISPARITIES AMONG PATIENTS WITH CARDIOVASCULAR DISEASE. C. Pollard. WVU Office of Health Services Research, West Virginia. The West Virginia Bureau for Public Health’s Cardiovascular Health Project and the West Virginia University Office of Health Services Research (OHSR) are collaborating with several federally qualified health centers (FQHCs) to eliminate the disparities in health care delivery for patients with cardiovascular disease or those who have risk factors for heart disease. At this time 5 FQHCs and over 450 patients have been enrolled in our project. The project requires the FQHCs to have a patient registry for patients with heart disease or those who have certain risk factors, such as hypertension. OHSR assists the FQHCs by abstracting charts and creating the patient registry. In addition, OHSR makes available to the FQHCs computer software that permits the FQHC’s providers to better manage their patient’s care. OHSR trains the FQHC’s staff in the use of the software and works with the provider to use the data to improve quality improvement in the practice. The population served by the FQHCs is comprised of rural, low income residents comprised of a large Medicaid and Medicare population with many of their clients having no health insurance at all. Thirty-eight percent of the patients in the project are covered by Medicare; 28% are uninsured; 19% have commercial insurance; and 15% have Medicaid. In addition, data from the patient registry show that 58% of those at risk for, or those already diagnosed with cardiovascular disease have blood pressures greater than 135/90. Half of the patients in the registry have hyperlipidemia; 27% suffer from depression; 17% have been diagnosed with coronary artery disease; 5% have had a cerebrovascular accident and 4% have renal failure. Laboratory test reveal that 45% of the patients have cholesterol levels above 200.

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24 PREVALENCE OF CARDIOVASCULAR DISEASE RISK FACTORS IN A SOUTHWESTERN TRIBE: A TRIBE-UNIVERSITY PARTNERSHIP. M. Veazie, C. Quezada-Gomez, J. Hunter, N. Rios-Burrows. Indian Health Service DHHS, Arizona. Objective: To measure cardiovascular disease (CVD) risk factors in a Southwestern tribe. Methods: In a tribally coadministered survey, tribal team members interviewed 94% of the adults ( >17 years old, n = 640) within 222 homes systematically selected within 10 sampling strata. Selfreported CVD risk factors included current smoking, overweight (Body Mass Index z 30), awareness of hypertension (informed by provider at least twice), high cholesterol (informed at least once), and non-gestational diabetes (informed by provider). Analyses by diabetes, age and sex used STATA Version 6.0 to account for the complex survey design. Results: The mean number of CVD risk factors (CVDmean) was 1.35 (CI = 1.25, 1.45), with following percents: current smoking (23.2, CI = 19.1, 27.2), overweight (58.8, CI = 54.5, 63.1), hypertension (19.5, CI = 16.1, 22.8), high cholesterol (10.0, CI = 7.5, 12.5), and diabetes (23.7, CI = 20.1, 27.2). Using linear regression, the CVDmean was 0.07 smaller among men than women adjusting for age (CI = .25, .11), and .80 larger among persons aged 40 or more adjusting for sex (CI = .57, 1.0). The CVDmean excluding diabetes was 0.7 larger among diabetics compared to non-diabetics adjusting for age and sex (CI = .50, .90). Adjusting for age and sex by logistic regression, hypertension was higher among diabetics than non-diabetics [odds ratio (OR) = 4.4, CI = 2.8, 7.1], as was obesity (OR = 2.3, CI = 1.4, 3.6), and high cholesterol (OR = 5.9, 3.1, 11.3). Conclusions: The high prevalence of CVD risk factors, especially among diabetics, underscores a prevention focus for the tribe. The tribe’s role in survey administration has strengthened its own assessment capacity, and survey findings will be used to justify, develop and evaluate tribal prevention measures.

25 REDUCING RACIAL AND ETHNIC HEALTH DISPARITIES: CLOSING THE GAP CARDIOVASCULAR HEALTH PROGRAM. M. Bowers, S. Allen, S. Ladd, W. Payne. Florida Department of Health, Florida. The objective of the poster is to present how a Florida grant program stimulated the development of community and neighborhood based projects to improve the health outcomes of racial and ethnic populations and fostered the development of coordinated, collaborative and broad-based participation between public and private entities. Responses to a request for application were awarded funding based on the appropriate completion of the application. Criteria included background, objectives, project requirements and community

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needs, community mobilization and partnerships, evaluation plan, management plan, sustainability plan, work plan, and budget justification with a matching funds requirement. Program objectives were selected from a list of Healthy People 2010 objectives related to reducing the risk of heart disease and stroke. Seven cardiovascular health (CVH) focused projects were funded that target Hispanic, Haitian and African American populations. Project data is collected through a centralized web-based reporting system. Formative and summative project evaluations are conducted. Projects successfully formed advisory groups, developed partnerships, reached their target populations, and implemented CVH interventions. Interventions include community screening, referral and follow-up services, counseling, educational classes, presentations, walking clubs and wellness groups, radio shows, health hotlines and other many other health promotion activities. Interventions are implemented in schools, faith-based, business and community settings. Important changes at the community level, particularly in environmental and policy, can be made. Partnerships are key to making these changes. We are confident that the evidence-based initiatives implemented will improve the health outcomes and reduce the burden of heart disease and stroke in the future.

26 IMPACT OF RACE CATEGORY CHANGES ON HYPERTENSION AND HIGH CHOLESTEROL PREVALENCE IN THE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM, 1999 AND 2001. M. Ochner, C. Ayala, R. Jiles, J. Minaya. Association of Schools of Public Health, Centers for Disease Control and Prevention. Background: Race information in the U.S. is used to identify populations at risk for disease or health behaviors. Using Behavioral Risk Factor Surveillance System (BRFSS) data from 1999 and 2001, this study examines shifts in racial distributions and cardiovascular risk factors with the addition of the multiracial category in 2001. Methods: The BRFSS is a state-based, random-digit-dialed telephone survey of the civilian, noninstitutionalized U.S. population z 18 years. Differences in age-adjusted weighted prevalences of self-reported high blood pressure (HBP) and high cholesterol (HC) were examined among Whites (NHW), Blacks (NHB), Asian/Pacific Islanders (API), American Indian/Alaska Natives (AIAN), multiracial, other (O), and Hispanics (H) using descriptive statistics and 95% confidence intervals (CI). To check for true changes in prevalence, the multiracial category was back-classified to original race categories. Results: The prevalence of NHW decreased significantly when the multiracial category was added. Overall, there was not a significant change in HC, but HBP increased significantly from 24.2% in 1999 to 25.6% (p < 0.05) in 2001. Among racial groups, when

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the multiracial category was added, HBP and HC increased significantly for NHW only (23.1% to 24.4% (p < 0.05) and 27.6% to 28.5% (p < 0.05), respectively). When the multiracial category was back-categorized, the proportion of NHW reporting HBP and HC remained significantly higher and virtually unchanged. Conclusion: Increases in self-reported HBP and HC for NHW do not appear to be caused by redefined racial/ethnic categories. To promote heart health, it is critical to focus not only on groups with high prevalence of HBP and HC, but also those with increasing rates.

27 GENDER DIFFERENCES IN SUDDEN CARDIAC DEATH: PROSPECTIVELY-DEFINED, MULTIPLE-SOURCE SURVEILLANCE IN A LARGE US COMMUNITY. S. Chugh, R. Mariani, Z.-J. Zheng, E. Stecker, B. John, C. Vickers, J. Boxer, K. Gunson, J. Jui. Oregon Health and Science University, Oregon. Objectives: Published autopsy and cohort studies indicate significant gender differences in the occurrence of sudden cardiac death (SCD), with a 3-fold higher rate in men vs. women. However, prospective, community-based evaluations have not been performed. We evaluated the SCD gender gap in the ongoing Oregon Sudden Unexplained Death Study (Ore-SUDS). Methods: All residents of Multnomah County, OR (Pop. 660,486) who suffered SCD were identified prospectively from emergency medical services, medical examiner and 16 area hospitals. Results: Between Feb 1, 2002 and Jan 31, 2003, 353 cases met criteria for SCD (Incidence 53/ 100,000; median age 69y), accounting for 5.6% of total mortality. Overall, 43% of SCD cases were female. Resuscitation was attempted in 237 cases and successful in 28 (8%). There were no significant gender differences in location of SCD (in-home or out-of-home) or rate of survival. However, women were less likely to have ventricular fibrillation (35 vs. 50%) and more likely to have asystole/pulseless electrical activity as the presenting arrhythmia. Conclusions: The current burden of SCD may be more equitably distributed between the sexes than previously expected (43:57). These data have important implications for prevention of SCD in the community, as well as health care policy.

28 THE COMMUNITY HEALTH WORKER HEART DISEASE AND PREVENTION SOURCEBOOK: REACHING DIVERSE AND DISPARATE POPULATIONS. J.N. Brownstein, M.J. Brewer, C. Cornell, M. Kuhajda. Cardiovascular Health Branch, Centers for Disease Control and Prevention, Oak Ridge Associated Universities, Oak Ridge Institute for Science and Education, Oak Ridge, University of Alabama, Tuscaloosa, AL.

Objective: The Institute of Medicine report on Racial and Ethnic Disparities recommends the integration of CHWs into the health care team. The Community Health Worker (CHW) Heart Disease and Stroke Sourcebook will be introduced at this conference. The Sourcebook is the result of a partnership effort and is designed to improve community health literacy on heart disease and stroke and to help communities eliminate heart disease and stroke disparities. Topics covered include coronary heart disease, stroke, congestive heart failure, high blood pressure, medicine compliance, communication with doctors, and CHWS role in is supporting life-style changes and patient self-care. Methods: The Sourcebook was developed by INMED as part of a series of CHW curricula focused on women. CDC identified missing content areas and worked with the University of Alabama (UAB) Prevention Research Center to update and pilot test a revised curriculum. CDC further developed the Sourcebook in partnership with the National Heart, Lung, and blood Institute (NHLBI), the American Heart and Stroke Associations and the Oak Ridge Institute for Science and education. Results: Experienced CHWs, trained on the UAB Sourcebook version, provided educational counseling to patients (N=159) at a rural health clinic in Pineapple, AL. The CHWs learned the material and their peers were satisfied with CHW counseling. The final version of the Sourcebook includes enhanced topics and was redesigned in the familiar format of NHLBI’s Your Heart, Your Life Promotora curricula. Conclusion: The CHW Sourcebook is a valuable resource for training CHWs to promote heart disease and stroke prevention for lowliteracy populations.

29 TRENDS IN PREMATURE HEART DISEASE DEATH AMONG ASIANS AND PACIFIC ISLANDERS, UNITED STATES, 1979-2001. S.S. Oh, J.B. Croft, N.L. Keenan, C. Ayala, K.J. Greenlund, Z.J. Zheng, G.A. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: The proportion of premature heart disease death has declined over the last two decades among Asians and Pacific Islanders (A/PI). However, the A/PI population is a diverse group and little is known about heart disease for the subgroups within this population. Objective: Identify trends in premature (i.e., < 65 years) heart disease deaths from 1979 to 2001 among A/PI populations in the U.S by ethnic subgroup. Methods: National mortality data were used to calculate proportions of premature death among all heart disease deaths during 1979 to 2001 occurring in U.S. A/PI residents. Results: In 2001, the proportion of premature heart disease death among U.S. residents was 50.0% in Samoans, 45.5% in Guamanians, 38.2% in Hawaiians, 35.3% in other A/PI, 32.0% in Asian Indians, 26.0% in Vietnamese, 18.5% in Filipinos and Koreans, 11.0% in

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Japanese, and 10.5% in Chinese. The proportion of premature heart disease death among A/PI residents declined from 26.2% in 1979 to 21.1% in 2001 ( 19.5% percent change relative to 1979). The greatest decline occurred among Japanese ( 52.8%), while Samoans experienced an increase (6.9% relative to 1992). The proportion of premature death decreased more among females (33.2%) than among males (6.7%). Conclusions: Asians/Pacific Islanders are a diverse group in the U.S. and subgroups were affected differentially by heart disease. Factors that contribute to these differences should be identified. Interventions targeting A/PI populations may need to be tailored for subgroups to reflect the heterogeneity of this diverse population.

collaborating on worksite-based programs to promote cardiovascular health. Conclusions: The Healthy People 2010 Disparities Work Group demonstrates a successful interagency partnership that shares the common goal of eliminating heart disease and stroke disparities.

30 HEALTHY PEOPLE 2010 PARTNERSHIP FOR HEART DISEASE AND STROKE: THE DISPARITIES WORKING GROUP. J.N. Brownstein, D. Matson-Koffman, E. Boulton, M. Schoeberl, E. Ochiai, J. Galloway, R. Fulwood, F. Grayshield, J. Kelly, M. Alvardo, J. Guyton-Krishnan, R. Horner. Centers for Disease Control and Prevention, American Heart Association, Department of Health and Human Services; Indian Health Service, Flagstaff, AZ; National Heart, Lung, and Blood Institute, National Institute of Neurological Diseases and Stroke, Bethesda, MD.

Background: Heart disease is the leading cause of death in the United States. Most premature deaths (i.e., < 65 years) from heart disease are often unnecessary, preventable, and contribute to health disparities. Objective: Identify trends in premature heart disease deaths from 1979 to 2001 by race, ethnicity, and gender. Methods: National mortality data were used to calculate proportions of premature death among all heart disease deaths during 1979 to 2001 among US residents. Results: In 2001, the proportion of premature heart disease death was 36.0% in American Indians/Alaska Natives (AI/AN), 31.4% in blacks, 21.1% in Asians/Pacific Islanders (A/PI), and 14.7% in whites. Premature heart disease death was higher for Hispanics (23.5%) than for non-Hispanics (16.5%), and for males (24.0%) than for females (10.0%). The proportion of premature heart disease deaths declined from 22.7% in 1979 to 16.8% in 2001 ( 26.0% change relative to 1979). The relative decline since 1979 was 30.6% among whites, 19.5% in A/PI, and 12.2% in blacks, while AI/AN experienced the least decline ( 4.8%). Premature heart disease death decreased more among females ( 26.2%) than among males ( 21.2%). The relative decline for Hispanics since 1989 was 15.0% and 5.3% for non-Hispanics. Conclusions: The proportion of premature death among all heart disease deaths declined over the last two decades but varied by race, ethnicity and gender. These disparities suggest that greater public health efforts are needed to further decrease the burden of heart disease and eliminate health disparities.

Objective: In 2003, the Disparities Work Group of the Healthy People (HP) 2010 Partnership for Heart Disease and Stroke was formed. The group collaborates on projects and strategies aimed at eliminating heart disease and stroke disparities among priority populations (HP 2010 objectives: 12-1, 2, 7, 8-12). Working group members include staff from the following agencies: Centers for Disease Control and Prevention (CDC); National Heart Lung, and Blood Institute (NHLBI); National Institutes of Neurological Disorders and Stroke (NINDS); Indian Health Service (IHS); Office of Disease Prevention and Health Promotion (ODPHP); American Heart Association (AHA), and American Stroke Association. Methods: Collaborative projects have been prioritized through monthly conferences and quarterly face-to-face meetings. Results: The Disparities Work Group has collaborated on the following joint activities: 1) planning and conducting a national lay health training for American Indians-Honoring the Gift of Heart Health; 2) recruiting CDC’s State Heart Disease and Stroke Programs and AHA affiliates to participate and support regional Honoring the Gift of Heart Health trainings; 3) conducting a heart disease training for Promotoras using NHLBI’s Your Heart, Your Life Manual; 4) providing input and resources for CDC’s Community Health Worker Heart Disease and Stroke Prevention Sourcebook; 5) promoting NHLBI’s Mission Possible campaign during high blood pressure month; 6) disseminating faith-based programs such as CDC’s Project Joy and AHA’s Search Your Heart; and 7)

31 DISPARITIES IN DECLINING PREMATURE HEART DISEASE DEATHS, UNITED STATES, 1979 – 2001. S.S. Oh, J.B. Croft, N.L. Keenan, C. Ayala, K.J. Greenlund, Z.J. Zheng, G.A. Mensah. Association of Schools of Public Health, Cardiovascular Health Branch, Centers for Disease Control and Prevention.

32 ELIMINATING HEALTH DISPARITIES IN AFRICAN AMERICANS THROUGH A DIRECT APPROACH. D. Smikes, B. Teyinka, T. Kinebrew, M. Marrs, L. McClellan, C. Larson, T. Jobe. Nashville R.E.A.C.H. 2010 Project, Tennessee. Background: The Nashville REACH 2010 Project, (Racial and Ethnic Approaches to Community Health) Health

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and Wellness Team, has addressed the need for a cookbook to reduce high sodium, carbohydrates and saturated fat intake in the diets of residents suffering from chronic diseases in the North Nashville population. Nashville REACH 2010’s goal is to reduce, and in time eliminate diabetes and cardiovascular disease among African Americans in North Nashville. Previous studies have indicated a decline in North Nashville resident’s physical activity and an increase in saturated fat intake. Several interventions were conducted in eliminating these disparities, including the development and distributions of the North Nashville cookbook to residents affected by diabetes and cardiovascular disease. Various strategies were used such as scheduling appointments with coordinators of local entities, which consisted of churches, business owners, public and private housing site managers, to initiate plans for a healthier community. Evaluation assessments were performed to monitor residents’ health status and their impression of the cookbook. Many were found to be at risk of or diagnosed with these diseases. Follow up process evaluations were conducted to determine the usage of the cookbook and behavioral lifestyle changes. This effort has provided us with the opportunity to partner with local organizations with the same mission, reducing disparities, and promoting a healthier community.

33 VALIDATING DISEASE SPECIFIC HEALTH-RELATED QUALITY OF LIFE MEASURES (HRQOL): COMMUNITY SURVEILLANCE OF CORONARY HEART DISEASE. L. Kazis, M. Gugliucci, A. Spiro III, D. Miller, A. Hamed, A. Selim, U. Iqbal, J. Newsom, C. Caruso, J. Ward, S. Bernard, K. Greenlund. Boston University School of Public Health, Massachusetts. Purpose: We developed a patient-based assessment for monitoring the HRQoL of persons with previous history of coronary heart disease (CHD) for use in telephone surveys. Methods: We conducted individual interviews with 14 ambulatory CHD patients, aged 56 –83 years; eliciting patients’ responses to CHD questions derived from published questionnaires chosen by a consensus panel of experts. Patient interviews were tape-recorded, transcribed, and analyzed using NUD*IST-6 software. A structured questionnaire then was administered to 100 patients by telephone with a previous clinical history of CHD. Responses were analyzed for internal consistency reliability, inter-scale coefficients and factor analysis to examine overlap between the current 4 item general HRQoL ‘‘healthy days’’ (4HD) questions in the BRFSS and the new disease specific scales. Results: Six disease specific themes were identified: mobility, social func-

tioning, emotional functioning, distress, role functioning and fatigue. Patient interviews revealed that many had difficulty understanding questions from established HRQoL questionnaires, leading to the revision of 28% of the CHD questions (11 of 39). Phone survey responses included 69% male with mean age of 62. Psychometric analysis of survey responses showed cronbach alphas ranging from 0.90 for role functioning to 0.76 for social functioning. Inter-scale correlations between the 4HD and new scales ranged from 0.10 to 0.57. Principal components with varimax rotation revealed a separate factor for the 4HD questions and two additional factors, one physical, and one psychological from the new scales. Conclusion: Newly developed disease specific scales provide a psychometrically sound unique supplement to general HRQoL scales used in telephone surveys.

34 PATIENT FACTORS RELATED TO DELAYS IN SEEKING STROKE TREATMENT. M. John, M. Broce, E. Faile, P. Palmer, M. Emmett. CNT. Health Services and Outcomes Research, West Virginia. Objective: The purpose of this study was to identify patient factors related to delays in seeking stroke treatment in West Virginia. Common reasons for delay included calling the physician instead of Emergency Medical Services, living alone or being at home at the time of stroke onset, having a mild stroke versus a more severe one, have the stroke at night, and failure to recognize the symptoms as serious and related to a stroke. The effect of age, gender and or race on response time varies across studies. Methods: This design was a prospective, structured patient or surrogate interview in conjunction with concurrent chart reviews of 64 acute stroke patients. from April 1 to July 21, 2003. Data documented: demographics, factors related to timing of treatment and medical details. Results: A majority of patients arrived beyond the critical threehour time limit for tPA medication. Patients who reported speech problems and confusion as initial symptoms, lived within 15 miles of the hospital and used ambulance transport, were more likely to arrive with two hours of stroke symptom onset. Patients who personally decided to seek care, had commercial insurance, had weakness as a prominent symptom or were younger were less likely to arrive with tow hours of symptom onset. Conclusions: To reduce delays, the community needs education about awareness of stroke symptoms with a focus on the fact that stroke is a medical emergency and calling 911 is necessary. Target audiences should be younger age groups in addition to the elderly population.

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35 EFFECTS OF RACE ON INPATIENT MEDICAL HISTORIES, PROCEDURES, AND INTERVENTIONS AMONG ACUTE ISCHEMIC STROKE PATIENTS. S. Stoeckle-Roberts, M. Reeves, A. Mullard, for the MASCOTS Writing Group. Michigan Department of Community Health, Michigan. Objectives: Healthy People 2010 objectives include a goal to eliminate racial disparities in stroke mortality. This report identifies racial differences among hospitalized acute ischemic (IS) stroke patients. Methods: A sample of 15 Michigan hospitals was obtained for a stroke registry prototype. All acute stroke admissions were prospectively identified over a 6-month period in 2002. Data on the documentation of prior medical history (present or absent vs. not documented), and in-hospital procedures and interventions were abstracted from the charts. This report includes only black or white subjects with a diagnosis of IS or TIA who were discharged alive. Adjusted odds ratios (OR) and 95% confidence intervals are reported. Results: Of the 1,841 subjects, 339 (18.4%) were black, and 1382 (75%) had IS. Compared to whites, blacks were significantly younger, more likely to have IS, and more likely to have Medicaid or no health insurance. Documentation of medical history varied from 17.4% for atrial fibrillation to 89.4% for hypertension. Blacks were significantly more likely to have hypertension documented (OR = 2.6, 1.8 –3.9), but less likely to have CHD (OR = 0.7, 0.5 –0.8), atrial fibrillation (OR = 0.5, 0.4– 0.7), or dyslipidemia (OR = 0.5, 0.4 – 0.6) documented. Blacks were less likely to receive cardiac monitoring (OR = 0.6, 0.5 – 0.8), to have cerebrovasculature investigated (OR = 0.7, 0.5– 0.9), to undergo dysphagia screening (OR = 0.6, 0.4 – 0.8), or to have smoking cessation counseling upon discharge (OR = 0.3 0.1 – 0.5). Conclusions: Differences in the documentation of prior medical history and in-hospital stroke care by race were identified. Further analyses are ongoing to examine their origin.

36 DEVELOPMENT AND TESTING OF A MEDICATION ADHERENCE SCALE FOR LOW-LITERATE POPULATIONS. S. Kripalani, A. Seright, J. Praska, R. Steadman, R. Robertson, T.A. Jacobson. Emory University School of Medicine, Atlanta, GA. Objective: Limited literacy skills are common and may be a risk factor for medication noncompliance. However, few instruments have been designed to measure adherence in low-literate populations. We report the development and psychometric testing of a self-reported medication compli-

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ance scale for use among patients with coronary heart disease (CHD) who may have limited literacy skills. Methods: We compiled questions from existing scales and from physicians, pharmacists, and health services researchers with expertise in literacy and medication adherence. We created an initial set of 13 items, each scored on a 4-point Likert scale. The items were tested among 30 patients with CHD in an inner-city medical clinic to assess reliability, validity, and dimensionality. We assessed concurrent validity by examining correlation with an accepted measure, the Morisky scale. Results: The patients were all African-American and mostly women (61%), with a mean age of 63.3, educational level of 10.2 years, and reading level of approximately 8th grade. In evaluating internal consistency, two items were dropped for low item-total correlation. Cronbach’s alpha for the reduced 11-item scale was 0.839. Correlation with the Morisky scale was high (r = .547, p < .005). Factor analysis resulted in a single factor accounting for 42% of the variance. Total scores on the 11item measure ranged from 11 to 24 (possible range 11 to 44, with lower scores indicating better compliance). The mean score was 14.2 (SD 3.4). Conclusion: In preliminary testing, our self-reported medication compliance scale appears valid and reliable in a low-literate population.

37 A COMPARISON OF STROKE RISK FACTORS IN MEN AND WOMEN WITH DISABILITIES. J. Hinkle. Villanova University, Pennsylvania. Statement of the problem: Stroke is the third leading cause of death in the United States. Little research has addressed stroke health risks in women with disabilities and the differences in women and men with disabilities, making it difficult to provide appropriate and specific education and counseling to reduce those risks. Methodology: The purpose of this study was to compare males and females with disabilities on modifiable risk factors for stroke. This descriptive study was designed to determine if males and females with disabilities differed in self-reported rates of hypertension (HTN), transient ischemic attack (TIA), atrial fibrillation, diabetes, or modifiable risk factors; or in the mean systolic or diastolic blood pressure taken the day of screening. Analysis: Data were collected on the modifiable risk factors at a variety of conferences and meetings targeted to people with disabilities. The primary instrument for this study was the Stroke Risk Screening tool; SPSS was used for analysis of the data. Results: A total of 146 individuals with a disability participated, 54% were female, 27% were African American, and the mean age was 58 years. There were no significant differences in self-reported history of TIA, atrial fibrillation or diabetes. Risk factors that differed significantly (p < .05) by gender included the incidence of hypertension (48% of men vs. 32% of women), current smoking (30% men vs. 4% women); history of heart disease

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(13% men vs. 1% women), daily consumption of alcohol (10% men vs. 1% women) and use of illicit drugs (men 10% vs. women 0%). Mean systolic and diastolic blood pressures were normal and there were no differences by gender. Implications: This information can be used to develop appropriate gender-specific targeted health promotion interventions to decrease stroke risk in the population of men and women with disabilities.

38 AN ASSESSMENT OF SOCIOECONOMIC STATUS ON CONGESTIVE HEART FAILURE PATIENTS IN A RURAL COMMUNITY HOSPITAL. Y. Xiang, J. Castaldo, C. Barreca, D. Petruccelli, S. Zhang, M. Rossi, T. Wasser, D. Liao. Lehigh Valley Hospital and Health Network. Objectives: The associations between socioeconomic status (SES) and cardiovascular disease (CVD) are well documented. However, less is understood about the impact of SES on congestive heart failure (CHF). The purpose of this study is to assess the socioeconomic profile in a sample of rural CHF patients. Methods: We randomly selected 56 CHF patients from an outpatient cardiology practice at Lehigh Valley Hospital and Health Network (LVHHN). During routine clinical visits from Dec, 2003 to Feb, 2004, patients with a confirmed diagnosis of CHF were asked to participate and given informed consent. 51 patients participated and were interviewed using a standardized questionnaire. Results: Of the 51 patients in this study, there were 34 males (67%), with an average age of 73. 44 were Caucasians (86%), 53% were smokers, 76% had hypertension, 82% had hyperlipidemia, 49% had diabetes. Among the 51 patients, 35% (18/51) received less than high school education, 43% (22/51) high school education. 49% have family income less than $25,000 and 40% between $25,000-$50,000. In a general cardiovascular disease patients population (N = 513) from the same hospital, 72% were males, the mean age was 62, 98.4% were Caucasians, 70% were smokers, 62% had hypertension, 63% had hyperlipidemia, 24% had diabetes. Conclusions: These CHF patients have a worse CVD risk factor profile compared to the general CVD patient population in the same hospital. The majority of these CHF patients have an overall low SES. Further investigation is needed to identify the risk factors in these rural, low SES CHF patients.

39 FAST STROKE EDUCATIONAL PROGRAM FOR MIDDLE SCHOOL STUDENTS: RESULTS OF A PILOT STUDY. E. Miller, K. King, R. Miller, D. Kleindorfer. University of Cincinnati, Ohio.

Objective: Describe the results of the FAST Stroke Prevention Education Program that was developed for middle school students and included knowledge, attitude, behavioral and self efficacy components to increase stroke knowledge and reduce stroke risk factors. Method: The sample consisted of middle school students between 10– 14 years of age who attended one of the two schools. After obtaining school, parental, and student permission, the FAST stroke educational program which had the following 5 components: pretest of stroke knowledge and risk factors; a 50 minute educational program; a posttest; an educational reinforcement at 1 month after the posttest; and a long-term posttest at 8 weeks was implemented. Results: 78 students participated with 60% African American, 35% Caucasian, and 5% other races. The mean age was 14 (29% male and 71% female). Data analysis revealed that for students in both schools there was a significant improvement in their knowledge of stroke warning signs and symptoms from pretest to posttest (t = 9.5, p = .01) and long-term posttest (t = 3.53, p = .001). With regard to stroke risk factors, students scored significantly higher at posttest on knowledge (t = 2.77, p = .007) and although there were positive gains no difference occurred between pretest to long-term posttest. Conclusions: The FAST educational program significantly improved middle school students’ knowledge of stroke signs and symptoms and stroke risk factors and the knowledge acquired regarding warning signs appears sustainable. Further refinement of this educational intervention needs to occur and a larger study performed with a racially diverse sample.

40 VALIDATING PATIENT-BASED MEASURES OF HEALTH-RELATED QUALITY OF LIFE (HRQOL) FOR COMMUNITY-WIDE STROKE SURVEILLANCE. M. Gugliucci, L. Kazis, A. Spiro III, D. Miller, A. Hamed, A. Selim, U. Iqbal, J. Newsom, C. Caruso, J. Ward, C. Kase, K. Greenlund. Boston University. Purpose: We developed an approach for disease-specific HRQoL assessments for persons with a history of stroke to supplement general measures of health for use in community-wide surveillance. Methods: Using well-established measures of HRQoL in stroke, we identified relevant domains (i.e., mobility, cognitive functioning, family relationships, emotional functioning, health distress, role functioning and fatigue) to supplement existing CDC BRFSS ‘healthy days’ measures. For each domain, 1 – 9 items were selected from extant measures. Structured questionnaires were tested using ‘Think-aloud’ methods in individual interviews with 15 stroke patients aged 56 – 83 years. Patients’ responses and reactions to survey questions, including how they interpreted the question and formulated their answers, were tape-recorded, transcribed, and analyzed

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using NUD*IST 6 software. Results: Patient responses led to revision of 52% of the structured questions (23 of 44 items). Patients were unclear about the temporal frame of the questions; i.e., should they answer from the perspective of ‘present day’ or ‘when their stroke occurred.’ Patients consistently reported that the mobility questions had either poor answer options or were inappropriate for stroke patients. Many questions were lengthy, and patients had difficulty following them. Mobility, role/social functioning and relationships had the highest percentage of changes, leading to shortened item and modified response choices. Conclusion: Despite use of previously validated standard questions, qualitative methodologies provide a fresh look at patient’s perspectives on these assessments. Our objective is now to conduct psychometric testing of the revised measures, for purposes of assessing QOL of stroke survivors in the community.

41 DIABETES INCREASES RISK OF CARDIOVASCULAR DISEASE-RELATED HOSPITALIZATIONS. Curtiss B. Cook, William J. Miller, David C. Ziemer, Circe Tsui, Joseph Hentz, Lance A. Waller, Kurt Greenlund, Rodolfo Valdez. Mayo Clinic Arizona. Objective: Cardiovascular disease (CVD) is a frequent complication of diabetes mellitus (DM), but few studies have examined how DM impacts on risk of CVD related hospitalizations. Methods: Hospital discharges were obtained from the Georgia Hospital Association by searching the Patient Discharge Data Set using DM and CVD specific ICD-9 codes for the period 1998 to 2001. Results: Half (54%) of all discharges (3.9 million) were among women, 70% were among NonHispanic whites, and 27% in NonHispanic blacks. DM and CVD as principle diagnoses constituted 1.3% and 12% of all discharges for the period; 30% of CVD admissions had co-existing diabetes. Average patient age was 66 years, length of stay (LOS) 4.8 days, and total charges (TC) were $15,032. The relative risk (RR) for hospitalization due to DM was greater among NonHispanic blacks (RR 2.9), and lower among Hispanics (RR 0.75); NonHispanic blacks with DM had a longer LOS (RR 3.1) and had greater total charges (RR 2.9). Women (RR 0.71) and Hispanics (RR 0.59) had lower risks of having a CVD hospitalization. Coexisting diabetes increased the risk of being hospitalized for a primary CVD diagnosis (RR 1.8), and increased the chances of incurring greater charges (RR 1.74) and of having a longer LOS (RR 1.83) compared to CVD admissions without diabetes. Conclusions: There are race and sex disparities in diabetes and CVD related hospitalizations. Coexisting diabetes increases the risk of a CVD admission and greatly magnifies the cost and length of stay.

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42 PREVALENCE OF ISCHEMIC HEART DISEASE AMONG AMERICAN INDIANS AND ALASKA NATIVES, UNITED STATES, 2002. N.R. Burrows, L. Geiss, J. Galloway, K. Acton. Centers for Disease Control and Prevention, Indian Health Service. Cardiovascular disease (CVD), which includes ischemic heart disease (IHD), is the leading cause of death among American Indians/Alaska Natives (AI/ANs). In the overall U.S. population, the risk for death from CVD is 2 – 4 times higher among adults with diabetes than those without diabetes. We examined prevalence of IHD among AI/ANs according to their diabetes and hypertension status. From ambulatory care data of the Indian Health Service (IHS), we obtained the number of visits for IHD (ICD 410 –414) in 7 of 12 IHS service areas during 2002 by patients with and by those without diabetes (ICD 250) and hypertension (ICD 401 – 405). We then calculated prevalence of IHD for AI/ANs aged 45 years or older in each category using 2002 estimates of the population. Prevalence was age-adjusted based on the 2000 U.S. standard population. Overall, the age-adjusted prevalence of IHD was 2.8 times higher among AI/ANs with diabetes than those without diabetes (16.8% vs. 6.1%). Consistent with findings from the Strong Heart Study, AI/ANs with hypertension alone had a higher age-adjusted prevalence of IHD than those with diabetes alone (13.4% vs. 7.2%). The highest age-adjusted prevalence (20.4%) was among AI/ANs with both diabetes and hypertension. With the growing prevalence of diabetes in the AI/AN population, the prevalence of IHD in this population is likely to increase as well. However, interventions to control blood glucose levels, lipid levels, and blood pressure can reduce diabetes-related cardiovascular complications.

43 CHALLENGES IN EVALUATING AWARENESS ACTIVITIES. J. Woodson, J. Black, L. Gamell. University of Nevada, Reno. Objective: To create an awareness of cardiovascular disease risk factors within the African American Community of Clark County, Nevada using multiple strategies. Methods: Six strategies were used to create awareness, such as media, newsletters, clergy health messages, heart healthy recipes, health posters, monthly radio talk show and health fairs. These strategies reached the community through churches, community centers, libraries, barber and beauty shops, food markets, and community resource centers. Surveys were administered on 3 different occasions to test the effectiveness of these awareness strategies. Community Based Instructors employed in the

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project administered the surveys in churches, food markets, beauty/barber shops, and community resource centers on three occasions over a period of one year. Results: Performance sites were churches, supermarkets, barber and beauty shops, and community resource centers. After careful review of the survey results, it was determined that each survey period brought us further away from what we sought to evaluate. Performance sites also were reviewed. It was also determined that the same survey was not appropriate for all strategies and sites. Conclusion: The current surveys were ineffective in producing results. It was also determined that health fairs would be a better site to gain community input. Two surveys (one for churches and one for the community) were developed to replace the current survey used. The new surveys are expected to be more effective in evaluating awareness activities.

44 HIGHER RECOGNITION OF STROKE THAN HEART ATTACK SIGNS AND SYMPTOMS AMONG MAINE ADULTS. J. Graber, D. Wigand. Maine Bureau of Health, Maine Cardiovascular Health Program. Objective: To assess recognition of heart attack and stroke signs and symptoms in Maine adults. Methods: Respondents aged z 18 to the 2001 Behavior Risk Factor Surveillance System, a statewide random digit dial survey, were asked: if they thought the following were symptoms of 1) a heart attack (back/neck pain; weakness/faintness; trouble seeing; chest pain; arm/shoulder pain; shortness of breath) or 2) a stroke (confusion/trouble speaking; face/extremity numbness/weakness; trouble seeing; chest pain; trouble walking/dizziness; idiopathic severe headache); and their first action if they thought someone was having a heart attack or stroke. One symptom in each list was a decoy question, trouble seeing (heart attack) and chest pain (stroke). Statistical associations were assessed using a ChiSquare test. Results: Of the 2,397 BRFSS respondents, 2,359 (98.4%) and 2,355 (98.3%), respectively, completed the heart attack and stroke symptoms questions. 255 (10.3%) and 369 (15.3%), respectively, correctly identified all 6 signs and symptoms of heart attack and stroke and indicated they would first call 9-1-1. Respondents who were older, had less education, and had less annual income were less likely to correctly identify all stroke symptoms and the need to call 9-1-1 (p < 0.05). Persons living in the Northeastern region were also less likely to first call 9-1-1 (p = 0.0002). Conclusions: Overall, recognition of heart attack and stroke symptoms is low in Maine. Efforts to increase recognition of these signs and symptoms should target the specific at-risk populations. Further study of regional variation, such as differential 9-1-1 coverage in the Northeastern region, is needed.

45 CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH EARLY HOSPITAL ARRIVAL AFTER STROKE SYMPTOM ONSET. T. Turan, V. Hertzberg, P. Weiss, W. McClellan, R. Presley, K. Krompf, H. Karp, M. Frankel. Emory University School of Medicine. Objective: We sought to identify the clinical characteristics and outcomes of ischemic stroke patients who present early after symptom onset using data collected from a representative sample of hospitals in the state of Georgia. Methods: Data was obtained retrospectively from a statewide observational stroke registry from 12/1/01 to 2/28/02 and 2/1/03 to 3/ 31/03. Univariate and multivariate analysis compared clinical characteristics of stroke patients arriving to the hospital within 2 hours verses those arriving later. Results: Of the 467 ischemic stroke patients identified with a specified time of onset, 172 (36%) presented within 2 hours. Univariate analysis showed that arrival to the hospital within 2 hours was associated with: history of coronary artery disease (P = 0.0122), dyslipidemia (P = 0.0002), ambulance transport (P = 0.0001), Stroke Team consultation (P < 0.0001), Emergency Department diagnosis of stroke (P = 0.0182), higher NIH Stroke Scale Score (NIHSS) (P < 0.0001), and lower Glasgow Coma Score (GCS) (P = 0.0012). Race, gender, age, smoking history, previous stroke, myocardial infarction, congestive heart failure, prosthetic heart valve, hypertension, diabetes, and family history of stroke were not associated with arrival within 2 hours. Multivariate analysis revealed arrival by ambulance (OR = 2.84, CI 1.53– 5.26, P = 0.0016), NIHSS (OR = 1.19, CI 1.08– 1.31, P = 0.0008), and GCS (OR = 0.84, CI 0.75– 0.93, P = 0.0023) were associated with arrival within 2 hours. Stroke patients arriving within 2 hours had higher in-hospital mortality (13 vs. 4%) (P = 0.0016). Among the patients arriving within 2 hours, there was a marginally significant benefit of tPA on mortality (P = 0.0592). Conclusions: Early arrival after ischemic stroke symptom onset is associated with increased stroke severity and higher mortality.

46 WALKING CLUB IN HIGH RISK COMMUNITY. I. Bealyer. Duval County Health Department, Florida. Thirty-eight walkers have signed up for a walking club at a local mall. Those with high blood pressure are referred to area physicians who are encouraged to prescribe appropriate medication and physical activity. Chronic Disease Prevention and Health Education staff visited a local mall in a high-risk neighborhood to evaluate physical activity opportunities and met walkers interested in starting a walking club. Permission was given by the property managers to conduct weekly health screenings. Surveys were completed to determine day, time, topics of interest

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for health education and screenings, including body mass index, weight, resting heart rate and blood pressure. A four-week Diabetes Management Program was conducted as a health education component. Participants walk for 30 minutes, 5 days per week and the above mentioned screenings are conducted weekly. Participants that are screened and have blood pressures of > 120/80 are referred to their physician for blood pressure counseling and control. Referrals are made to County Health Department Adult Medicine Clinic if they do not have a physician. Of the 38 participants, 21 (55%) have been diagnosed with hypertension and are under a physician’s care for blood pressure control, nine have been diagnosed with type 2 diabetes, 9 are overweight (BMI z 25 < 30) and 12 are obese (BMI z 30). Preliminary results show significant improvements in the participants’ blood pressures. Pre-test/post-test results for a 4-week Diabetes Management Program shows an improvement from 76.5% pretest scores to 80% post test with a 17% decrease in the number of questions answered incorrectly.

47 STATE DATA FOR HEART DISEASE AND STROKE PREVENTION PROGRAM DEVELOPMENT AND MONITORING. S. Dai, J.B. Croft, K.J. Greenlund, N.L. Keenan, L.L. Lawton, G.A. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: The Burden of Heart Disease and Stroke in the United States: State and National Data, 1999 is the first in a series of surveillance reports on national and statespecific burden of heart disease and stroke. Objective: To provide baseline (1999) information on disease outcomes, relevant behaviors, and risk factors for heart disease and stroke. Methods: Age-adjusted mortality rates for diseases of the heart and stroke were calculated using data from the National Vital Statistics System. Prevalences of hospitalization among older adults were estimated from Medicare data. Prevalences of risk factors and behaviors were calculated using data from the Behavioral Risk Factor Surveillance System. Results: The 1999 death rates (per 100,000) were 267.6 for diseases of the heart and 61.8 for stroke. Prevalences (per 1000 enrollees) of hospitalizations among Medicare beneficiaries were 38.3 for coronary heart disease, 17.1 for stroke, and 22.7 for congestive heart failure. Prevalences of self-reported risk factors or behaviors were 24.2% for high blood pressure, 28.0% for high cholesterol, 22.7% for current smoking, 5.8% for diabetes, and 56.1% for overweight or obesity. Among non-institutionalized adults, 6.6% had survived coronary heart disease and 2.4% were stroke survivors. Death rates, hospitalizations, and risk factors varied substantially by sex, race/ethnicity, and state. Conclusions: The surveillance report summarizes state-specific burden in heart disease and stroke and helps set priorities in

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prevention programs and aid public health professionals in policy and program development. Subsequent publications of this report will be helpful in monitoring the progress and effectiveness of such programs. 48 EFFECTIVENESS OF A PHYSICAL ACTIVITY INTERVENTION ON CARDIOVASCULAR RISK FACTORS AMONG FAITH-BASED COMMUNITIES. G. Fierle, S. Carrow, F. Munschauer. Research Center for Stroke and Heart Disease, New York. Objective: Moving in Faith (MIF) evaluated the effectiveness of a 6-month intervention to increase physical activity levels and improve cardiovascular risk factors in faith-based communities throughout Western New York. Methods: Blood pressure (BP), weight, body mass index (BMI), and waist were measured during a pilot and expanded program that included 16 faith sites (most of low socioeconomic status). Participants selected personal weekly physical activity goals. Changes in cardiovascular risk factors, specifically hypertension and overweight/obesity, were compared at baseline and final screenings. Results: During the pilot program, average resting systolic BP was reduced among all participants attending both baseline and final screenings by 2.6 mmHg and during the expanded program, by 3.6 mmHg. Thirty-eight percent of participants in both programs had systolic BP z 130 at baseline which dropped to < 130 by the final screening. More than 50% of participants in each program lost weight. Among participants who lost weight, the average loss was six pounds in the pilot and seven pounds in the expanded program. Seventy percent of participants in the pilot lost inches around their waist, 62% lost inches in the expanded program. Among overweight participants (BMI 25.0 – 29.9) at baseline, 8% moved their BMI into the normal range (BMI < 25.0) by the final screening in both programs. Among obese (BMI z 30.0), participants, 16% and 9% reduced their BMI to < 30.0 by the final screening in the pilot and expanded MIF programs, respectively. Conclusion: MIF was successful in improving health behaviors among faith-based communities, in turn, reducing measurable cardiovascular risk factors. 49 AN ASSESSMENT OF DIFFERENCES IN BLOOD PRESSURE CONTROL STATUS AMONG DIABETIC AND NON-DIABETIC VETERANS. V. Welch, S. Tang, J. Grant, M. Mattox, G. Strayhorn. Emory University. Objective: Determine blood pressure (BP) control status (controlled, partially controlled or uncontrolled) by presence or absence of diabetes among veterans seeking care at the Atlanta Veterans Administration Medical Center. Methods:

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Data from outpatient medical records, including BP, comorbidities, and medications for 4,106 veterans newly diagnosed as hypertensive (i.e. no prior diagnosis of hypertension and no prior prescription for antihypertensive medications), was abstracted for visits between October 1, 2001 and September 30, 2003. Veterans with congestive heart failure were excluded. Control BP for diabetics was defined as systolic blood pressure (SBP) < 130 and diastolic blood pressure (DBP) < 80; control for non-diabetics was defined as SBP < 140 and DBP < 90. Results: Overall 33.1% of hypertensive veterans were diabetic. Differences were not observed by diabetic status in age, SBP, or number of comorbidities. Hypertensive diabetic veterans had lower DBP (78.5mmHg versus 81.0mmHg); more antihypertensive medications (6.3 versus 5.3); and more primary care visits (7.3 versus 5.9). BP control varied by diabetic status; with 67.3% of diabetics having uncontrolled BP compared to 42.3% of non-diabetics (p < 0.001). The prevalence of partially controlled BP (13.8% versus 16.2%) and controlled BP (18.9% versus 41.4%) were significantly lower among diabetics compared to non-diabetics, respectively. Conclusions: The prevalence of uncontrolled BP among diabetics found among Atlanta veterans is higher than that of their non-diabetic counterparts and higher than the nationally reported prevalence of 66%. Since veterans have ‘‘equal access’’ to health care resources, these results suggest there is room for improvement in delivery of care, especially among diabetics.

50 ESSENTIALS FOR THE ROAD TO CULTURAL COMPETENCY. M. Casey, E. Bradt, E. Weiskopf, C. Ferrari, D. Douglass. New York State Dept. of Health. Objective: Provide participants with a template for a replicable one-day training in cultural competency that can be used for local and state partners, as a first step in eliminating disparities. Participants will also learn ways for chronic disease programs to collaborate on training efforts. Methods: NYS Department of Health Division of Chronic Disease Prevention developed a one-day curriculum called ‘‘Pack Your Bags: Essentials for the Road to Cultural Competency.’’ The program uses staff from the following programs to conduct the trainings: cardiovascular health, diabetes, cancer services, and injury prevention. Trainings are provided to local health departments, hospitals and other program contractors and partners. The training focuses how culture influences our own decisions and perceptions, as well as those we interact with and serve. Local panelists drawn from cultural groups represented in the training location discuss their health perceptions and beliefs. Results: Over 500 individuals have been trained in the last 18 months. The demand for the training is so great, that a train-the-trainer program is now being developed.

Conclusion: Before changes in health disparities are achieved, public health practitioners need to understand how culture influences the populations they serve, and themselves. 51 THE BURDEN OF STROKE IN THE ATLANTA METROPOLITAN AREA –BENEATH THE SURFACE. V. Welch, L. Penix, M. MacLeish, E. Yancey, P. MacLeish. Emory University. Objective/Background: Evaluate the stroke burden in metropolitan Atlanta at the community level. Since the mid1960s literature has documented an excess burden of stroke in the southeastern United States and designated this region the ‘‘Stroke Belt’’. Simultaneously, a debate has ensued regarding the geographic boundaries of this ill-defined region and whether urban areas within the Stroke Belt such as Atlanta should be excluded. The debate regarding the exclusion of metropolitan Atlanta is based on its stroke mortality rates that are much lower than the state of Georgia rates. Unfortunately, most data describe the stroke burden for metropolitan Atlanta by county or metropolitan statistical area. The heterogeneity of metropolitan Atlanta suggests the potential for large variations in the stroke burden within the metropolitan area. Methods: Zip code-specific stroke hospitalization rates were calculated using 2001 discharge data for the 22 county Atlanta metropolitan area. Data were abstracted for residents with primary discharge diagnoses of 430– 438 using the International Classification of Diseases – Ninth Revision. Due to small sample size ageadjusted and race-and gender-specific rates were not calculated. Results: Crude stroke hospitalization rates per 100,000 residents ranged from 60.0 (Lawrenceville, Gwinnett County, zip code 30043) to 658.9 (Murrayville, Hall County, zip code 30564). Higher hospitalization rates were seen in zip codes with predominately Black residents, median incomes near or below poverty, and south of Interstate 20. Conclusions: Estimates of stroke hospitalizations appear to substantiate the inclusion of metropolitan Atlanta in the stroke Belt and suggest the need for targeted interventions for minority and low-income metropolitan Atlanta communities.

52 SURVEILLANCE OF HOSPITAL EMERGENCY DEPARTMENT UTILIZATION: IMPLICATIONS FOR PREVENTION AND TREATMENT OF CARDIOVASCULAR DISEASE. C. Larson, R. Belue, D. Schlundt, C. Chambers, L. McClellan. Metro Public Health Department, Tennessesse. Understanding patterns of health care utilization is critical to assuring most appropriate care and treatment for historically

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underserved populations. This information will enable health care leaders and policy makers to make informed decisions regarding policies and guidelines to improve health care access and health education for individuals who have been disenfranchised from the health care system. Less access to ambulatory care has been associated with higher hospitalization rates for chronic diseases including asthma, diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and hypertension. Improved access to outpatient services would prevent some of these hospitalizations. The purpose of the study was to assess emergency department inpatient admissions and outpatient records of presenting patients who were assigned a primary diagnosis of hypertension. Hospital emergency department (ED) records were aggregated across hospitals located in a mid-south urban community. The analysis excluded visits of persons younger than 18 and older then 65 years of age. The results indicated that inpatient ED admission rates and ED outpatient encounter rates based on primary diagnosis of hypertension was up to five times higher for African Americans compared to the rate for Caucasians. Further analyses explored the geographic representation of area of residence utilizing Geographic Information System software. The information will be used to track patterns of utilization over time. In response to this problem, REACH 2010, a community based intervention, has initiated a systematic approach to improving access to care that targets organizational changes and individual behavioral changes to reduce cardiovascular disease among African Americans.

53 MEETING THE PUBLIC HEALTH CHALLENGE TO REDUCE STROKE DISABILITY AND DEATH. J.B. Croft, N.B. Watkins, Z.J. Zheng, M.L. Casper, K.J. Greenlund, D.R. Orenstein, M.A. Malone, G.A. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: Congress provided the first appropriations for CDC to specifically address stroke in fiscal year 2001. Recognition has increased that stroke prevention and intervention involves different levels of target audiences and systems policies. Objective: Identify public health action steps and approaches to reduce stroke disability and death. Methods: We adapted American Heart Association (AHA) Chain of Recovery action steps to include prevention steps that address Healthy People 2010 objectives and AHA secondary prevention recommendations. We reviewed A Public Health Action Plan to Prevent Heart Disease and Stroke, AHA continuing education material and treatment guidelines, and activities recommended for CDC’s Heart Disease and Stroke Prevention Program to develop a framework of public health strategies to address and monitor each action step. Results: Public health action

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steps include 1) prevent risk factors, 2) detect and control risk factors, 3) increase public awareness of stroke signs, urgency, and actions, 4) reduce delay time to the emergency room, 5) improve evaluation and diagnosis, 6) improve treatment, 7) improve secondary prevention, 8) improve access to stroke rehabilitation, 9) improve quality of life for survivors, and 10) educate policy makers. Eliminating disparities is a goal within each action step. Target audiences include the public, high-risk persons, emergency services, health care providers, hospital systems, and caregivers. Strategies include developing new surveillance systems and applied research, supporting stroke networks, collaborating on informational campaigns, and promoting policy development and changes. Conclusions: Stroke prevention and intervention is complex. Aligning public health strategies with appropriate partners at specific action steps is critical towards reaching target audiences.

54 DOES OBESITY MODIFY THE ASSOCIATION BETWEEN HYPERTENSION AND RACE? AN ANALYSIS OF THE KEEP POPULATION. C. Jurkovitz, K. Norris, S. Li, S.C. Shen, J. McGill, P.A. McCullough, A. Narva, G. Bakris, A. Collins, M. Klag, W. Brown. Emory University, Georgia. African-Americans are more likely to be hypertensive than whites. Whether obesity modifies the association between hypertension and race is unknown. We examined this association in the National Kidney Foundation Kidney Early Evaluation Program (KEEP) population. KEEP is a screening program for kidney disease (KD) enrolling individuals 18 years or older, with a family history (FH) of KD or personal or FH of diabetes or hypertension. Population characteristics were compared according to blood pressure (BP) status. Hypertension was defined as systolic BP z 130 mmHg or diastolic BP z 80 mmHg. A logistic regression analysis was used to estimate the association between hypertension and race after adjusting for age, sex, obesity (BMI z 30), education, chronic kidney disease (CKD), diabetes, cardiovascular disease (CVD), FH of diabetes and hypertension. The population characteristics are described below. Black participants were more likely to have hypertension than whites (adjusted odds ratio (OR) = 1.42, p < 0.0001); obesity was also a significant risk factor (OR = 2.58, p < 0.0001). The interaction between race and obesity was significant (p = 0.0094). When BMI < 30, black participants were 53% more likely to be hypertensive than whites (OR = 1.53, p < 0.0001) whereas they were only 25% more likely when BMI > =30 (OR = 1.25, p = 0.0004). Obesity reduces the effect of race on the likelihood of hypertension in the KEEP population. It may do so by increasing the risk of hypertension in whites.

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55 COMMUNITY HEALTH WORKERS PARTNERING WITH AFRICAN AMERICAN CHURCHES TO PREVENT HEART ATTACK AND STROKE. C. Taylor, K. Ferdinand, J. Jones, New Orleans Public Library. REACH 2010 at the Heart Of New Orleans. Participants will be able identify and understand techniques developing coalitions to share resources and expand primary prevention services to African Americans at risk for heart attack, stroke, and diabetes. How respected community leaders use collaborative relationships to make a difference in high risk African American communities will be highlighted. Quantitative and qualitative community based survey data collection targeting 1200 African American women and 40 churches were analyzed using quasi-experimental research design methodology. Baseline survey results indicated the majority of New Orleans’ residents did not recognize signs of stroke or heart attack. Women study participants were more aware of their family history of cardiovascular risk factors than they were of their own susceptibility to heart disease. One conclusion of this faith based intervention research is that participants reported a need for chronic disease interventions on a risk reduction continuum. Based on community assessment data, education interventions focused on recognizing and responding to signs and symptoms of heart attacks and strokes were implemented. One successful example of targeted action involved establishing annual CPR training, targeting church ushers as first responders to recognize and respond to heart attacks in church settings. Seven communication strategies for successfully engaging community partners and the state office of public health heart disease and stroke prevention section to increase awareness, promote change among change agents and build capacity through targeted interventions will be included in the presentation. Methods for engaging public library systems to build community-wide capacity for access to on-line heart health resources will be discussed.

56 PREEXISTING RISK FACTORS FOR CARDIAC DISEASE IN MIDLIFE WOMEN EXPERIENCING ACUTE MYOCARDIAL INFARCTION (AMI). L. Kamm Steigelman, L. Kimble, S. Dunbar. Emory University, Atlanta, GA. Background: Clinical research has defined risk factors for cardiac disease. Purpose: This descriptive study assessed the preexisting risk factors for cardiac disease in midlife women experiencing AMI. Sample: The convenience sample included 50 women residing in the greater Atlanta, Georgia area, aged 35 – 64 years, mean 53.6 +/ 8.19 years. Methods: Following written informed consents, data were obtained from records and interviews. Results: The following risk factors were experienced: menopause (n=39, 78%)

family history of CAD, (n = 40, 80%), CAD previously diagnosed (n = 19, 38%), diabetes (n = 22, 44%), hypertension (n = 32, 64%), hyperlipidemia (n = 28, 56%), a moderate depression score of 17 –29 on Beck Depression Inventory (n = 18, 36%), lack of exercise (n = 38, 76%) body mass index z 25 (n = 34, 68%), and current smoking (n = 29, 58%) with mean pack years of 13.24 +/ 16.28. Conclusion: Percent of sample who experienced risk factors were: 1, 2, or 3 risk factors (18%), 4, 5, or 6 risk factors (42%), and 7, 8, 9 or 10 risk factors (40%). The majority of women in this sample experienced menopause, hyperlipidemia, hypertension, a family history of CAD, a body mass index z 25 kg./m 2, a lack of exercise, and were smokers. For women experiencing AMI, cardiac risk factors were strongly present and public health and clinical prevention programs are clearly needed.

57 TRENDS IN MORTALITY AND HOSPITALIZATIONS FOR VALVULAR HEART DISEASE IN THE UNITED STATES, 1980 –2000. H.D. Shoob, J.B. Croft, C. Ayala, A. Hyduk, S.B. Dunbar, Z.J. Zheng, G.A. Mensah. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: Valvular Heart Disease (VHD) is an important underlying cause of heart failure, stroke, and sudden death in the US. VHD is the underlying cause for 20,000 deaths and a contributing factor for over 42,000 deaths each year in the US. Objectives. This study provides a national perspective on the impact of VHD. Methods: Death certificate data from the National Vital Statistics System and information on discharges from the National Hospital Discharge Survey from 1980– 2000 were used to obtain age-adjusted and age-specific estimates of VHD as any contributing cause of death or hospitalization. Results: Death rates (per 100,000) with VHD as any contributory cause increased from 9.1 in 1980 to 15.5 in 2000, were higher for men than women, higher for whites than blacks, and increased with age. Almost 90% of all deaths with reported VHD occurred among adults aged z 65 years; 57% were among women. The number and age-adjusted prevalence (per 100,000) of hospitalizations with VHD as any listed diagnosis increased from 307,862 (152.9) in 1980 to 906,822 (330.9) in 2000. Hospital prevalences with VHD were higher for women than men and higher for whites than blacks. Almost 30% of hospital diagnoses for VHD occurred among persons aged < 45 years; 61% were among women. Conclusion: Mortality from VHD increased over the last two decades. Women and older adults represent the majority of decedents and hospital patients with VHD. Public health initiatives should support public and professional education efforts to increase awareness that early detection is vital for prompt, effective treatment.

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58 TRENDS IN THE PREVALENCE OF HOSPITALIZATIONS FOR PULMONARY HYPERTENSION – UNITED STATES, 1980– 2000. Alexandra Hyduk, Janet B. Croft, Carma Ayala, Kan Zheng, Zhi-Jie Zheng, George A. Mensah. Association of Schools of Public Health, Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: Little is known about pulmonary hypertension, a debilitating and often fatal condition. Objectives. We assessed trends (1980 – 2000) in mortality and hospitalizations with pulmonary hypertension (P-HTN). Methods: The National Hospital Discharge Survey, Medicare hospital claims, and the National Vital Statistics System provided data for death rates and prevalences of hospitalizations for P-HTN (ICD-9 codes 416.0 – 416.9 and ICD-10 codes I27.0 –I27.9) as any listed condition. Results: In 2000, there were 15,146 deaths and 284,979 estimated hospitalizations with any mention of P-HTN. Deaths, hospitalizations, and prevalences of hospitalizations for P-HTN increased among women and older adults from 1980 to 2000. Age standardized death rates increased for women and a decreased for men. Age adjusted death rates (per 100,000) were 5.9 for men and 5.1 for women in 1995 –1999. Death rates (per 100,000) in 1995 – 1999 were 7.9 in blacks and 5.2 in whites. Prevalences of hospitalizations were higher for men than women until around 1995 when prevalences were higher among women. There was geographic clustering of the highest state prevalences of Medicare hospitalizations for P-HTN in the western states and in the Appalachian region. Conclusions: Older adults represent the majority of patients and decedents with P-HTN. Important racial and gender differences in mortality were observed. Public health initiatives should support patient and provider education of early recognition of symptoms and the importance of early diagnosis and treatment.

59 RACIAL DISPARITIES IN STROKE MORTALITY AND RESIDENTIAL SEGREGATION. T. Dark, C. Williams, E. Barnett. University of South Florida, Department of Epidemiology and Biostatistics. Background: Although stroke mortality rates have declined for all racial groups over time, variations in stroke death rates among racial groups persist, with Black Americans experiencing the slowest decline and highest rates. Residential segregation is a proposed cause of racial disparities in health. Measures of segregation capture some of the effects of racism, and these effects are one reason for the persistence of observed racial differences in health status even after controlling for other risk factors. Objectives: Because previous studies of residential segregation and health outcomes are limited to a single dimension of residential segregation,

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the current study examines the impact of five segregation measures on racial disparities in stroke mortality in 167 US metropolitan areas (MSAs). US mortality and census data for years 1990– 97 were used to examine age-adjusted stroke mortality rates for Blacks and Whites aged 35 years and older. Discussion: Black stroke death rates were elevated compared to rates of White Americans across all MSAs. Elevated rates were associated with significant changes in levels of racial residential segregation defined by four residential segregation indices. Black-White stroke death rate ratios varied substantially across MSAs. Increased Black residential isolation and percent Black population were individually associated with higher Black-White stroke mortality ratios. Opposite results were obtained for the relative concentration and centralization indices, with stroke mortality ratios significantly decreasing with elevations in these segregation measures. Conclusion: These contrasting results underscore the need for further understanding of specific processes by which different dimensions of racial residential segregation adversely affect health outcomes for Black Americans.

60 EFFECTIVE PARTNERSHIPS TO ADDRESS HYPERTENSION AND ELIMINATE HEALTH DISPARITIES. M. Ellis. South Carolina Department of Health and Environmental Control. Objective: There will be an increase in the number of physicians in South Carolina who participate in the Expert In Hypertension Series through the Medical University of South Carolina (MUSC) and who become Certified Hypertension Specialist. There will also be an increase in the control of hypertension in patients seen in rural primary care practices. Methods: The South Carolina Cardiovascular Health (CVH) Program collaborates with the MUSC Hypertension Initiative to increase blood pressure control, especially among underserved, high-risk populations. There will be an increase in expertise among primary care providers statewide, through peer-led provider training on best practices and quality of care monitoring and feedback. Carolina Medical Review, the state’s quality improvement organization, will analyze the Medicaid database to determine the impact of the strategies on quality of care. Baseline data from participating providers indicate 50% of hypertensive patients have controlled blood pressure, with the goal of increasing blood pressure control to 70%. Results: Over 300 providers from 38 of the state’s 46 counties have participated in this Expert in Hypertension Series and the MUSC Initiative. Quality improvement opportunities were identified, which has led to an increase in the number of physicians utilizing nationally accepted standards of care for hypertension. Conclusions: Improvement in the hypertension control of 70,000 + patients was demonstrated in the participating physician practices. Quality improvement data

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will be shared with the State Program this year. The American Society of Hypertension has adopted this quality improvement approach.

61 GEOGRAPHIC DISPARITIES IN HEART DISEASE MORTALITY, 1996-2000. M. Casper, I. Williams, K. Greenlund, S. Davis. Objectives: One of the objectives of CDC’s Cardiovascular Health Program is to monitor temporal changes in geographic disparities of heart disease. The maps presented here for 1996– 2000 are updated from the 1991– 1995 maps of heart disease mortality published in our earlier atlases and available on-line at our interactive website. Methods: County-level data regarding the number of heart disease deaths (ICD 9 codes 390 –398, 402, 404 – 429 and ICD 10 codes I00 – I09, I11, I13, I20 – I51 listed as the underlying cause of death) and population size were obtained from the National Center of Health Statistics and the Bureau of the Census, respectively. County-level age-adjusted (using the 2000 US standard population) and spatially smoothed heart disease death rates were calculated for ages 35 and older for each of the five largest racial and ethnic groups. Spatial smoothing was performed by calculating a spatial moving average. Maps of the age-adjusted and spatially smoothed heart disease death rates were mapped using ArcView. Summary of results: The maps show subtle changes in the pattern of geographic disparities for each racial and ethnic group from 1991 –1995 to 1996 –2000. The range of heart disease death rates across the counties does not change much over these time periods, reflecting the slow rates of decline in heart disease mortality that have been observed nationally. These maps are available on-line at http:// www.cdc.gov/cvh/maps/. Conclusions: The updated maps provide viewers with important information regarding the location of counties with the greatest risk of heart disease, and when compared with earlier maps provide insights into the determinants of the geographic disparities.

62 USING DATA TO DEFINE AND FOCUS PUBLIC HEALTH INTERVENTIONS ON PRIORITY POPULATIONS. B. Minta, N. Watkins. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: Multiple data collection systems and surveys are used to gather national, state, and local demographic information. Utilization of data abstracted by and found in these instruments can assist state health departments in identifying and developing interventions that are specific and appropriate for populations with increased heart disease and stroke risk factors, morbidity and mortality (also known

as priority or vulnerable populations). Objectives: To identify data sources that can use to define high risk populations and direct the development of appropriate interventions. Methods: A review of evidence-based literature using Medline and reports published by national and community health organizations; search of the National Center for Health Statistics, U.S. Census Bureau, and Centers for Medicare and Medicaid websites to identify data sources. Results: Government (federal, state, and local), private (hospitals, health plans, provider groups), and community organizations capture data across a spectrum of demographic and geographic characteristics. Existing national, state, local, and private data collection systems include, the US decennial census, National Hospital Discharge Survey, National Health Interview Survey (NHIS), Health Plan Employer Data Information Set (HEDIS), National and State Vital Statistics System, State and Local Area Integrated, Behavioral Risk Factor Surveillance System (BRFSS), and CDC Heart Disease and Stroke Atlas. These data systems are used by State health departments, community service organizations, hospitals, researchers, and managed care organizations to identify demographic characteristics (race, ethnicity, and socioeconomic status) and analyze health care utilization, chronic disease prevalence, and death rates to find populations and geographic areas with health and resource disparities that are priorities for public health interventions. Conclusion: Multiple data instruments and sources collect morbidity, hospitalization, mortality, anfsd economic and other data across US demographic groups and geographic areas. Data abstracted from these sources can be used to identify populations at greater risk for adverse health outcomes (populations within racial, ethnic, socioeconomic, age and gender groups, and geographic areas).

63 FACILITATING HEALTH CARE SYSTEMS CHANGE TO IMPROVE THE QUALITY OF CARE FOR HEART DISEASE AND STROKE. B. Minta, R. Todd. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Background: Increased cost, high utilization of medical services, and health disparities associated with treating heart disease and stroke necessitate an increased role for public health in working with health care services to facilitate effective management of chronic diseases. Objective: To identify and describe effective strategies supported by public health that can be adopted to effect change within health care settings. Method: A review of MEDLINE evidence-based literature, State progress reports received by the Cardiovascular Health Branch, American Heart Association programs, and Health Disparities Collaborative models was conducted to identify approaches that are being used to improve quality of care across health care settings. Results: Multiple approaches exist and are being employed

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to bring about systemic changes within health care settings. Statewide partnerships facilitated by Departments of Health have resulted in the establishment of coalitions that are developing and implementing policy and environmental strategies to improve health care. Community health centers participating in Health Disparities Collaboratives are making use of models, which utilize inter-and multidisciplinary teams, decision support tools, clinical information systems, and leadership buy-in to implement, test and refine systems and policies to improve care for patients with cardiovascular diseases. Lastly, hospitals are utilizing care teams and patient management tools to enhance adherence to evidence-based treatment guidelines. Conclusion: Public health, in collaboration with key stakeholders, has a role in facilitating successful health care systems change using proven methods for clinical improvement to: 1) collect and review data to identify need; 2) implement a multidisciplinary approach to treating patients across the continuum of care, including patient self-management; and 3) develop means for monitoring and enhancing the quality of care based on continued data collection and evaluation.

64 SMALL AREA RACIAL DISPARITIES IN HEART DISEASE MORTALITY. Eric C. Tassone, Lance A. Waller, Michele Casper, Ishmael Williams, Kurt Greenlund. Emory University and the Cardiovascular Health Branch, Centers for Disease Control and Prevention. Objectives: Interest in documenting and eliminating racial and ethnic disparities in health, as expressed in Healthy People 2010, suggests a pressing need to develop methods to measure such disparities at the local level. We develop methodology to measure county-level disparities in heart disease mortality between African Americans and whites in South Carolina during 1991 –1995, analyzing women and men separately. Methods: County-level data of the number of heart disease deaths (coded 390– 398, 402, or 404 –429, International Classification of Disease-9th Revision) and population size were obtained from the National Center of Health Statistics and the Bureau of the Census, respectively. Our disparity measure extends a typical hierarchical Bayesian disease mapping model using the group structure of the study population. Maps of disparity, along with other maps and plots, are provided. Summary of results: Maps of our small area disparity measure show geographic patterns of racial disparity in South Carolina for both men and women, with African Americans bearing an excess burden. Clusters of counties with high disparity were found in the eastern and southern corners and in the center of the state for men and women. Low disparity occurred in inland southeastern counties for both sexes. Conclusions: Our disparity measure provides information regarding the location of counties with the greatest racial disparity of heart disease. Further,

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the disparity measure provides insight into the structure of the disparity. Consequently, data analyzed in this way may help public health professionals tailor interventions and policy changes to the needs of specific communities.

65 KANSAS CITY-CHRONIC DISEASE COALITION (KC-CDC) PRESENTS ITS RED DRESS QUILT. J.P. Cyprus, K.A. Smith. Kansas City-Chronic Disease Coalition (KC-CDC), Missouri. Background: First Lady Laura Bush unveiled a new Heart Truth initiative in February 2003, focused on cardiovascular disease among women-The Red Dress Campaign. Kansas City, Missouri was one of the first cities to showcase The Red Dress Exhibit, which took place September 11 – 21, 2003 at Halls Crown Center. A Red Dress quilt was created that would remain in Kansas City, traveling to different sites throughout Kansas City to highlight Heart Truth issues and distribute related literature. Authors: JP Cyprus, KA Smith. Missouri Primary Care Association (MPCA) Objective To obtain maximum exposure of the Heart Truth campaign utilizing the Red Dress Quilt as an ongoing component of Kansas City’s Healthy Habits initiative. Methods: Authors researched national literature and internal progress reports, reviewed schedule of events where the quilt was displayed, and results generated to raise the levels of awareness on women’s heart health issues through maximum exposure of the quilt. Summary of results: During the 10 day Red Dress exhibit, the Kansas City-Chronic Disease Coalition (KC-CDC), Missouri’s REACH 2010 project, partnered to support the exhibit with related events including the distribution of a self-guided Health Walk brochures, red ‘‘We Practice Healthy Habits’’ shoe laces to persons completing the Health Walk, creation and distribution of ‘‘Healthy Habits’’/Red Dress T-shirts and the hosting of a ‘‘Red Accessories Fashion Show’’. The quilt has been in use since September, 2003 to promote Heart Truth Women’s Health awareness. Conclusions: The Red Dress quilt serves as a permanent vehicle to make people aware of the Heart Truth campaign for ongoing use in the Heartland, making women more aware of the importance of heart disease and stroke issues.

66 ADAPTATION OF THE PUBLIC ACTION PLAN TO PREVENT HEART DISEASE AND STROKE FOR USE WITH COMMUNITY AND FAITH ORGANIZATIONS. J.P. Cyprus, K.A. Smith. Kansas City-Chronic Disease Coalition (KC-CDC), Missouri. Background: Heart disease and stroke are among the nation’s leading causes of death and disability. The CDC’s

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2003 Public Health Action Plan to Prevent Heart Disease and Stroke is charting a national course to prevent heart disease and stroke through 2020 and beyond. Missouri’s REACH 2010 project – the Kansas City – Chronic Disease Coalition (KC – CDC) has developed an ancillary 4 page brochure targeted for use with local community and faith groups to take action in preventing heart disease and stroke within the respective local networks. This document is designed to summarize content from the CDC public health action plan report and provide an outline for use by community and faith-based groups. Objective: To develop and field-test an education brochure focused for use with community and faith-based audiences to guide implementation of the national public health Action Plan recommendations. Methods: Authors reviewed the national Action Plan, adapted it for use by community and faith-based leaders. The resulting brochure states the challenges that exists in preventing heart disease and stroke, provides tools that support local implementation efforts and summarizes ten recommendations for action and applied use in local community and faith settings. Summary of results: This community-based brochure enables neighborhood and faithbased leaders to guide discussions and document each group’s local results in reducing heart disease and stroke. The poster will include copies of the four page brochure, projected outcomes achieved through its use to date, and visuals that demonstrate its use in community settings. Conclusions. The brochure enables leaders from community and faith-based organizations to examine and implement public health Action Plan recommendations on a local level Missouri Primary Care Association (MPCA).

67 TRAUMA: A RISK FACTOR FOR INADEQUATE ASSESSMENT OF HYPERTENSION IN EMERGENCY DEPARTMENT PATIENTS. David Cline, Carlos Ferrario, Carma Ayala, Akaki Lekiachvili, George A. Mensah, Aimee Tracy, Jennifer Escojido. Wake Forest University, North Carolina. Background: Transient elevation in blood pressure (BP) due to pain from trauma among patients seen in the emergency department may render BP assessment for significant cardiovascular conditions inadequate. Objective: To study the adequacy of blood pressure assessment for hypertension in the Emergency Department (ED) among patients presenting with a traumatic injury. Setting: A university hospital with 65,000 annual emergency patient visits. Methods: All patients ages z 18 years presenting to the emergency department were prospectively screened for hypertension (BP over 130/85 mm Hg). Data from ED charts were retrospectively reviewed for race, sex, history of hypertension, or current use of anti-hypertensives. Results: In this analysis, 3098 patients met inclusion criteria, 608 (19.6%) have traumatic injury and 2490 (80.4%) were medical

patients. Only 243 (40.0%) of trauma patients had a repeat BP measurement, while 1612 (64.73) of medical patients had a repeat BP measure (p < 0.001). Among the 3098 included patients, 2173 patients (70.1%) were discharged from the ED. Among the discharged patients, only 128 (27.0%) of 473 trauma patients had repeat BP measures. The frequency of previously known hypertension was less for trauma patients (37%) than in medical patients (47.0%). However, the mean BPs of trauma patients were not significantly different from medical patients, but were slightly higher for patients that did have second and third measurements (2 to 4 mmHg). Conclusion: Patients presenting to the ED with trauma are at risk for inadequate (repeat) blood pressure assessment and therefore may not receive proper referral for hypertension assessment, follow-up, or continued primary care.

68 STROKE HOSPITALIZATIONS AMONG MEDICARE BENEFICIARIES BY SUBTYPE, DISCHARGE STATUS AND GEOGRAPHY. I. Nwaise, J. Croft, M. Casper, H. McGruder. Cardiovascular Health Branch, Centers for Disease Control and Prevention. Objective: To examine the characteristics of stroke hospitalizations among Medicare beneficiaries in the United States by stroke subtype, discharge status, race/ethnicity and geography. Methods: Medicare hospital claims and enrollment record data for 2000 were obtained from the Centers for Medicare and Medicaid Services. Stroke subtypes were classified according to the following ICD 9 codes: hemorrhagic stroke (ICD-9 430 – 432), ischemic stroke (ICD-9 433 –434), ill-defined cerebrovascular diseases (ICD-9 436– 437) and late effects of cerebrovascular diseases (ICD-9 438). For the number of persons at risk, Medicare enrollment records were extracted for enrollees aged 65 years or older who, on July 1st of 2000, were alive, entitled to Medicare hospital insurance benefits, and not enrolled in a HMO plan. Age-adjusted prevalences of stroke hospitalizations per 1,000 Medicare enrollees were calculated using the 2000 US standard population and mapped at the county level. For each subtype, the distribution of discharge outcomes (home, skilled nursing facility, other facility, died in hospital, or other outcome) was calculated. Results: The majority of stroke hospitalizations were ischemic strokes (65.3%), followed by ill defined cerebrovascular diseases (20.9%) and hemorrhagic strokes (11.9%). Substantial geographic disparities are observed at the county level, with the highest prevalences observed in parts of the Southeast. Hospitalizations for hemorrhagic strokes were most likely to result in in-hospital deaths (30.5%), whereas ischemic strokes, ill defined stroke and late effect strokes were most likely to be discharged to home (57.2%, 44.3% and 49.9% respectively). Conclusions: These data provide important information for understanding the burden of

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stroke, identifying areas with the highest prevalences of stroke hospitalizations, and guiding primary and secondary prevention efforts.

69 THE MORTON HAVE-A-HEART PROJECT: BASELINE ASSESSMENT OF CARDIOVASCULAR RISK FACTORS. K. Harrell, D. King, M. Wofford, J. Olivier, D. Jones, S. Noble. University of Mississippi Medical Center. Background: Mississippi ranks first in the number of deaths due to CVD, and in the prevalence of obesity and diabetes. The Morton Have-A-Heart Project (MHHP) is a communitywide project whose overarching goal is to improve CVD health awareness in rural populations. The objectives are to: generate and nurture community partnerships; to assess CVD risk factors in the community-at-large; and to provide education programs developed for diverse audiences. Purpose. The purpose of this poster presentation is to describe initial

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baseline assessment of CVD metabolic risk factors in the MHHP. Methods: Community committees were initially formed to determine the best approaches to reach every resident in the community. Subsequently, risk assessment screenings were conducted at schools, businesses, and churches. Participants were assessed for all CVD risk factors including blood pressure, total lipid panel, blood glucose, height and weight, and waist circumference. Results: A total of 1,139 participants were enrolled. Thirty-two percent had a BMI 25-30, and 24% had a BMI 30 or higher. For waist circumferences, 29% of males measured greater than 40 inches and 45% of women measured greater than 35 inches. There were positive correlations between BMI and blood sugar (r = 0.19, p < 0.0001), total cholesterol (r = 0.22, p < 0.0001), SBP (r = 0.27, p < 0.0001), and DBP (r = 0.36, p < 0.0001). Conclusions: These data suggest high prevalence for all CVD risk factors in the community. They also support the need for additional education and awareness at the community level. Community interventions similar to the MHHP are warranted to meet Healthy People 2010 objectives and eliminate health disparities.