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Adherence and persistence to direct oral anticoagulants in atrial fibrillation: a population-based study.
Banerjee, A, Benedetto, V, Gichuru, P, Burnell, J, Antoniou, S, Schilling, RJ, Strain, WD, Ryan, R, Watkins, C, Marshall, T, et al
Heart (British Cardiac Society). 2020;(2):119-126
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Abstract
BACKGROUND Despite simpler regimens than vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF), adherence (taking drugs as prescribed) and persistence (continuation of drugs) to direct oral anticoagulants are suboptimal, yet understudied in electronic health records (EHRs). OBJECTIVE We investigated (1) time trends at individual and system levels, and (2) the risk factors for and associations between adherence and persistence. METHODS In UK primary care EHR (The Health Information Network 2011-2016), we investigated adherence and persistence at 1 year for oral anticoagulants (OACs) in adults with incident AF. Baseline characteristics were analysed by OAC and adherence/persistence status. Risk factors for non-adherence and non-persistence were assessed using Cox and logistic regression. Patterns of adherence and persistence were analysed. RESULTS Among 36 652 individuals with incident AF, cardiovascular comorbidities (median CHA2DS2VASc[Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] 3) and polypharmacy (median number of drugs 6) were common. Adherence was 55.2% (95% CI 54.6 to 55.7), 51.2% (95% CI 50.6 to 51.8), 66.5% (95% CI 63.7 to 69.2), 63.1% (95% CI 61.8 to 64.4) and 64.7% (95% CI 63.2 to 66.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. One-year persistence was 65.9% (95% CI 65.4 to 66.5), 63.4% (95% CI 62.8 to 64.0), 61.4% (95% CI 58.3 to 64.2), 72.3% (95% CI 70.9 to 73.7) and 78.7% (95% CI 77.1 to 80.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. Risk of non-adherence and non-persistence increased over time at individual and system levels. Increasing comorbidity was associated with reduced risk of non-adherence and non-persistence across all OACs. Overall rates of 'primary non-adherence' (stopping after first prescription), 'non-adherent non-persistence' and 'persistent adherence' were 3.5%, 26.5% and 40.2%, differing across OACs. CONCLUSIONS Adherence and persistence to OACs are low at 1 year with heterogeneity across drugs and over time at individual and system levels. Better understanding of contributory factors will inform interventions to improve adherence and persistence across OACs in individuals and populations.
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Associations of community programs and policies with children's dietary intakes: the Healthy Communities Study.
Ritchie, LD, Woodward-Lopez, G, Au, LE, Loria, CM, Collie-Akers, V, Wilson, DK, Frongillo, EA, Strauss, WJ, Landgraf, AJ, Nagaraja, J, et al
Pediatric obesity. 2018;(Suppl 1):14-26
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BACKGROUND The impact of community-based obesity prevention efforts on child nutrition has not been adequately studied. OBJECTIVE Examine relationships between number, type and intensity of community programs and policies (CPPs) and child nutrition. METHODS An observational study of 5138 children (grades K-8) in 130 U.S. communities was conducted in 2013-2015. CPPs were identified by 10-14 key informant interviews per community. CPPs were characterized based on: count, intensity, number of different strategies used and number of different behaviours targeted. Scores for the prior 6 years were calculated separately for CPPs that addressed primarily nutrition, primarily physical activity (PA) or total combined. Child intakes were calculated from a dietary screener and dietary behaviours were based on survey responses. Multi-level statistical models assessed associations between CPP indices and nutrition measures, adjusting for child and community-level covariates. RESULTS Implementing more types of strategies across all CPPs was related to lower intakes of total added sugar (when CPPs addressed primarily PA), sugar-sweetened beverages (for nutrition and PA CPPs) and energy-dense foods of minimal nutritional value (for total CPPs). Addressing more behaviours was related to higher intakes of fruit and vegetables (for nutrition and total CPPs) and fibre (total CPPs). Higher count and intensity (PA and total CPPs) were related to more consumption of lower fat compared with higher fat milk. A higher count (PA CPPs) was related to fewer energy-dense foods and whole grains. No other relationships were significant at P < 0.05. CONCLUSION Multiple characteristics of CPPs to prevent obesity appear important to improve children's diets.
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Associations between community programmes and policies and children's physical activity: the Healthy Communities Study.
Pate, RR, Frongillo, EA, McIver, KL, Colabianchi, N, Wilson, DK, Collie-Akers, VL, Schultz, JA, Reis, J, Madsen, K, Woodward-Lopez, G, et al
Pediatric obesity. 2018;(Suppl 1):72-81
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BACKGROUND Community initiatives to promote physical activity in children are common, but evidence supporting their effectiveness is limited. OBJECTIVES The objective of this study is to examine the relationships between community programmes and policies and children's physical activity in a large and diverse sample of US communities. METHODS Programmes and policies to promote children's physical activity were assessed in 130 communities by key informant interviews, and physical activity behaviours were measured by self-report and parental report in samples of children in each community (total n = 5138). Associations between composite indices of community programmes and policies and indicators of total and moderate-to-vigorous physical activity were examined without and with adjustment for demographic factors. RESULTS An index reflecting the 6-year history of the number of behaviour change strategies used in community programmes and policies was positively associated with children's moderate-to-vigorous physical activity. This association was attenuated with adjustment for demographic factors. Effect modification analyses found that the association was positive among non-Hispanic children but was negative for Hispanic children. CONCLUSIONS Community initiatives to promote physical activity in children were positively associated with children's physical activity in non-Hispanic children. Such initiatives were negatively associated with physical activity in Hispanic children, suggesting that future research should consider unique cultural factors when designing community initiatives to promote activity in this population sub-group.
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Objectives of community policies and programs associated with more healthful dietary intakes among children: findings from the Healthy Communities Study.
Webb, KL, Hewawitharana, SC, Au, LE, Collie-Akers, V, Strauss, WJ, Landgraf, AJ, Nagaraja, J, Wilson, DK, Sagatov, R, Kao, J, et al
Pediatric obesity. 2018;(Suppl 1):103-112
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BACKGROUND Rational planning of community policies and programs (CPPs) to prevent obesity requires an understanding of CPP objectives associated with dietary behaviours. OBJECTIVE The objective of the study is to identify objectives of CPPs associated with healthful dietary behaviours. METHODS An observational study identified 4026 nutrition CPPs occurring in 130 communities in the prior 6 years. Dietary intakes of fruits and vegetables, added sugar and sugar-sweetened beverages, among others, were reported among 5138 children 4-15 years of age from the communities, using a Dietary Screener Questionnaire with children age 9 years and older (parent assisted) or parent proxies for younger children. CPPs were documented through key informant interviews and characterized by their intensity, count, and objectives including target dietary behaviour and food environment change strategy. Associations between dietary intakes and CPP objectives were assessed using hierarchical statistical models. RESULTS CPPs with the highest intensity scores that targeted fast food or fat intake or provided smaller portions were associated with greater fruit and vegetable intake (0.21, 0.19, 0.23 cup equivalents/day respectively with p values <0.01, 0.04, 0.03). CPPs with the highest intensity scores that restricted the availability of less healthful foods were associated with lower child intakes of total added sugar (-1.08 tsp/day, p < 0.01) and sugar from sugar-sweetened beverages (-1.63 tsp/day, p = 0.04). Similar associations were observed between CPP count and dietary outcomes. No other significant associations were found between CPP target behaviours or environmental strategies and dietary intakes/behaviours. CONCLUSION CPPs that targeted decreases in intakes of less healthful foods and/or aimed to modify the availability of less healthful foods and portions were associated with healthier child dietary behaviours.
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Community characteristics modify the relationship between obesity prevention efforts and dietary intake in children: the Healthy Communities Study.
Woodward-Lopez, G, Gosliner, W, Au, LE, Kao, J, Webb, KL, Sagatov, RD, Strauss, WJ, Landgraf, AJ, Nagaraja, J, Wilson, DK, et al
Pediatric obesity. 2018;(Suppl 1):46-55
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BACKGROUND The influence of community characteristics on the effectiveness of childhood obesity prevention efforts is not well understood. OBJECTIVE Examine the interaction of community characteristics with the relationship between community programmes and policies (CPPs) and dietary intake. METHODS An observational study of 5138 children in grades K-8 in 130 US communities was conducted in 2013-2015. Key informant interviews identified and characterized CPPs. CPP scores were generated for the number of target behaviours (CPP-Behav) and the number of behaviour change strategies (CPP-Strat) addressed by all CPPs and CPPs with nutrition goals over the prior 6 years in each community. Dietary intake was assessed by dietary screener and included intake of sugar from sugar-sweetened beverages; energy-dense foods; fruits and vegetables; whole grains; and fibre. Multivariate statistical models assessed the interactions between US region, urbanicity, community-level income, and community-level race/ethnicity and CPP scores in relation to dietary intake. RESULTS CPP-Strat was positively associated with healthier dietary intakes in the Northeast and West, and in high Hispanic communities; the reverse was true in the South, and in high African-American and low-income communities. The CPP-Behav was positively associated with healthier dietary intakes in the South and rural areas, and the reverse was true in the West. CONCLUSION The relationships between CPP index scores and dietary intake were most strongly influenced by region and urbanicity and to a lesser extent by community-level race/ethnicity and income. Findings suggest that different considerations may be needed for childhood obesity prevention efforts in communities with different characteristics.
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The longitudinal relationship between community programmes and policies to prevent childhood obesity and BMI in children: the Healthy Communities Study.
Strauss, WJ, Nagaraja, J, Landgraf, AJ, Arteaga, SS, Fawcett, SB, Ritchie, LD, John, LV, Gregoriou, M, Frongillo, EA, Loria, CM, et al
Pediatric obesity. 2018;:82-92
Abstract
BACKGROUND Although a national epidemic of childhood obesity is apparent, how community-based programmes and policies (CPPs) affect this outcome is not well understood. OBJECTIVES This study examined the longitudinal relationship between the intensity of CPPs in 130 communities over 10 years and body mass index (BMI) of resident children. We also examined whether these relationships differ by key family or community characteristics. METHODS Five thousand one hundred thirty-eight children in grades K-8 were recruited through 436 schools located within 130 diverse US communities. Measures of height, weight, nutrition, physical activity and behavioural and demographic family characteristics were obtained during in-home visits. A subsample of families consented to medical record review; these weight and height measures were used to calculate BMI over time for 3227 children. A total of 9681 CPPs were reported during structured interviews of 1421 community key informants, and used to calculate a time series of CPP intensity scores within each community over the previous decade. Linear mixed effect models were used to assess longitudinal relationships between childhood BMI and CPP intensity. RESULTS An average BMI difference of 1.4 kg/m2 (p-value < 0.01) was observed between communities with the highest and lowest observed CPP intensity scores, after adjusting for community and child level covariates. BMI/CPP relationships differed significantly by child grade, race/ethnicity, family income and parental education; as well as community-level race/ethnicity. CONCLUSIONS These results indicate that, over time, more intense CPP interventions are related to lower childhood BMI, and that there are disparities in this association by sociodemographic characteristics of families and communities.
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Measuring the intensity of community programs and policies for preventing childhood obesity in a diverse sample of US communities: the Healthy Communities Study.
Collie-Akers, VL, Schultz, JA, Fawcett, SB, Landry, S, Obermeier, S, Frongillo, EA, Forthofer, M, Weinstein, N, Weber, SA, Logan, A, et al
Pediatric obesity. 2018;(Suppl 1):56-63
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INTRODUCTION Efforts to address the critical public health problem of childhood obesity are occurring across the USA; however, little is known about how to characterize the intensity of these efforts. OBJECTIVES The purposes of this study are to describe the intensity of community programs and policies (CPPs) to address childhood obesity in 130 US communities and to examine the extent to which observed CPPs targeted multiple behaviours and employed a comprehensive array of strategies. METHODS To document CPPs occurring over a 10-year period, key informants were interviewed using a semi-structured interview protocol. Staff coded CPPs for key characteristics related to intensity, including reach, duration and strategy. Three types of CPP scores were calculated for intensity of CPPs, targeting of CPPs towards multiple behaviours and strategies used. RESULTS Nine thousand six hundred eighty-one CPPs were identified. On average, communities had 74 different CPPs in place (standard deviation 30), with variation in documented CPPs (range 25-295). Most communities experienced a steady, modest increase in intensity scores over 10 years. CPP targeting scores suggested that communities expanded the focus of their efforts over time to include more behaviours and strategies. CONCLUSIONS Findings of this large-scale study indicate that great variation exists across communities in the intensity and focus of community interventions being implemented to address childhood obesity.
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Turkish doctors' cohort: healthy despite low screening.
Unal, S, Tanriover, MD, Ascioglu, S, Demirkazik, A, Ertenli, I, Eskioglu, E, Guler, K, Kiraz, S, Ozbakkaloglu, M, Ozer, B, et al
Postgraduate medicine. 2017;(3):393-398
Abstract
OBJECTIVES We aimed to determine the prevalence of chronic diseases and unhealthy lifestyle behaviors of Turkish doctors as compared with the general population and the frequency of compliance with preventive clinical practices among doctors. METHODS This was an observational, prospective cohort study that enrolled graduates between 1975 and 2004 from six medical schools in Turkey. Data on demographics, disease conditions, and unhealthy lifestyle behaviors were gathered. Preventive care practices were analyzed with regards to age and gender. RESULTS A total of 7228 doctors participated in the study. Comparison with the national data revealed higher hyperlipidemia and coronary artery disease rates. While 54.5% of the doctors had a doctor visit in the last 12 months, only 31.5% of those over 40 years of age reported a recent blood pressure measurement. Colon cancer screening rate over 50 years of age with any of the acceptable methods was only 3%. One-fourth of the female doctors over 40 years of age underwent mammography within the last two years. Only 7.1% of the doctors over 65 years of age and 10% of the doctors having an indication for a chronic disease had a pneumococcal vaccine, while nearly one-fifth had no hepatitis B vaccine. CONCLUSION In this cohort of mainly middle-aged Turkish doctors, the age-standardized rates of chronic diseases were lower than the rates in the general population except for the rates of hyperlipidemia and coronary artery disease. However, doctors did show quite low rates of receipt of screening practices. These results might provoke questions about how to use Turkish doctors' health behaviors to further improve doctors' and, relatedly, patients' health.
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Urban-rural disparity in utilization of preventive care services in China.
Liu, X, Li, N, Liu, C, Ren, X, Liu, D, Gao, B, Liu, Y
Medicine. 2016;(37):e4783
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Preventive care service is considered pivotal on the background of demographic ageing and a rise in chronic diseases in China. The disparity in utilization of preventive care services between urban and rural in China is a serious issue. In this paper, we explored factors associated with urban-rural disparity in utilization of preventive care services in China, and determined how much of the urban-rural disparity was attributable to each determinant of utilization in preventive care services. Using representative sample data from China Health and Nutrition Survey in 2011 (N = 12,976), the present study performed multilevel logistic model to examine the factors that affected utilization of preventive care services in last 4 weeks. Blinder-Oaxaca decomposition method was applied to divide the utilization of preventive care disparity between urban and rural residents into a part that can be explained by differences in observed covariates and unobserved part. The percentage of rural residents utilizing preventive care service in last 4 weeks was lower than that of urban residents (5.1% vs 9.3%). Female, the aged, residents with higher education level and household income, residents reporting self-perceived illness in last 4 weeks and physician-diagnosed chronic disease had higher likelihood of utilizing preventive care services. Household income was the most important factor accounting for 26.6% of urban-rural disparities in utilization of preventive care services, followed by education (21.5%), self-perceived illness in last 4 weeks (7.8%), hypertension (4.4%), diabetes (3.3%), other chronic diseases (0.8%), and health insurance (-1.0%). Efforts to reduce financial barriers for low-income individuals who cannot afford preventive services, increasing awareness of the importance of obtaining preventive health services and providing more preventive health services covered by health insurance, may help to reduce the gap of preventive care services utilization between urban and rural.
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The challenge of cardiovascular prevention in primary care: implications of a European observational study in 8928 patients at different risk levels.
Ludt, S, Wensing, M, Campbell, SM, Ose, D, van Lieshout, J, Rochon, J, Uhlmann, L, Szecsenyi, J
European journal of preventive cardiology. 2014;(2):203-13
Abstract
BACKGROUND Cardiovascular prevention can be provided to patients at different risk levels. The aim of this study was to compare the quality of cardiovascular prevention provided in European primary care between patients with diagnosed coronary heart disease (CHD) and individuals at high risk due to known risk factors but not labelled with a diagnosis of cardiovascular disease (CVD). Additionally, we aimed to identify individual and practice factors to predict risk factor control. METHODS An international cross-sectional study was conducted in 10 European countries. Clinical record data were abstracted for quality indicators for 8928 patients in 10 countries and patient questionnaires were completed by 7846 patients in nine countries. Information about 320 general practices was assessed using practice questionnaires and interviews. Hierarchical multilevel modelling was used for analyses. RESULTS Recording of risk factors and advice was higher in the CHD than in the high-risk group. Risk factor control was better in the CHD group: uncontrolled levels of blood pressure (34.2 vs. 49.3%; p < 0.001), cholesterol (32.4 vs. 64.5%; p < 0.001). Predictors of risk factor control were medication adherence (RR 0.97; p = 0.007) and health-related quality of life (RR 0.86; p = 0.005). Being at high risk (RR 1.42; p < 0.001), being single (RR 1.12; p < 0.001), and having lower educational level (RR 1.09; p < 0.001) were associated with poorer risk factor control. Practice factors were not associated with outcomes. CONCLUSIONS Strategies to improve guidelines adherence in cardiovascular prevention may be stronger focused on individuals at risk before CVD is diagnosed and require organizational and political support to reinforce general practices.