Background:
Trends in cardiovascular disparities are poorly understood, even as diversity increases in the United States.
Objective:
To examine U.S. trends in racial/ethnic and nativity disparities in cardiovascular health.
Design:
Repeated cross-sectional study.
Setting:
NHANES (National Health and Nutrition Examination Survey), 1988 to 2014.
Participants:
Adults aged 25 years or older who did not report cardiovascular disease.
Measurements:
Racial/ethnic, nativity, and period differences in Life's Simple 7 (LS7) health factors and behaviors (blood pressure, cholesterol, hemoglobin A1c, body mass index, physical activity, diet, and smoking) and optimal composite scores for cardiovascular health (LS7 score ≥10).
Results:
Rates of optimal cardiovascular health remain below 40% among whites, 25% among Mexican Americans, and 15% among African Americans. Disparities in optimal cardiovascular health between whites and African Americans persisted but decreased over time. In 1988 to 1994, the percentage of African Americans with optimal LS7 scores was 22.8 percentage points (95% CI, 19.3 to 26.4 percentage points) lower than that of whites in persons aged 25 to 44 years and 8.0 percentage points (CI, 6.4 to 9.7 percentage points) lower in those aged 65 years or older. By 2011 to 2014, differences decreased to 10.6 percentage points (CI, 7.4 to 13.9 percentage points) and 3.8 percentage points (CI, 2.5 to 5.0 percentage points), respectively. Disparities in optimal LS7 scores between whites and Mexican Americans were smaller but also decreased. These decreases were due to reductions in optimal cardiovascular health among whites over all age groups and periods: Between 1988 to 1994 and 2011 to 2014, the percentage of whites with optimal cardiovascular health decreased 15.3 percentage points (CI, 11.1 to 19.4 percentage points) for those aged 25 to 44 years and 4.6 percentage points (CI, 2.7 to 6.5 percentage points) for those aged 65 years or older.
Limitation:
Only whites, African Americans, and Mexican Americans were studied.
Conclusion:
Cardiovascular health has declined in the United States, racial/ethnic and nativity disparities persist, and decreased disparities seem to be due to worsening cardiovascular health among whites rather than gains among African Americans and Mexican Americans. Multifaceted interventions are needed to address declining population health and persistent health disparities.
Primary Funding Source:
National Institute of Neurological Disorders and Stroke and National Center for Advancing Translational Sciences of the National Institutes of Health.
References
- 1.
Mozaffarian D ,Benjamin EJ ,Go AS ,Arnett DK ,Blaha MJ ,Cushman M ,et al ;Writing Group Members . Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133:e38-360. [PMID:26673558 ] doi:10.1161/CIR.0000000000000350 CrossrefMedlineGoogle Scholar - 2.
Rodriguez CJ ,Allison M ,Daviglus ML ,Isasi CR ,Keller C ,Leira EC ,et al ;American Heart Association Council on Epidemiology and Prevention . Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association. Circulation. 2014;130:593-625. [PMID:25098323 ] doi:10.1161/CIR.0000000000000071 CrossrefMedlineGoogle Scholar - 3.
Daviglus ML ,Talavera GA ,Avilés-Santa ML ,Allison M ,Cai J ,Criqui MH ,et al . Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States. JAMA. 2012;308:1775-84. [PMID:23117778 ] doi:10.1001/jama.2012.14517 CrossrefMedlineGoogle Scholar - 4.
Heidenreich PA ,Trogdon JG ,Khavjou OA ,Butler J ,Dracup K ,Ezekowitz MD ,et al ;American Heart Association Advocacy Coordinating Committee . Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123:933-44. [PMID:21262990 ] doi:10.1161/CIR.0b013e31820a55f5 CrossrefMedlineGoogle Scholar - 5.
LaVeist TA ,Gaskin D ,Richard P . Estimating the economic burden of racial health inequalities in the United States. Int J Health Serv. 2011;41:231-8. [PMID:21563622 ] CrossrefMedlineGoogle Scholar - 6.
Lloyd-Jones DM ,Hong Y ,Labarthe D ,Mozaffarian D ,Appel LJ ,Van Horn L ,et al ;American Heart Association Strategic Planning Task Force and Statistics Committee . Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation. 2010;121:586-613. [PMID:20089546 ] doi:10.1161/CIRCULATIONAHA.109.192703 CrossrefMedlineGoogle Scholar - 7.
Ford ES ,Greenlund KJ ,Hong Y . Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States. Circulation. 2012;125:987-95. [PMID:22291126 ] doi:10.1161/CIRCULATIONAHA.111.049122 CrossrefMedlineGoogle Scholar - 8.
Folsom AR ,Yatsuya H ,Nettleton JA ,Lutsey PL ,Cushman M ,Rosamond WD ;ARIC Study Investigators . Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol. 2011;57:1690-6. [PMID:21492767 ] doi:10.1016/j.jacc.2010.11.041 CrossrefMedlineGoogle Scholar - 9.
Dong C ,Rundek T ,Wright CB ,Anwar Z ,Elkind MS ,Sacco RL . Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and Hispanics: the northern Manhattan study. Circulation. 2012;125:2975-84. [PMID:22619283 ] doi:10.1161/CIRCULATIONAHA.111.081083 CrossrefMedlineGoogle Scholar - 10.
Kulshreshtha A ,Vaccarino V ,Judd SE ,Howard VJ ,McClellan WM ,Muntner P ,et al . Life's Simple 7 and risk of incident stroke: the reasons for geographic and racial differences in stroke study. Stroke. 2013;44:1909-14. [PMID:23743971 ] doi:10.1161/STROKEAHA.111.000352 CrossrefMedlineGoogle Scholar - 11.
Folsom AR ,Shah AM ,Lutsey PL ,Roetker NS ,Alonso A ,Avery CL ,et al . American Heart Association's Life's Simple 7: avoiding heart failure and preserving cardiac structure and function. Am J Med. 2015;128:970-6. [PMID:25908393 ] doi:10.1016/j.amjmed.2015.03.027 CrossrefMedlineGoogle Scholar - 12.
Fretts AM ,Howard BV ,McKnight B ,Duncan GE ,Beresford SA ,Mete M ,et al . Life's Simple 7 and incidence of diabetes among American Indians: the Strong Heart Family Study. Diabetes Care. 2014;37:2240-5. [PMID:24804696 ] doi:10.2337/dc13-2267 CrossrefMedlineGoogle Scholar - 13.
Thacker EL ,Gillett SR ,Wadley VG ,Unverzagt FW ,Judd SE ,McClure LA ,et al . The American Heart Association Life's Simple 7 and incident cognitive impairment: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. J Am Heart Assoc. 2014;3:e000635. [PMID:24919926 ] doi:10.1161/JAHA.113.000635 CrossrefMedlineGoogle Scholar - 14.
Kronish IM ,Carson AP ,Davidson KW ,Muntner P ,Safford MM . Depressive symptoms and cardiovascular health by the American Heart Association's definition in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. PLoS One. 2012;7:e52771. [PMID:23300767 ] doi:10.1371/journal.pone.0052771 CrossrefMedlineGoogle Scholar - 15.
Muntner P ,Judd SE ,Gao L ,Gutiérrez OM ,Rizk DV ,McClellan W ,et al . Cardiovascular risk factors in CKD associate with both ESRD and mortality. J Am Soc Nephrol. 2013;24:1159-65. [PMID:23704285 ] doi:10.1681/ASN.2012070642 CrossrefMedlineGoogle Scholar - 16.
Institute of Medicine . Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Pr; 2003. Google Scholar - 17.
Koh HK . A 2020 vision for healthy people. N Engl J Med. 2010;362:1653-6. [PMID:20445177 ] doi:10.1056/NEJMp1001601 CrossrefMedlineGoogle Scholar - 18.
Djoussé L ,Petrone AB ,Blackshear C ,Griswold M ,Harman JL ,Clark CR ,et al . Prevalence and changes over time of ideal cardiovascular health metrics among African-Americans: the Jackson Heart Study. Prev Med. 2015;74:111-6. [PMID:25712326 ] doi:10.1016/j.ypmed.2015.02.006 CrossrefMedlineGoogle Scholar - 19.
Colby SL ,Ortman JM . Projections of the Size and Composition of the U.S. Population: 2014 to 2060 Current Population Reports. Washington, DC: U.S. Census Bureau; 2015. Google Scholar - 20.
Daviglus ML ,Pirzada A ,Talavera GA . Cardiovascular disease risk factors in the Hispanic/Latino population: lessons from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Prog Cardiovasc Dis. 2014;57:230-6. [PMID:25242694 ] doi:10.1016/j.pcad.2014.07.006 CrossrefMedlineGoogle Scholar - 21. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey: survey methods and analytic guidelines. 2018. Accessed at wwwn.cdc.gov/nchs/nhanes/analyticguidelines.aspx on 21 February 2018. Google Scholar
- 22. Centers for Disease Control and Prevention. Analytic note regarding 2007-2010 survey design changes and combining data across other survey cycles. 2011. Accessed at www.cdc.gov/nchs/data/nhanes/analyticnote_2007-2010.pdf on 1 September 2017. Google Scholar
- 23.
Selvin E ,Parrinello CM ,Sacks DB ,Coresh J . Trends in prevalence and control of diabetes in the United States, 1988-1994 and 1999-2010. Ann Intern Med. 2014;160:517-25. [PMID:24733192 ]. doi:10.7326/M13-2411 LinkGoogle Scholar - 24.
Caleyachetty R ,Echouffo-Tcheugui JB ,Muennig P ,Zhu W ,Muntner P ,Shimbo D . Association between cumulative social risk and ideal cardiovascular health in US adults: NHANES 1999-2006. Int J Cardiol. 2015;191:296-300. [PMID:25984898 ] doi:10.1016/j.ijcard.2015.05.007 CrossrefMedlineGoogle Scholar - 25.
Yang Q ,Cogswell ME ,Flanders WD ,Hong Y ,Zhang Z ,Loustalot F ,et al . Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA. 2012;307:1273-83. [PMID:22427615 ] doi:10.1001/jama.2012.339 CrossrefMedlineGoogle Scholar - 26.
Ogunmoroti O ,Oni E ,Michos ED ,Spatz ES ,Allen NB ,Rana JS ,et al . Life's Simple 7 and incident heart failure: the Multi-Ethnic Study of Atherosclerosis. J Am Heart Assoc. 2017;6. [PMID:28655734 ] doi:10.1161/JAHA.116.005180 CrossrefMedlineGoogle Scholar - 27. Centers for Disease Control and Prevention. Third National Health and Nutrition Examination Survey (NHANES III), 1988–1994: NHANES houshold adult data file documentation. December 1996. Accessed at wwwn.cdc.gov/nchs/data/nhanes3/1a/ADULT-acc.pdf on 1 December 2017. Google Scholar
- 28.
Berglund P ,Heeringa S . Multiple Imputation of Missing Data Using SAS. Cary, NC: SAS Institute; 2014. Google Scholar - 29.
Kolenikov S . Resampling variance estimation for complex survey data. Stata J. 2010;10:165-99. CrossrefGoogle Scholar - 30.
Flegal KM ,Kruszon-Moran D ,Carroll MD ,Fryar CD ,Ogden CL . Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315:2284-91. [PMID:27272580 ] doi:10.1001/jama.2016.6458 CrossrefMedlineGoogle Scholar - 31.
Fryar CD ,Chen TC ,Li X . Prevalence of uncontrolled risk factors for cardiovascular disease: United States, 1999-2010. NCHS Data Brief. 2012:1-8. [PMID:23101933 ] MedlineGoogle Scholar - 32.
Gregg EW ,Cheng YJ ,Cadwell BL ,Imperatore G ,Williams DE ,Flegal KM ,et al . Secular trends in cardiovascular disease risk factors according to body mass index in US adults. JAMA. 2005;293:1868-74. [PMID:15840861 ] CrossrefMedlineGoogle Scholar - 33.
Guo F ,Garvey WT . Trends in cardiovascular health metrics in obese adults: National Health and Nutrition Examination Survey (NHANES), 1988-2014. J Am Heart Assoc. 2016;5. [PMID:27413039 ] doi:10.1161/JAHA.116.003619 CrossrefMedlineGoogle Scholar - 34.
Ogden CL ,Carroll MD ,Kit BK ,Flegal KM . Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311:806-14. [PMID:24570244 ] doi:10.1001/jama.2014.732 CrossrefMedlineGoogle Scholar - 35.
Saydah S ,Bullard KM ,Cheng Y ,Ali MK ,Gregg EW ,Geiss L ,et al . Trends in cardiovascular disease risk factors by obesity level in adults in the United States, NHANES 1999-2010. Obesity (Silver Spring). 2014;22:1888-95. [PMID:24733690 ] doi:10.1002/oby.20761 CrossrefMedlineGoogle Scholar - 36.
Menke A ,Casagrande S ,Geiss L ,Cowie CC . Prevalence of and trends in diabetes among adults in the United States, 1988-2012. JAMA. 2015;314:1021-9. [PMID:26348752 ] doi:10.1001/jama.2015.10029 CrossrefMedlineGoogle Scholar - 37.
Crimmins EM ,Kim JK ,Alley DE ,Karlamangla A ,Seeman T . Hispanic paradox in biological risk profiles. Am J Public Health. 2007;97:1305-10. [PMID:17538054 ] CrossrefMedlineGoogle Scholar - 38.
Kanjilal S ,Gregg EW ,Cheng YJ ,Zhang P ,Nelson DE ,Mensah G ,et al . Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971-2002. Arch Intern Med. 2006;166:2348-55. [PMID:17130388 ] CrossrefMedlineGoogle Scholar - 39.
Kershaw KN ,Greenlund KJ ,Stamler J ,Shay CM ,Daviglus ML . Understanding ethnic and nativity-related differences in low cardiovascular risk status among Mexican-Americans and non-Hispanic Whites. Prev Med. 2012;55:597-602. [PMID:23036519 ] doi:10.1016/j.ypmed.2012.09.019 CrossrefMedlineGoogle Scholar - 40.
Case A ,Deaton A . Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015;112:15078-83. [PMID:26575631 ] doi:10.1073/pnas.1518393112 CrossrefMedlineGoogle Scholar - 41.
Lackland DT ,Roccella EJ ,Deutsch AF ,Fornage M ,George MG ,Howard G ,et al ;American Heart Association Stroke Council . Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke. 2014;45:315-53. [PMID:24309587 ] doi:10.1161/01.str.0000437068.30550.cf CrossrefMedlineGoogle Scholar - 42.
Pearson-Stuttard J ,Guzman-Castillo M ,Penalvo JL ,Rehm CD ,Afshin A ,Danaei G ,et al . Modeling future cardiovascular disease mortality in the United States: national trends and racial and ethnic disparities. Circulation. 2016;133:967-78. [PMID:26846769 ] doi:10.1161/CIRCULATIONAHA.115.019904 CrossrefMedlineGoogle Scholar - 43.
Kurian AK ,Cardarelli KM . Racial and ethnic differences in cardiovascular disease risk factors: a systematic review. Ethn Dis. 2007;17:143-52. [PMID:17274224 ] MedlineGoogle Scholar - 44.
Mensah GA . Eliminating disparities in cardiovascular health: six strategic imperatives and a framework for action. Circulation. 2005;111:1332-6. [PMID:15769777 ] CrossrefMedlineGoogle Scholar - 45.
Sacco RL ,Boden-Albala B ,Abel G ,Lin IF ,Elkind M ,Hauser WA ,et al . Race-ethnic disparities in the impact of stroke risk factors: the northern Manhattan stroke study. Stroke. 2001;32:1725-31. [PMID:11486097 ] CrossrefMedlineGoogle Scholar - 46.
Sharma S ,Malarcher AM ,Giles WH ,Myers G . Racial, ethnic and socioeconomic disparities in the clustering of cardiovascular disease risk factors. Ethn Dis. 2004;14:43-8. [PMID:15002922 ] MedlineGoogle Scholar - 47.
Gonzalez-Barrera A . More Mexicans Leaving Than Coming to the US. Washington, DC: Pew Research Center; 2005. Google Scholar - 48.
Dominguez K ,Penman-Aguilar A ,Chang MH ,Moonesinghe R ,Castellanos T ,Rodriguez-Lainz A ,et al ;Centers for Disease Control and Prevention (CDC) . Vital signs: leading causes of death, prevalence of diseases and risk factors, and use of health services among Hispanics in the United States—2009-2013. MMWR Morb Mortal Wkly Rep. 2015;64:469-78. [PMID:25950254 ] MedlineGoogle Scholar - 49.
Aadahl M ,Jørgensen T . Validation of a new self-report instrument for measuring physical activity. Med Sci Sports Exerc. 2003;35:1196-202. [PMID:12840642 ] CrossrefMedlineGoogle Scholar - 50.
Rauh MJ ,Hovell MF ,Hofstetter CR ,Sallis JF ,Gleghorn A . Reliability and validity of self-reported physical activity in Latinos. Int J Epidemiol. 1992;21:966-71. [PMID:1468861 ] CrossrefMedlineGoogle Scholar - 51.
Sallis JF ,Saelens BE . Assessment of physical activity by self-report: status, limitations, and future directions. Res Q Exerc Sport. 2000;71:S1-14. [PMID:10925819 ] CrossrefMedlineGoogle Scholar - 52.
Murillo R ,Albrecht SS ,Daviglus ML ,Kershaw KN . The role of physical activity and sedentary behaviors in explaining the association between acculturation and obesity among Mexican-American adults. Am J Health Promot. 2015;30:50-7. [PMID:25162320 ] doi:10.4278/ajhp.140128-QUAN-49 CrossrefMedlineGoogle Scholar - 53.
Gutiérrez-Fisac JL ,Guallar-Castillón P ,Díez-Gañán L ,LópezGarcía E ,Banegas Banegas JR ,Rodríguez Artalejo F . Work-related physical activity is not associated with body mass index and obesity. Obes Res. 2002;10:270-6. [PMID:11943836 ] CrossrefMedlineGoogle Scholar - 54.
He XZ ,Baker DW . Body mass index, physical activity, and the risk of decline in overall health and physical functioning in late middle age. Am J Public Health. 2004;94:1567-73. [PMID:15333316 ] CrossrefMedlineGoogle Scholar - 55.
Koenig W ,Sund M ,Döring A ,Ernst E . Leisure-time physical activity but not work-related physical activity is associated with decreased plasma viscosity. Results from a large population sample. Circulation. 1997;95:335-41. [PMID:9008446 ] CrossrefMedlineGoogle Scholar - 56.
Kershaw KN ,Giacinto RE ,Gonzalez F ,Isasi CR ,Salgado H ,Stamler J ,et al . Relationships of nativity and length of residence in the U.S. with favorable cardiovascular health among Hispanics/Latinos: the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Prev Med. 2016;89:84-9. [PMID:27196144 ] doi:10.1016/j.ypmed.2016.05.013 CrossrefMedlineGoogle Scholar - 57.
Shay CM ,Gooding HS ,Murillo R ,Foraker R . Understanding and improving cardiovascular health: an update on the American Heart Association's concept of cardiovascular health. Prog Cardiovasc Dis. 2015;58:41-9. [PMID:25958016 ] doi:10.1016/j.pcad.2015.05.003 CrossrefMedlineGoogle Scholar - 58.
Bartolome RE ,Chen A ,Handler J ,Platt ST ,Gould B . Population care management and team-based approach to reduce racial disparities among African Americans/blacks with hypertension. Perm J. 2016;20:53-9. [PMID:26824963 ] doi:10.7812/TPP/15-052 CrossrefMedlineGoogle Scholar - 59.
Jaffe MG ,Lee GA ,Young JD ,Sidney S ,Go AS . Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310:699-705. [PMID:23989679 ] doi:10.1001/jama.2013.108769 CrossrefMedlineGoogle Scholar - 60.
Krueger PM ,Reither EN . Mind the gap: race/ethnic and socioeconomic disparities in obesity. Curr Diab Rep. 2015;15:95. [PMID:26377742 ] doi:10.1007/s11892-015-0666-6 CrossrefMedlineGoogle Scholar - 61.
Sequist TD ,Taveras EM . Clinic-community linkages for high-value care. N Engl J Med. 2014;371:2148-50. [PMID:25470692 ] doi:10.1056/NEJMp1408457 CrossrefMedlineGoogle Scholar - 62.
Galea S ,Riddle M ,Kaplan GA . Causal thinking and complex system approaches in epidemiology. Int J Epidemiol. 2010;39:97-106. [PMID:19820105 ] doi:10.1093/ije/dyp296 CrossrefMedlineGoogle Scholar - 63.
Cohen MG ,Fonarow GC ,Peterson ED ,Moscucci M ,Dai D ,Hernandez AF ,et al . Racial and ethnic differences in the treatment of acute myocardial infarction: findings from the Get With the Guidelines–Coronary Artery Disease program. Circulation. 2010;121:2294-301. [PMID:20479153 ] doi:10.1161/CIRCULATIONAHA.109.922286 CrossrefMedlineGoogle Scholar - 64.
Ellrodt AG ,Fonarow GC ,Schwamm LH ,Albert N ,Bhatt DL ,Cannon CP ,et al . Synthesizing lessons learned from get with the guidelines: the value of disease-based registries in improving quality and outcomes. Circulation. 2013;128:2447-60. [PMID:24166574 ] doi:10.1161/01.cir.0000435779.48007.5c CrossrefMedlineGoogle Scholar - 65.
Ford ES ,Ajani UA ,Croft JB ,Critchley JA ,Labarthe DR ,Kottke TE ,et al . Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356:2388-98. [PMID:17554120 ] CrossrefMedlineGoogle Scholar - 66.
Kypridemos C ,Bandosz P ,Hickey GL ,Guzman-Castillo M ,Allen K ,Buchan I ,et al . Quantifying the contribution of statins to the decline in population mean cholesterol by socioeconomic group in England 1991–2012: a modelling study. PLoS One. 2015;10:e0123112. [PMID:25856394 ] doi:10.1371/journal.pone.0123112 CrossrefMedlineGoogle Scholar - 67.
Centers for Disease Control and Prevention (CDC) . Federal and state cigarette excise taxes—United States, 1995-2009. MMWR Morb Mortal Wkly Rep. 2009;58:524-7. [PMID:19478719 ] MedlineGoogle Scholar - 68.
Centers for Disease Control and Prevention (CDC) . State smoke-free laws for worksites, restaurants, and bars—United States, 2000-2010. MMWR Morb Mortal Wkly Rep. 2011;60:472-5. [PMID:21508923 ] MedlineGoogle Scholar - 69. Kindig D. What are we talking about when we talk about population health? Health Affairs Blog. 2015. Accessed at http://healthaffairs.org/blog/2015/04/06/what-are-we-talking-about-when-we-talk-about-population-health on 3 April 2017. Google Scholar
- 70.
U.S. Department of Health and Human Services . Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the U.S. Department of Health and Human Services. Washington, DC: Office of the Assistant Secretary for Health; 2010. Google Scholar
Author, Article and Disclosure Information
University of California, Los Angeles, Los Angeles, California; Olive View-UCLA Medical Center (A.F.B.)
University of California, Los Angeles, Los Angeles, California (L.L., S.D.V., J.J.E., S.S.M., E.C., A.R., T.S.)
University of Washington, Seattle, Washington (W.L.)
Financial Support: By award U54NS081764 from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health and grant UL1TR001881 from the National Center for Advancing Translational Sciences of the National Institutes of Health to the University of California, Los Angeles, Clinical and Translational Science Institute.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0996.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Brown (e-mail, [email protected]
Corresponding Author: Arleen F. Brown, MD, PhD, Professor, UCLA Department of Medicine, Division of General Internal Medicine and Health Services Research, Box 951736, 911 Broxton Avenue, Los Angeles, CA 90095; e-mail, [email protected]
Current Author Addresses: Drs. Brown, Liang, Escarce, and Richards and Ms. Vassar: UCLA Department of Medicine, Division of General Internal Medicine and Health Services Research, Box 951736, 911 Broxton Avenue, Los Angeles, CA 90095.
Drs. Merkin and Seeman: UCLA Department of Medicine, Division of Geriatrics, Box 951687, 2339 PVUB, Los Angeles, CA 90095.
Dr. Cheng: UCLA Neurology, Box 957250, Oppenheimer Tower, 10880 Wilshire Boulevard, Suite 700, Los Angeles, CA 90095.
Dr. Longstreth: Department of Neurology, Box 359775, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104.
Author Contributions: Conception and design: A.F. Brown, L.J. Liang, E. Cheng, A. Richards, W.T. Longstreth.
Analysis and interpretation of the data: A.F. Brown, L.J. Liang, S.D. Vassar, J.J. Escarce, S.S. Merkin, A. Richards, T. Seeman.
Drafting of the article: A.F. Brown, L.J. Liang, S.D. Vassar, J.J. Escarce.
Critical revision of the article for important intellectual content: A.F. Brown, L.J. Liang, S.D. Vassar, S.S. Merkin, E. Cheng, A. Richards, T. Seeman, W.T. Longstreth.
Final approval of the article: A.F. Brown, L.J. Liang, S.D. Vassar, J.J. Escarce, S.S. Merkin, E. Cheng, A. Richards, T. Seeman, W.T. Longstreth.
Statistical expertise: L.J. Liang.
Obtaining of funding: A.F. Brown, S.D. Vassar, J.J. Escarce.
Administrative, technical, or logistic support: S.D. Vassar.
Collection and assembly of data: A.F. Brown, S.D. Vassar.
This article was published at Annals.org on 20 March 2018.
Submit a Comment
Contributors must reveal any conflict of interest. Comments are moderated. Please see our information for authorsregarding comments on an Annals publication.
*All comments submitted after October 1, 2021 and selected for publication will be published online only.