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Background: There are few national- and state-level data on multiple cardiovascular disease (CVD) risk factor status and trends over time. We examined the prevalence of self-reported multiple CVD risk factors from 1991 through 1999. Methods: The Behavioral Risk Factor Surveillance System is a state-based telephone survey of adults 18 years or older. Surveys in 1991, 1993, 1995, 1997, and 1999 ascertained reported high blood pressure, high blood cholesterol level, diabetes, obesity, and current smoking status. Trends in the prevalence of persons with each risk factor and of having 2 or more risk factors were calculated. Data were age standardized to the 2000 US population. Results: From 1991 to 1999, the prevalence of reported high blood pressure increased from 23.8% to 25.4%, high cholesterol levels increased from 24.9% to 27.7%, diabetes increased from 5.5% to 7.1%, obesity increased from 13.5% to 20.3%, and smoking remained at approximately 21%. The prevalence of adults with 2 or more risk factors increased from 23.6% in 1991 to 27.9% in 1999 and significantly increased for both men and women and for all race or ethnic, age, and education groups. Among states, the prevalence of multiple risk factors ranged from 15.0% to 29.9% in 1991 and from 18.7% to 37.1% in 1999. From 1991 to 1999, the prevalence of multiple risk factors increased by 10% or more in 36 states. Conclusions: The substantial proportion of persons with known multiple risk factors (25% of the population) suggests that increased CVD prevention and risk factor reduction efforts should focus on comprehensive risk reduction strategies. [ABSTRACT FROM AUTHOR]

Background: Excess body weight (EBW), which continues to become more prevalent, is a clear contributor to cardiovascular disease (CVD), the leading cause of death and disability among U.S. adults. Information on the economic impact of CVD associated with EBW is lacking, however.Objective: To estimate the direct medical costs of CVD associated with EBW.Methods: We conducted a population-based analysis of direct medical costs by linking the 1995 National Health Interview Survey and the 1996 Medical Expenditure Panel Survey. The study subjects are adults (aged > or =25 years, excluding pregnant women) in the non-institutionalized, civilian population in 1996.Results: The prevalence of CVD among people in the normal weight (body mass index [BMI] > or =18.5 to <25), overweight (BMI > or =25 to <30), and obese (BMI > or =30) groups was 20%, 28%, and 39%, respectively. There were 12.95 million CVD cases among overweight people, more than 25% of which was associated with overweight. There were 9.3 million CVD cases among obese people, of which more than 45% was associated with obesity. This extra disease burden led to $22.17 billion in direct medical costs in 1996 ($31 billion in 2001 dollars, 17% of the total direct medical cost of treating CVD).Conclusions: The strong positive association between EBW and CVD, and the significant economic impact of EBW-associated CVD demonstrate the need to prevent EBW among U.S. adults. [ABSTRACT FROM AUTHOR]

: BackgroundA Healthy People 2010 objective includes increasing public awareness of the warning signs of stroke, yet few data exist about the level of awareness. Recognition of stroke symptoms and awareness of the need to call 911 for acute stroke events were examined among the general population.: MethodsData are from 61,019 adults participating in the 2001 Behavioral Risk Factor Surveillance System, a state-based telephone survey. Respondents indicated whether the following were symptoms of stroke: confusion/trouble speaking; numbness/weakness of face, arm, or leg; trouble seeing; chest pain (false symptom); trouble walking, dizziness, or loss of balance; and severe headache with no known cause. Persons also reported the first action they would take if they thought someone was having a stroke.: ResultsOnly 17.2% of respondents overall (5.9% to 21.7% by state) correctly classified all stroke symptoms and indicated that they would call 911 if they thought someone was having a stroke. Recognition of all symptoms and knowledge of when to call 911 were comparable by gender but lower among ethnic minorities, younger and older people, those with less education, and current smokers compared to whites, middle-aged people, those with more education, and nonsmokers, respectively. There were no substantive differences by history of hypertension, diabetes, heart disease, or stroke.: ConclusionsPublic recognition of major stroke symptoms is low. Educational campaigns to increase awareness among the general population and targeted messages to those at high-risk persons and their families may help to improve time to treatment for adults suffering acute strokes. [Copyright &y& Elsevier]

We sought to determine the annual incidence of sudden cardiac death (SCD) in the general population using a prospective approach. To assess the validity of retrospective surveillance, a simultaneous comparison was made with a death certificate-based method of determining SCD incidence.Accurate surveillance and characterization of SCD in the general population is likely to significantly facilitate current and future community-based preventive and therapeutic interventions.We performed a prospective evaluation of SCD among all residents of Multnomah County, Oregon (population 660,486) using multiple sources of surveillance. A comprehensive analysis of circumstances of death, medical records, and available autopsy data was performed. Comparisons were made with a retrospective, death certificate-based determination of SCD incidence using International Classification of Diseases-Version 10 codes and location of death.Between February 1, 2002, and January 31, 2003, 353 residents suffered SCD (incidence 53 of 100,000; median age 69 years, 57% male) accounting for 5.6% of overall mortality. Of these, 75 cases (21%) were identified using sources other than first responders. Resuscitation was attempted in 237 cases (67%) and successful (survival to hospital discharge) in 28 (8%). The retrospective death certificate-based review yielded 1,007 cases (incidence 153 of 100,000; median age 81 years, 51% male), and the positive predictive value of this methodology was 19%.Sudden cardiac death accounts for 5.6% of annual mortality, and prospective evaluation in the general population appears to be feasible. The use of multiple sources of ascertainment and information significantly enhances phenotyping of SCD cases. Retrospective death certificate-based surveillance results in significant overestimation of SCD incidence. [Copyright &y& Elsevier]

Background: This study investigated socioeconomic inequalities in premature cancer mortality by cancer types, and evaluated the associations between socioeconomic status (SES) and premature cancer mortality by cancer types., Methods: Using multiple databases, cancer mortality was linked to SES and other county characteristics. The outcome measure was cancer mortality among adults ages 25-64 years in 3,028 U.S. counties, from 1999 to 2018. Socioeconomic inequalities in mortality were calculated as a concentration index (CI) by income (annual median household income), educational attainment (% with bachelor's degree or higher), and unemployment rate. A hierarchical linear mixed model and dominance analyses were used to investigate SES associated with county-level mortality. The analyses were also conducted by cancer types., Results: CIs of SES factors varied by cancer types. Low-SES counties showed increasing trends in mortality, while high-SES counties showed decreasing trends. Socioeconomic inequalities in mortality among high-SES counties were larger than those among low-SES counties. SES explained 25.73% of the mortality. County-level cancer mortality was associated with income, educational attainment, and unemployment rate, at -0.24 [95% (CI): -0.36 to -0.12], -0.68 (95% CI: -0.87 to -0.50), and 1.50 (95% CI: 0.92-2.07) deaths per 100,000 population with one-unit SES factors increase, respectively, after controlling for health care environment and population health., Conclusions: SES acts as a key driver of premature cancer mortality, and socioeconomic inequalities differ by cancer types., Impact: Focused efforts that target socioeconomic drivers of mortalities and inequalities are warranted for designing cancer-prevention implementation strategies and control programs and policies for socioeconomically underprivileged groups., (©2021 American Association for Cancer Research.)

Importance: Identifying the factors associated with premature stroke mortality and measuring between-county disparities may provide insight into how to reduce variations and achieve more equitable health outcomes., Objective: To examine the between-county disparities in premature stroke mortality in the US, investigate county-level factors associated with mortality, and describe differences in mortality disparities by place of death and stroke subtype., Design, Setting, and Participants: This retrospective cross-sectional study linked the mortality and demographic data of US counties from the Centers for Disease Control and Prevention WONDER database to county-level characteristics from multiple databases. The outcome measure was county-level age-adjusted stroke mortality among adults aged 25 to 64 years in 2637 US counties from 1999 to 2018. This study was conducted from April 1, 2019, to October 31, 2020. Generalized linear Poisson regressions were fitted to investigate 4 sets of factors associated with county-level mortality: demographic composition, socioeconomic status, health care and environmental features, and population health. The Theil index score was calculated to assess the mortality disparities., Main Outcomes and Measures: Stroke mortality was measured as the number of deaths attributed to stroke in the data set. Out-of-stroke-unit death was defined as any death occurring in outpatient or emergency departments or at the pretransport location. Five stroke subtypes were included in the analysis., Results: Although mortality did not change substantially from 1999 to 2018 (from 12.62 to 11.81 per 100 000 population), the proportion of deaths occurring out of the stroke unit increased from 23.56% (4328 of 18 369) to 34.57% (6978 of 20 188). A large percentage of stroke of an uncertain cause was reported, with most deaths (55.20%) occurring out of the stroke unit. In the county with the highest premature stroke mortality, the incidence was 20.78 times as high as that in the county with the lowest mortality (65.04 vs 3.13 deaths per 100 000 population). The highest between-county disparities were found for stroke of uncertain cause. For out-of-stroke-unit death, county-level mortality was largely associated with demographic composition (31.6%) and health care and environmental features (25.8%). For in-hospital death, 29.8% of county-level mortality was associated with population health and 28.7% was associated with demographic composition., Conclusions and Relevance: These findings suggest that strategies addressing specific factors that underlie the mortality disparities among US counties, especially for out-of-stroke-unit death and stroke of uncertain cause, may be useful when tailored to the county-level context before implementing interventions for the neediest counties.

Background & Aims: We studied incidence and mortality trends of colorectal cancer (CRC) in 39 countries according to age, sex, and anatomic location (colon vs rectum)., Methods: We retrieved incidence data from registries from 36 countries. The registries included the following: Cancer Incidence in 5 Continents volumes I to XI; the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute; and the Nordic Cancer Registries from Europe. We obtained mortality data from 39 countries of the World Health Organization database. We evaluated average annual percentage changes in CRC incidence and mortality in the past decade using joinpoint regression analysis., Results: From 2007 to 2016, 2006 to 2015, or 2005 to 2014, depending on the availability of the data, the incidence of colon cancer increased in 10 of 36 countries analyzed (all in Asia or Europe); India had the greatest increase, followed by Poland. All 10 of these countries have medium to high Human Development Index (HDI) scores. Six countries had a decrease in colon cancer incidence; these countries had the highest HDI scores; the United States had the greatest decrease, followed by Israel. Seven countries (including all countries from Northern America) had a decrease in incidence among persons older than 50 years. Eight countries had an increase in colon cancer incidence among persons younger than 50 years, including the United Kingdom and India. Countries with a decreased or stable incidence among persons 50 years or older but a significant increase in persons younger than 50 years, included Germany, Australia, the United States, Sweden, Canada, and the United Kingdom. Only Italy had a decrease in CRC incidence among persons younger than 50 years. Among women, 12 of 36 countries (all from Asia and Europe) had an increase in colon cancer incidence and 7 countries had a decrease; India had the greatest increase followed by Slovenia. Five of 36 countries had an increase in incidence of rectal cancer and 8 countries had a decrease; Ecuador and Thailand had the greatest increases in incidence. The incidence of rectal cancer among persons younger than 50 years increased significantly in Finland, Australia, Canada, the United States, and The Netherlands. Four countries had an increase in the incidence of rectal cancer in women; Ecuador had the greatest increase followed by Thailand. The incidence of rectal cancer in women decreased in 8 countries. Among women younger than 50 years, rectal cancer incidence increased, despite a decrease in women older than 50 years, in Costa Rica, Slovenia, Japan, Slovakia, Canada, and the United States there was an increase in incidence, although their elder population had a stable or decreased incidence. Twenty-four countries reported a reduction in CRC mortality, including North America, Oceania, and most European countries. Nevertheless, some countries from Asia, Latin America, and Southern Europe had significant increases in CRC mortality., Conclusions: In an analysis of incidence and mortality databases from 39 countries, we found that the incidence of colon and rectal cancers has continued to increase in countries with medium to high HDI and in younger populations. Preventive strategies are needed for countries with increasing CRC and rectal cancer incidence and mortality., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background Disparities in premature cardiac death (PCD) might stagnate the progress toward the reduction of PCD in the United States and worldwide. We estimated disparities across US counties in PCD rates and investigated county-level factors related to the disparities. Methods and Results We used US mortality data for cause-of-death and demographic data from death certificates and county-level characteristics data from multiple databases. PCD was defined as any death that occurred at an age between 35 and 74 years with an underlying cause of death caused by cardiac disease based on International Classification of Diseases, Tenth Revision ( ICD-10 ), codes. Of the 1 598 173 PCDs that occurred during 1999-2017, 60.9% were out of hospital. Although the PCD rates declined from 1999-2017, the proportion of out-of-hospital PCDs among all cardiac deaths increased from 58.3% to 61.5%. The geographic disparities in PCD rates across counties widened from 1999 (Theil index=0.10) to 2017 (Theil index=0.23), and within-state differences accounted for the majority of disparities (57.4% in 2017). The disparities in out-of-hospital PCD rates (and in-hospital PCD rates) associated with demographic composition were 36.51% (and 37.51%), socioeconomic features were 18.64% (and 18.36%), healthcare environment were 18.64% (and 13.90%), and population health status were 23.73% (and 30.23%). Conclusions Disparities in PCD rates exist across US counties, which may be related to the decelerated trend of decline in the rates among middle-aged adults. The slower declines in out-of-hospital rates warrants more precision targeting and sustained efforts to ensure progress at better levels of health (with lower PCD rates) against PCD.

Importance: Progress against premature death due to noncommunicable chronic disease (NCD) has stagnated. In the United States, county-level variation in NCD premature mortality has widened, which has impeded progress toward mortality reduction for the World Health Organization (WHO) 25 × 25 target., Objectives: To estimate variations in county-level NCD premature mortality, to investigate factors associated with mortality, and to present the progress toward achieving the WHO 25 × 25 target by analyzing the trends in mortality., Design, Setting, and Participants: This cross-sectional study focused on NCD premature mortality and its factors from 3109 counties using US mortality data for cause of death from the Centers for Disease Control and Prevention WONDER databases and county-level characteristics data from multiple databases. Data were collected from January 1, 1999, through December 31, 2017, and analyzed from April 1 through October 28, 2019., Exposures: County-level factors, including demographic composition, socioeconomic features, health care environment, and population health status., Main Outcomes and Measures: Variations in county-level, age-adjusted NCD mortality in the US residents aged 25 to 64 years and associations between mortality and the 4 sets of county-level factors., Results: A total of 6 794 434 deaths due to NCD were recorded during the study period (50.58% women; 16.49% aged 65 years or older). Mortality decreased by 4.30 (95% CI, -4.54 to -4.08) deaths per 100 000 person-years annually from 1999 to 2010 (P < .001) and decreased annually at a rate of 0.90 (95% CI, -1.13 to -0.73) deaths per 100 000 person-years annually from 2010 to 2017 (P < .001). Mortality in the county with the highest mortality was 10.40 times as high as that in the county with the lowest mortality (615.40 vs 59.20 per 100 000 population) in 2017. Geographic inequality was decomposed by between-state and within-state differences, and within-state differences accounted for most inequality (57.10% in 2017). County-level factors were associated with 71.83% variation in NCD mortality. Association with intercounty mortality was 19.51% for demographic features, 23.34% for socioeconomic composition, 16.40% for health care environment, and 40.75% for health-status characteristics., Conclusions and Relevance: Given the stagnated trend of decline and increasing variations in NCD premature mortality, these findings suggest that the WHO 25 × 25 target appears to be unattainable, which may be related to broad failure by United Nations members to follow through on commitments of reducing socioeconomic inequalities. The increasing inequalities in mortality are alarming and warrant expanded multisectoral efforts to ameliorate socioeconomic disparities.

Background: Measurement of the global burden of disease with disability-adjusted life-years (DALYs) requires disability weights that quantify health losses for all non-fatal consequences of disease and injury. There has been extensive debate about a range of conceptual and methodological issues concerning the definition and measurement of these weights. Our primary objective was a comprehensive re-estimation of disability weights for the Global Burden of Disease Study 2010 through a large-scale empirical investigation in which judgments about health losses associated with many causes of disease and injury were elicited from the general public in diverse communities through a new, standardised approach., Methods: We surveyed respondents in two ways: household surveys of adults aged 18 years or older (face-to-face interviews in Bangladesh, Indonesia, Peru, and Tanzania; telephone interviews in the USA) between Oct 28, 2009, and June 23, 2010; and an open-access web-based survey between July 26, 2010, and May 16, 2011. The surveys used paired comparison questions, in which respondents considered two hypothetical individuals with different, randomly selected health states and indicated which person they regarded as healthier. The web survey added questions about population health equivalence, which compared the overall health benefits of different life-saving or disease-prevention programmes. We analysed paired comparison responses with probit regression analysis on all 220 unique states in the study. We used results from the population health equivalence responses to anchor the results from the paired comparisons on the disability weight scale from 0 (implying no loss of health) to 1 (implying a health loss equivalent to death). Additionally, we compared new disability weights with those used in WHO's most recent update of the Global Burden of Disease Study for 2004., Findings: 13,902 individuals participated in household surveys and 16,328 in the web survey. Analysis of paired comparison responses indicated a high degree of consistency across surveys: correlations between individual survey results and results from analysis of the pooled dataset were 0·9 or higher in all surveys except in Bangladesh (r=0·75). Most of the 220 disability weights were located on the mild end of the severity scale, with 58 (26%) having weights below 0·05. Five (11%) states had weights below 0·01, such as mild anaemia, mild hearing or vision loss, and secondary infertility. The health states with the highest disability weights were acute schizophrenia (0·76) and severe multiple sclerosis (0·71). We identified a broad pattern of agreement between the old and new weights (r=0·70), particularly in the moderate-to-severe range. However, in the mild range below 0·2, many states had significantly lower weights in our study than previously., Interpretation: This study represents the most extensive empirical effort as yet to measure disability weights. By contrast with the popular hypothesis that disability assessments vary widely across samples with different cultural environments, we have reported strong evidence of highly consistent results., Funding: Bill & Melinda Gates Foundation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Context: Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality., Objective: To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI., Design, Setting, and Patients: Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men)., Main Outcome Measures: We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality., Results: The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P < .001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable adjusted age-specific odds ratios (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (P < .001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P < .001)., Conclusion: In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age.

Background: Coronary heart disease (CHD) affects 15.8 million Americans. However, data on the national impact of CHD on health-related quality of life, particularly among people of different age, sex, racial, and ethnic groups, are limited., Methods and Results: Using data from the 2000 and 2002 Medical Expenditure Panel Survey, we examined various measures of patient-reported health status, including health-related quality of life, in the CHD and non-CHD populations and differences in the measures among demographic subgroups. These measures included short-form generic measures (Short Form 12; Mental Component Summary-12 and Physical Component Summary-12) and EuroQol Group measures (EQ-5D index and EQ visual analog scale). Ordinary least-squares regressions were used to adjust for sociodemographic characteristics, risk factors, comorbidities, and proxy report. The adjusted difference between the CHD and non-CHD populations was -1.2 for Mental Component Summary-12 (2.4% of the score in the non-CHD population), -4.6 for Physical Component Summary-12 (9.2%), -0.04 for EQ-5D (4.6%), and -7.3 for EQ visual analog scale (9.0%) (all P<0.05). Differences among demographic subgroups were observed. Particularly, compared with whites, the differences between CHD and non-CHD in blacks were bigger in all measures except Physical Component Summary-12. A significantly bigger difference in Mental Component Summary-12 also was observed among Hispanics compared with non-Hispanics., Conclusions: CHD is associated with significant impairment of health-related quality of life and other patient-reported health status in the US adult population. Differences in the impairment associated with CHD exist across different age, racial, and ethnic groups. In addition to preventing CHD, effective public health interventions should be aimed at improving health-related quality of life and perceived health status in the CHD population, especially the most vulnerable groups.

Objective: Heart attacks are more prevalent among Hispanics and Blacks than among Whites. Bystanders must be able to recognize heart attack symptoms and activate the emergency response system in order to receive time-dependent therapies that increase survival. This study estimated racial/ethnic disparities in awareness of heart attack symptoms in a sample of the US population., Methods: We evaluated data from 33,059 adult participants in the 2001 National Health Interview Survey. Respondents indicated their awareness of five heart attack symptoms and the need to call 911 in the presence of such symptoms., Results: Hispanics and Blacks were less likely to recognize each heart attack symptom than were Whites (P<.05). Hispanics (25.6%), people aged 18-24 years (33.6%), men (39.1%), and those with less than a high school education (31.3%) were less likely to recognize all five heart attack symptoms and report that they would call 911 than were Whites (45.8%), Blacks (36.1%), respondents aged 45-64 years (47.7%) and >65 years (43.9%), and those with a high school education (41.0%) or more (45.6%). In multivariate logistic regression analyses, Blacks (OR .73, 95% CI .66-.80) and Hispanics (OR .49, 95% CI .45-.54) were less likely than were Whites to recognize all five heart attack symptoms and the need to call 911 if someone had these symptoms., Conclusions: One Healthy People 2010 goal is to eliminate health disparities. Racial/ethnic disparities exist in knowledge of heart attack symptoms and the need to call 911. Special educational efforts should focus on Black and Hispanic populations and highlight the importance of symptoms and time-dependent therapies.

This study aims to assess and compare the completeness and reliability of data collected by prospective and retrospective methods for the Paul Coverdell National Acute Stroke Registry. The prototypes consisted of eight states that used the same data elements but differed in their collection approach. Three prototypes employed retrospective case ascertainment (n=1218), and five prototypes used prospective or a combination of prospective and retrospective case ascertainment (n=1602). RTI International performed an audit analysis of the eight prototypes. Completeness, exact match, and discrepancy analyses were performed with data elements grouped into 12 categories for this analysis. A sample of 2820 (37.6%) from a total of 7494 records from 91 hospitals was studied. The "in-hospital complications" section had the highest percentage of completeness (99.6%), followed by "demographic data" (97.7%), and "in-hospital diagnostic procedures" (93.4%). The section with the lowest percentage of completeness was "thrombolytic treatment" (53.5%), followed by "reasons for nontreatment with thrombolytics" (57.1%), and "signs and symptoms onset" (63.5%). Across all prototype elements, exact matches with audit data ranged from 62.8% to 95.9%. Documentation of the date/time of stroke onset and of arrival in the emergency department had a high number of discrepancies with audit data, with exact match percentages of 69.7% and 64.5%, respectively. No significant difference was found between retrospective and prospective case ascertainment in completeness or matching with audit data. Combined retrospective and prospective data-collection approaches for different types of data elements may be best in terms of both completeness and accuracy.

Background and Purpose: Stroke is a major cause of long-term disability in the United States. This study examined the national impact of stroke on health-related quality of life (HRQoL) and disparities in HRQoL across different demographic groups., Methods: Combined 2000 and 2002 Medical Expenditure Panel Survey data were used, which include quality-of-life measures based on the short-form generic measures (SF-12) and the EuroQol Group measures (EQ-5D index and EQ VAS) for 39,680 adults aged >18 years. Stratified analysis and ordinary least square regressions were used to compare HRQoL scores between stroke and nonstroke populations., Results: The study included 1040 noninstitutionalized stroke survivors. After adjustment for sociodemographics, risk factors, and comorbidities, stroke survivors had statistically significantly lower mean scores for mental health (-4.1%), physical health (-7.9%), health utility (-6.9%), and self-rated health (-7.2%) (all P<0.01). In general, stroke did not affect differences in HRQoL among age or gender groups. However, racial and ethnic disparities in HRQoL were greater among stroke survivors than nonstroke individuals, particularly in health utility scores for black vs white participants (-0.06 in stroke survivors and -0.02 in the nonstroke population, P<0.01) and Hispanic versus non-Hispanic participants (-0.11 in stroke survivors and -0.01 in the nonstroke population)., Conclusions: Stroke significantly impairs HRQoL in the United States. The findings suggest that racial and ethnic disparities in HRQoL among stroke survivors are more pronounced than in the nonstroke population. The burden of nonfatal stroke, especially among racial and ethnic minorities, should be recognized more widely.

Background: Out-of-hospital cardiac death (OHCD), often occurring suddenly and unexpectedly, is a major public health problem. The purpose of this study is to assess the epidemiologic pattern and secular trend of OHCD in adolescents and young adults aged 15-34 years in the United States., Methods: United States national vital statistics mortality data from 1989 to 1998 were analyzed. OHCD was defined as death that occurred either at a pre-transport location, or in the emergency room, or was classified as "dead on arrival" in the emergency room, with an underlying cause of death as a cardiac disease (ICD-9 codes 390-398, 402, 404-429, 745, or 746)., Results: Of the 48,573 cardiac deaths occurring during 1989 to 1998, 31,827 (66%) were out of hospital. Of all OHCD victims from 1989 to 1998, 70% were men, and 76% were aged 25-34 years. The leading underlying causes of OHCD were coronary heart disease (29%), cardiomyopathy (18%), and arrhythmias (14%). The OHCD rates (per million population) were twice as high in men as in women (57.0 vs. 26.7 in 1997 and 1998), in African Americans as in whites (84.9 vs. 35.9 in 1997 and 1998), and increased with age. From 1989-1990 to 1997-1998, the age-adjusted OHCD death rates increased in both men (11%) and women (33%), and in African Americans (11%) and whites (19%)., Conclusions: Although cardiac death remains rare in U.S. adolescents and young adults, the increased trend in OHCD rates in this age group warrants further investigation of etiology and prevention strategies.

Problem/condition: Pulmonary hypertension, which is listed on hospital records and death certificates as either primary (i.e., idiopathic) pulmonary hypertension or pulmonary hypertension secondary to another underlying condition or disease, is considered rare amongst the U.S. population. Limited reports have been published regarding surveillance data for this debilitating and often fatal condition., Reporting Period Covered: 1980-2002., Description of Systems: This report summarizes mortality data from the National Vital Statistic System (NVSS) and hospital discharge data from the National Hospital Discharge Survey (NHDS) for 1980-2002 and Medicare hospital claims data for 1990-2002. NVSS, maintained by CDC's National Center for Health Statistics (NCHS), compiles multiple cause of death information from official death certificates filed in the United States. NHDS, also conducted annually by NCHS, includes information on discharges from a sample of nonfederal, short-stay hospitals. Annual hospital claims and enrollment data for all Medicare beneficiaries aged > or =65 years are provided by the Center for Medicare and Medicaid Services. Because pulmonary hypertension might be reported secondary to other diseases, this report presents data for pulmonary hypertension as any contributing cause of death or any-listed hospital diagnosis. Since 1980, the numbers of deaths and hospitalizations, death rates, and hospitalization rates have increased for pulmonary hypertension, particularly among women and older adults. During 1980-2000, death rates were higher for men than women; however, by 2002, no difference in rate was observed because of increasing death rates among women and declining death rates among men. Hospitalization rates were higher for men than for women until 1995; after 1995, higher rates were observed among women. Death rates since 1985 and Medicare hospitalization rates throughout the reporting period 1990-2002 have been higher for blacks than for whites. In addition, two distinct geographic clusters were observed for the highest hospitalization rates in the Medicare population and the highest death rates for pulmonary hypertension, in the western United States and in the Appalachian region., Interpretation: Increases in mortality from and hospitalization for pulmonary hypertension might reflect increased physician awareness and changes in diagnosing and reporting this chronic disease. Although pulmonary hypertension historically has been considered a disease of women of childbearing age, it affects all ages and racial populations. Older women represent the majority of patients and decedents with this condition. More research is needed concerning cause, prevention, and treatment of pulmonary hypertension. Public health initiatives should include increasing physician awareness that early detection is needed to initiate prompt, effective disease management. Additional epidemiologic initiatives also are needed to ascertain prevalence and incidence of various pulmonary hypertension disease entities such as pulmonary arterial hypertension.

The Centers for Disease Control and Prevention (CDC) has available a large number of datasets from previous and current surveillance and research.1 Until now, these datasets have not been catalogued. Metadata would organize these datasets and enhance CDC's ability to efficiently use this data to quickly gain the broader view of the nation's health status to effectively carry out public health activities. This project was to develop metadata for cataloguing CDC datasets and a system that would allow researchers to search at least 95% of databases within CDC based on the most relevant criteria for research. It also explored the need to involve stakeholders and users in the project. The resulting metadata and system are available only to CDC researchers on the CDC intranet.

Background: Physical inactivity is an established independent risk factor for cardiovascular disease (CVD), the leading cause of death and disability among U.S. adults. Information on the economic impact of CVD associated with inactivity is lacking, however, although it is needed to attract more resources for preventing CVD and promoting physical activity., Purpose: The objective of this study was to estimate the direct medical expenditures of CVD associated with inactivity., Methods: A population-based analysis of direct medical expenditure was performed by linking the 1996 Medical Expenditure Panel Survey to the 1995 National Health Interview Survey. The study participants were adults (N = 2,472; ages > or = 19 years; not pregnant) in the noninstitutionalized, civilian population in 1996. Medical expenditures associated with inactivity were derived by comparing the medical expenditures between population groups stratified by physical activity and CVD status., Results: In 1996, the prevalence of physical inactivity was 47.5%. The overall prevalence of CVD was 21.5% (16.7% in active persons, 23.6% in inactive persons, and 49.5% in persons with physical limitations). In this population, there were 7.3 million CVD cases. 1.1 million of them (15.3%) were associated with inactivity. The total medical expenditure of persons with CVD was US 41.3 billion dollars, of which US 5.4 billion dollars (13.1%) was associated with inactivity. Applying these percentages to the total health and economic burdens of CVD in the United States, there were 9.2 million CVD cases (US 23 .7 billion dollars direct medical expenditure) associated with inactivity in 2001., Conclusions: The high economic burden of inactivity-associated CVD demonstrates the need to promote physical activity among U.S. adults.

Background: Timely access to emergency cardiac care and survival is partly dependent on early recognition of heart attack symptoms and immediate action by calling emergency services. We assessed public recognition of major heart attack symptoms and knowledge to call 9-1-1 for an acute event., Methods: Data are from the 2001 Behavioral Risk Factor Surveillance System, a state-based telephone survey. Participants (n = 61,018) in 17 states and the U.S. Virgin Islands indicated whether the following were heart attack symptoms: pain or discomfort in the jaw, neck, back; feeling weak, lightheaded, faint; chest pain or discomfort; sudden trouble seeing in 1 or both eyes (false symptom); pain or discomfort in the arms or shoulder; shortness of breath. Participants also indicated their first action if someone was having a heart attack., Results: Most persons (95%) recognized chest pain as a heart attack symptom. However, only 11% correctly classified all symptoms and knew to call 9-1-1 when someone was having a heart attack. Symptom recognition and the need to call 9-1-1 was lower among men than women, persons of various ethnic groups than whites, younger and older persons than middle-aged persons, and persons with less education. Persons with high blood pressure, high cholesterol, diabetes mellitus, or prior heart attack or stroke were not appreciably more likely to recognize heart attack symptoms than were persons without these conditions., Conclusions: Public health efforts are needed to increase recognition of the major heart attack symptoms in both the general public and groups at high risk for an acute event.

Objective: We examined national trends in places where stroke deaths occurred., Methods: National vital statistics data (1990-1998) for stroke death (ICD-9 codes 430-438) were analyzed for place of death by selected socio-demographic characteristics and stroke subtype., Results: Half of all stroke deaths in 1998 occurred in-hospital, 46.1% occurred pre-transport, 0.6% were dead on arrival, and 3.3% occurred in the emergency department. Pre-transport deaths accounted for 55.0% of ischemic strokes, 12.8% of intracerebral strokes, and 12.9% of subarachnoid hemorrhagic strokes. The proportions of stroke deaths occurring pre-transport increased from 1990 through 1998 by 22.9% for all strokes, by 25.3% for ischemic, and by 24.3% for hemorrhagic stroke deaths., Conclusions: Almost half of stroke deaths occur prior to hospital admission. Research must identify factors that promote more timely access to effective medical care. Further efforts are needed to increase public awareness about stroke symptoms in order to reduce both delays in seeking treatment, and untimely deaths from stroke.

Objectives: This study examines the prevalence of lower extremity arterial disease (LEAD) and its association with cardiovascular disease (CVD) risk factors., Methods: Linear and logistic regression were used to analyze cross-sectional data from 1333 Chippewa and Menominee Indians., Results: Approximately 6.4% of participants (6.9% of men, 6.1% of women) had LEAD. Among women, LEAD was associated with lower high-density lipoprotein cholesterol; higher levels of diastolic blood pressure, creatinine, and triglycerides; and current smoking, diabetes, microalbuminuria, prior myocardial infarction, and stroke (P < or = .05). Among men, LEAD was associated with higher levels of creatinine (P < or = .05)., Conclusions: Use of the ankle-brachial index to assess LEAD is a noninvasive and inexpensive measurement that can be used by clinicians to identify persons at increased risk of developing CVD, and may provide opportunities to prevent CVD.