Our findings suggest that the effect of hospital volume and surgical treatment delay on overall survival of cancer patients should be considered in formulating or revising national health policy.

Background: The effect of physical activity (PA) on incidence of atrial fibrillation (AF) is unclear in African Americans (AA). This study aimed to determine if higher levels of PA are associated with decreased incidence of AF in the Jackson Heart Study (JHS). Methods: Participants of the JHS with PA assessment and without previous AF at baseline were included in the study. PA was categorized based on the American Heart Association physical activity levels. Incident AF was defined as having 12 lead electrocardiogram evidence at a subsequent follow up, or a documented diagnosis code at the time of hospital discharge from 2000 to 2016. Cox proportional hazards models were used to evaluate for the association between baseline PA and incidence of AF. Given significant correlation between PA and baseline cardiovascular disease (CVD), stratified analysis was performed based on CVD status. Results: Of the 4,477 participants followed for a median of 12.5 years, 398 developed AF (7.13 cases per 1,000 person-years). Ideal and intermediate PA were associated with a reduced risk of incident AF compared with poor PA (unadjusted HRs with 95% CIs 0.47 [0.34 - 0.64] and 0.72 [0.58 - 0.90], respectively) (Table). After adjustment for traditional cardiovascular risk factors, the associations attenuated and became no longer significant (0.73 [0.53 - 1.00] and 1.00 [0.80 - 1.25], respectively). In stratified analysis based on baseline CVD status, in participants without baseline CVD, ideal PA was significantly associated with a reduced risk of AF while intermediate PA was not (0.68 [0.47 - 0.98] and 1.00 [0.78-1.29], respectively). In participants with baseline CVD, ideal PA or intermediate PA was not associated with incident AF. Conclusion: Ideal PA was associated with a reduced risk of AF in participants without baseline CVD in this AA community cohort. Our findings show intertwined relationship among PA, CVD, and incident AF. Physical activity could be a possible therapeutic target to reduce AF incidence in the AA general population without CVD.

Introduction: African Americans (AAs) have among the highest prevalence of type 2 diabetes in the U.S. Research has shown that positive affect and supportive networks are associated with better health outcomes and may improve regulation of physiological processes. We examined the extent to which psychosocial resources were protective of diabetes outcomes among a sample of 5,306 AAs. Hypothesis: Psychosocial resource measures are inversely associated with prediabetes and diabetes [defined by hemoglobin (Hb)A1c categories] and prevalent diabetes (defined by self-report diabetes status and medication use). Methods: Using data from the Jackson Heart Study (JHS), we evaluated the cross-sectional associations of four psychosocial-resource indicators (social support, optimism, religiosity, social networks) with two diabetes outcomes [1) HbA1c categories: normal (HbA1c ≤ 5.7%), at risk/pre-diabetic (5.7% < HbA1c < 6.5%), diabetic (HbA1c ≥ 6.5%) and 2) prevalent diabetes (vs. no diabetes)]. For each psychosocial-resource measure, we created high vs. low categories (median split) and continuous standard deviation (SD) units. Associations with HbA1c categories were examined using multinomial logistic regression to estimate odds ratios (OR 95% confidence interval-CI) of pre-diabetes (vs. normal) and diabetes (vs. normal). Associations with prevalent diabetes were examined using Poisson regression to estimate prevalence ratios (PR 95% CI) of diabetes (vs. no diabetes). Models adjusted for demographics, SES, waist circumference, health behaviors, and depression. Results: Participants with diabetes reported fewer psychosocial resources than those with pre-diabetes and normal HbA1c ( p <0.01). After full adjustment, 1-SD unit increase in social support was associated with an 11% lower odds of pre-diabetes (vs. normal HbA1c) (OR 0.89, 95% CI 0.81-0.99). High (vs. low) religiosity was associated with an increased odds of diabetes (vs. normal Hba1c) (OR 1.29, 95% CI 1.01-1.64) after full adjustment. Optimism and social networks were only associated with lower diabetes prevalence after adjustment for demographics and education, respectively. Conclusion: With the exception of religiosity, psychosocial-resource measures were inversely associated with diabetes. Social support and social networks, especially, should be considered when addressing the reduction of diabetes burden among AAs.

Background The Jackson Heart Study (JHS) assesses cardiovascular disease risk factors among African Americans in Jackson, Mississippi. Whether characteristics of JHS participants differ from those of a broader African American population is unknown. Methods In a retrospective observational analysis, we compared characteristics and outcomes of JHS participants 65 years and older and enrolled in Medicare (n = 1105) to regional (n = 57,489) and national (n = 95,494) cohorts of African American Medicare beneficiaries. We weighted the regional and national cohorts to match the age and sex distributions of the JHS–Medicare cohort for pairwise baseline comparisons. Outcomes of interest included mortality and Medicare costs. We used Cox proportional hazards models to test associations between cohorts and outcomes. Results The JHS–Medicare cohort was younger, included more women, and had fewer beneficiaries with dual Medicare-Medicaid eligibility, compared with regional and national Medicare cohorts. The cohort also had lower risks of stroke, lung disease, heart failure, diabetes, and renal disease. Mean Medicare costs were lower ($5066 [SD, $11,932]) than in the regional ($7419 [SD, $17,574]) and national ($8013 [SD, $19,378]) cohorts. The regional and national cohorts had higher mortality (adjusted hazard ratios, 1.52; 95% CI, 1.31–1.76; and 1.49; 95% CI, 1.29–1.73, respectively). Subgroup analysis for dual Medicare-Medicaid eligibility attenuated mortality differences. Conclusion JHS–Medicare participants had fewer comorbid conditions, better survival, and lower Medicare costs compared with regional and national cohorts. Observed differences may reflect healthy volunteer bias and higher socioeconomic status.

Background: Cardiovascular disease (CVD) risk assessment tools such as the Framingham Risk Score are useful to identify population high risk subgroups for targeted intervention. However, no CVD risk score specific for African Americans (AAs) were available until the Pooled Cohort Equations (PCE) was introduced in 2013 for calculating sex- and race-specific10-year predicted risk of atherosclerotic cardiovascular disease (ASCVD). This study evaluated the performance of PCE in the Jackson Heart Study (JHS), a prospective cohort study of CVD in AAs. Methods: The analytic sample included 2,191 JHS participants who were 40-79 years old without a history of CVD or CVD procedures at baseline (2000-2004) and who were not a shared participant in the Atherosclerosis Risk in Communities (ARIC) Study. ASCVD events (CHD and stroke) were ascertained by active surveillance with medical records abstraction. Because all participants were followed at least 8 years through 2012, validation of the PCE was based on 8-year observed and predicted risks of ASCVD. The PCE was evaluated for discrimination and calibration properties using c-index and Hosmer-Lemeshow (HL) x 2 statistic, respectively. Overall and subgroup analysis among participants (no diabetes, LDL between 70 and 189 mg/dL and not taking statins) for whom CVD risk assessment may be applied to guide treatment for high blood cholesterol were performed. Stratified analyses evaluating the performance of PCE by baseline characteristics, including sex, age (<50/≥50 years), income (affluent*/not affluent), education (<high school/≥high school), BMI (<30/≥30), diabetes status (yes/no), self-reported use of hypertension medications (yes/no), self-reported use of statins (yes/no) and current smoking status (yes/no) were also performed. Results: There were a total of 63 incident ASCVD events (29 CHD; 34 stroke). The PCE predicted total number of event was 130, with a c-index=0.78 (95% CI 0.54-0.96) and a HL x 2 =38.2 (p<0.001). The PCE showed a similar discrimination but better calibration property in the subset of participants for whom CVD risk assessment may be applied to guide treatment for high blood cholesterol (n=1,576, c-index=0.78, 95% CI 0.43-1; HL x 2 =21.9, p=0.005). In stratified analyses, PCE had better calibration in participants who were younger (n=831, HL x 2 =10.5, p=0.23), not affluent (n=1,120, HL x 2 =12.6, p=0.12), less educated (n=186, HL x 2 =6.6, p=0.58), those with lower BMI (n=833, HL x 2 =8.5, p=0.39), those with diabetes (n=287, HL x 2 =11.1, p=0.20), and statin users (n=159, HL x 2 =10.8, p=0.21). Conclusions: Overall, the PCE showed good discrimination but did not calibrate well and overestimated the risk of ASCVD. In the subset of participants for whom CVD risk assessment may be applied to guide treatment for high blood cholesterol, the PCE showed improved calibration but still overestimated risk. *Defined as 3 times above poverty level.

Introduction: Compared to other racial and ethnic groups, African Americans experience greater negative psychosocial factors (depression, stress), which are related to increased risk of cardiovascular disease (CVD). Little research has examined the association of positive psychosocial factors (optimism) with cardiovascular health in this population. Using the Jackson Heart Study (JHS) data, we examined the association of optimism with the American Heart Association Life’s Simple 7 TM (LS7), a measure of seven metrics that assesses a person’s cardiovascular health. Hypothesis: Higher levels of optimism are positively associated with individual LS7 metrics, and positively associated with the total LS7 score. Methods: We evaluated cross-sectional associations of optimism with each LS7 metric [cigarette smoking, physical activity, diet, body mass index (BMI), blood pressure, cholesterol, glucose] and with a composite LS7 score among 4,761 participants, 21-95 years old (women=3,070; men=1,691) enrolled in the JHS, a single-site, community-based cohort of African Americans residing in Jackson, MS. Optimism was measured in tertiles (low, moderate, high) to examine threshold effects. Each LS7 metric was classified as poor, intermediate, and ideal. LS7 metrics were also summed to create a total continuous score (0-13) categorized in tertiles (low, moderate, high). Multinomial logistic regression estimated the odds ratios (OR, 95% confidence interval-CI) of intermediate (vs. poor) and ideal (vs. poor) LS7 metric by levels of optimism. Multinomial regression also estimated the odds of moderate (vs. low) or high (vs. low) total LS7 score by optimism. Models adjusted for demographics, SES, and depressive symptoms. Results: Descriptive findings showed that participants who reported high optimism had ideal physical activity, nutrition, smoking, blood pressure, glucose and high total LS7 score (all p<0.01). After adjustment for age, sex, education, income, marital status, and insurance status, participants who reported high (vs. low) optimism had a 39% increased odds of having ideal (vs. poor) physical activity (OR 1.39; 95% CI 1.10-1.76) and a 33% increased odds of having ideal (vs. poor) smoking (OR 1.33; 95% CI 1.02-1.73). Participants who reported high (vs. low) optimism had a 34% greater odds of having a high (vs. low) total LS7 score (OR 1.34 95% CI 1.03-1.74) after full adjustment. Conclusion: Optimism is associated with ideal physical activity and ideal smoking, which is important for promoting cardiovascular health and reducing the risk of CVD among African Americans in this sample.

Background: Research has found that socioeconomic status (SES) is associated with cardiovascular disease (CVD) risk. However, few studies have reported the SES correlates of CVD risk in African Americans (AA). Since low SES is over-represented in AA, our objective is to examine the socioeconomic correlates of CVD risk in this population, which may provide new insights on racial/ethnic disparities in CVD risk. Methods: A cross-sectional analysis of baseline data collected in the Jackson Heart Study (JHS), an entirely AA population, was performed. Multivariable logistic regression analysis estimated the age and sex-adjusted association of SES indicators (education, household income and occupation) with prevalent CVD (myocardial infarction (MI), stroke and hypertension). Stratified analyses by age (<65 and ≥65 years) and sex were also performed. Additional analyses were performed using logistic models with a backward selection procedure that included age, sex, education, household income, occupation and burden of CVD risk factors (measured by the number of Life’s Simple 7® metrics meeting ideal health) as independent variables and prevalent CVD as dependent variables, Due to missing data, sample sizes for these analyses ranged from 3,473 to 5,301. Results: Baseline prevalence for MI, stroke and hypertension were 5.5%, 4.4% and 60.1%. About one-third (32.5%) of the participants had a bachelor’s degree, 35% held management or professional occupations and 30% were “affluent” (≥3.5 US Census poverty level). We observed an inverse relationship between prevalent CVD and SES indicators. The largest and most consistent SES correlate of prevalent CVD was observed with income on MI (odds ratio (OR) 3.5; 95% CI 2.3, 5.4) and stroke (OR 3.7; 95% CI 2.3, 6.0) comparing the poor (below US Census poverty level) to the affluent income categories. Stratified analyses suggested stronger SES gradients in individuals <65 years and in females for MI. In the backward logistic regression models, the significant SES indicators (p<0.05) remaining in the final model were income for MI and stroke, and occupation for hypertension. The burden of CVD risk factors was statistically significant and remained in the final model for all three CVD outcomes. Conclusions: Inverse SES gradients on the prevalence of MI, stroke and hypertension were observed among AA in the JHS. The most important SES correlates were income for MI and stroke, and occupation for hypertension. These findings suggest SES, and income in particular, is an important factor contributing to health disparities in CVD among AA and possibly AA-White disparities in health outcomes.

Introduction: African Americans are disproportionately affected by hypertension (HTN) and cardiovascular disease (CVD). Determining the population attributable risk (PAR) for CVD associated with HTN and prehypertension in African Americans can help inform policymakers and prioritize public health interventions. Methods: Among 3770 participants in the Jackson Heart Study without prevalent CVD, we used Cox-proportional hazard analysis adjusted for traditional CVD risk factors to determine the association of HTN and prehypertension with incident CVD and its components including coronary heart disease, heart failure, and stroke. The PAR was calculated as pd*(HR-1)/HR; where pd is the prevalence of the exposure and HR is the hazard ratio for the outcome associated with the exposure. HTN was defined as a systolic blood pressure (SBP) ≥140 mmHg, diastolic blood pressure (DBP) ≥90 mmHg, or self-reported antihypertensive medication use and prehypertension as SBP of 120 to 139 mmHg or DBP of 80 to 89 mmHg. Results: At baseline, 52.4% of the cohort had HTN and 77.1% had prehypertension or HTN. Over a median of 9.9 years follow-up, 349 (9.3%) participants developed CVD. The HR for CVD and PAR associated with HTN was 2.17 (95% CI 1.63, 2.89) and 0.28 (95% CI 0.20, 0.35), respectively (Table). The HR for CVD and PAR associated with HTN and prehypertension pooled together was 2.21 (95% CI 1.41, 3.47) and 0.42 (95% CI 0.25, 0.56), respectively. In the pooled group there were significant associations with incident coronary heart disease, heart failure, and stroke. Sex-specific sensitivity analysis demonstrated PAR for CVD associated with HTN and prehypertension was 0.40 (95% CI 0.07, 0.62) in men and 0.43 (95% CI 0.19, 0.61) in women. Conclusions: Approximately 40% of incident CVD is attributable to HTN and prehypertension among African Americans in the southeastern United States. Preventing HTN and prehypertension in this population is a major public health priority.