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1.  Short-Term Trends in Heart Failure-Related Hospitalizations in a High-Risk State 
Southern medical journal  2013;106(2):147-154.
We sought to determine whether there are signs of improvement in the rates of heart failure (HF) hospitalizations given the recent reports of improvement in national trends.
HF admissions data from the Tennessee Hospital Discharge Data System were analyzed.
Hospitalization for primary diagnosis of HF (HFPD) in adults (aged 20 years old or older) decreased from 4.5% in 2006 to 4.2% in 2008. Similarly, age-adjusted HF hospitalization (per 10,000 population) declined by 19.1% (from 45.5 in 2006 to 36.8 in 2008). The age-adjusted rates remain higher among blacks than whites and higher among men than women. Notably, the rate ratio of black-to-white men ages 20 to 34 years admitted with HFPD increased from 8.5 in 2006 to 11.1 in 2008; similarly, the adjusted odds ratios for HFPD were 4.75 (95% confidence interval 3.29–6.86) and 5.61 (95% confidence interval 3.70–8.49), respectively. There was, however, a significant improvement in odds ratio for HF rates among young black women, as evidenced by a decrease from 4.60 to 3.97 (aged 20–34 years) and 4.21 to 3.12 (aged 35–44 years) between 2006 and 2008, respectively. Among patients aged 20 to 34 and 35 to 44 years, hypertension was the strongest independent predictor for HF. Diabetes and myocardial infarction emerged as predictors for HF among patients aged 35 years and older.
The overall rate of HF hospitalization declined during the period surveyed, but the persistent disproportionate involvement of blacks with evidence of worsening among younger black men, requires close attention.
PMCID: PMC3565177  PMID: 23380751
heart failure; prevention; blacks; disparities; risk factors
2.  Depression Increases Stroke Hospitalization Cost: An Analysis of 17,010 Stroke Patients in 2008 by Race and Gender 
Stroke Research and Treatment  2013;2013:846732.
Objective. This analysis focuses on the effect of depression on the cost of hospitalization of stroke patients. Methods. Data on 17,010 stroke patients (primary diagnosis) were extracted from 2008 Tennessee Hospital Discharge Data System. Three groups of patients were compared: (1) stroke only (SO, n = 7,850), (2) stroke + depression (S+D, n = 3,965), and (3) stroke + other mental health diagnoses (S+M, n = 5,195). Results. Of all adult patients, 4.3% were diagnosed with stroke. Stroke was more prevalent among blacks than whites (4.5% versus 4.2%, P < 0.001) and among males than females (5.1% versus 3.7%, P < 0.001). Nearly one-quarter of stroke patients (23.3%) were diagnosed with depression/anxiety. Hospital stroke cost was higher among depressed stroke patients (S+D) compared to stroke only (SO) patients ($77,864 versus $47,790, P < 0.001), and among S+D, cost was higher for black males compared to white depressed males ($97,196 versus $88,115, P < 0.001). Similar racial trends in cost emerged among S+D females. Conclusion. Depression in stroke patients is associated with increased hospitalization costs. Higher stroke cost among blacks may reflect the impact of comorbidities and the delay in care of serious health conditions. Attention to early detection of depression in stroke patients might reduce inpatient healthcare costs.
PMCID: PMC3608101  PMID: 23555070
3.  Race, Gender, and Age Differences in Heart Failure-Related Hospitalizations in a Southern State: Implications for Prevention 
Circulation. Heart failure  2010;4(2):161-169.
Since heart failure (HF) is the final common pathway for most heart diseases, we examined its 10-year prevalence trend by race, gender, and age in Tennessee.
Methods and Results
HF hospitalization data from the Tennessee Hospital Discharge Data System were analyzed by race, gender and age. Rates were directly age-adjusted using the Year 2000 standard population. Adult (age 20+) in-patient hospitalization for primary diagnosis of HF (HFPD) increased from 4.2% in 1997 to 4.5% in 2006. Age-adjusted hospitalization for HF (per 10,000 population) rose by 11.3% (from 29.3 in 1997 to 32.6 in 2006). Parallel changes in secondary HF admissions were also noted. Age-adjusted rates were higher among blacks than whites and higher among men than women. The ratios of black to white by gender admitted with HFPD in 2006 were highest (9:1) among the youngest age categories (20-34 and 35-44 years). Furthermore, for each age category of black men below 65 years, there were higher HF admission rates than for white men in the immediate older age category. In 2006, the adjusted rate ratios for HFPD in black to white men aged 20-34 and 35-44 years were OR=4.75, CI (3.29-6.86) and OR 5.10, CI (4.15-6.25) respectively. Hypertension was the independent predictor of HF admissions in black men age 20-34 years.
The higher occurrence of HF among young adults in general, particularly among young black men, highlights the need for prevention by identifying modifiable biological and social determinants in order to reduce cardiovascular health disparities in this vulnerable group.
PMCID: PMC3070602  PMID: 21178017
heart failure; hospitalization; prevention; diagnosis; risk factors
4.  Diabetes, depression, and healthcare utilization among African Americans in primary care. 
PURPOSE: This study tested for an association between diabetes and depressive symptoms and assessed the effect of co-occurring diabetes and depressive symptoms on healthcare utilization outcomes among African-American patients. PROCEDURE: The sample consisted of 303 adult African-American patients age 40 and over from a primary care clinic serving the low-income population in Nashville, TN. Measures were based on self-reports during a structured interview. Multivariate analyses adjusted for age, gender, socioeconomic status, and comorbid chronic conditions. FINDINGS: African-American patients with and without diabetes did not differ on the presence or severity of depressive symptoms. However, the co-occurrence of major depressive symptoms with diabetes among African Americans was associated with nearly three times more reported emergency room visits and three times more inpatient days, but was only marginally associated with a lower number of physician visits. CONCLUSIONS: In contrast to previous studies with predominantly white samples that found a positive association between diabetes and depression, no association was found in this African-American sample. Nevertheless, the results did concur with research findings based on other samples, in that the co-occurrence of depression with diabetes was associated with more acute care utilization, such as emergency room visits and inpatient hospitalizations. This pattern of utilization may lead to higher healthcare costs among patients with diabetes who are depressed, regardless of race.
PMCID: PMC2595010  PMID: 15101668

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