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Objectives. To examine 47 years of US urban and rural mortality trends at the county level, controlling for effects of education, income, poverty, and race. Methods. We obtained (1) Centers for Disease Control and Prevention WONDER (Wide-ranging ONline Data for Epidemiologic Research) data (1970–2016) on 104 million deaths; (2) US Census data on education, poverty, and race; and (3) Bureau of Economic Analysis data on income. We calculated ordinary least square regression models, including interaction models, for each year. We graphed standardized parameter estimates for 47 years. Results. Rural–urban mortality disparities increased from the mid-1980s through 2016. We found education, race, and rurality to be strong predictors; we found strong interactions between percentage poverty and percentage rural, indicating that the largest penalty was in high-poverty, rural counties. Conclusions. The rural–urban mortality disparity was persistent, growing, and large when compared to other place-based disparities. The penalty had evolved into a high-poverty, rural penalty that rivaled the effects of education and exceeded the effects of race by 2016. Public Health Implications. Targeting public health programs that focus on high-poverty, rural locales is a promising strategy for addressing disparities in mortality.

BACKGROUND: Hypertension control and diabetes control are important for reducing cardiovascular disease burden. A growing body of research suggests an association between neighborhood environment and hypertension or diabetes control among patients engaged in clinical care. OBJECTIVE: To investigate whether neighborhood conditions (i.e., healthy food availability, socioeconomic status (SES), and crime) were associated with hypertension and diabetes control. DESIGN: Cross-sectional analyses using electronic medical record (EMR) data, U.S. Census data, and secondary data characterizing neighborhood food environments. Multivariate logistic regression analyses adjusted for potential confounders. Analyses were conducted in 2017. PARTICIPANTS: Five thousand nine hundred seventy adults receiving primary care at three Baltimore City clinics in 2010–2011. MAIN MEASURES: Census tract–level neighborhood healthy food availability, neighborhood SES, and neighborhood crime. Hypertension control defined as systolic blood pressure

Introduction: Hypertension and diabetes control are leading modifiable risk factors for cardiovascular disease (CVD) risk. Contemporary epidemiological research suggests that individual and health system characteristics are associated with control. Yet, there is little evidence examining how the neighborhood environment influences hypertension or diabetes control among patients engaged in primary care. Methods: We analyzed data of adult patients (n = 5,711) with hypertension or diabetes who received primary care at 1 of 3 clinics of a statewide health care organization in Baltimore, MD and lived within the Baltimore city limits. The neighborhood environment exposures were tertiles of neighborhood socioeconomic status (SES), crime, and healthy food availability index (HFAI) assessed at the census tract level. Separate multivariate logistic regression models were constructed to estimate the odds ratio (OR) for each of these neighborhood environment characteristics and hypertension and diabetes control, adjusting for patient demographics, and health behaviors; and for physician demographic characteristics. Results: The overall mean age was 57.8 ± 14.3 years, 67.2% were female, and 89.6% were Black. There were 5,325 patients with hypertension and 2,094 patients with diabetes (not mutually exclusive). In bivariate analyses, high neighborhood SES (p= 0.030) and low crime (p= 0.006) were associated with hypertension control, and none of the neighborhood exposures were associated with diabetes control. In fully adjusted analyses, being Black was significantly associated with decreased odds of hypertension control in all models (OR range: 0.63 – 0.65), independent of neighborhood exposures. Among those with hypertension, living in a low or moderate SES neighborhood or a high crime neighborhood was associated with lower odds of hypertension control; however, these associations were attenuated in adjusted models. None of the neighborhood exposures were significantly associated with odds of diabetes control in models that adjusted for patient characteristics. Yet, compared to high SES neighborhoods, living in a low or moderate SES neighborhood (OR=0.74, 95% CI: 0.57 - 0.97 and OR=0.75, 95% CI: 0.57 - 0.98, respectively) was associated with reduced diabetes control after adjusting for both patient and physician characteristics. Conclusion: Exposure to neighborhood disadvantage may contribute to poor diabetes and hypertension control among patients in primary care, independent of patient and physician characteristics. Patient-centered risk assessments including measures of social need and preventive interventions adapted to neighborhood environments could be useful for optimizing hypertension and diabetes control in clinical settings.

Item does not contain fulltext OBJECTIVE: To investigate the association between individual and area-level socioeconomic status and hypertension risk among individuals later in life. METHODS: We used Cox proportional hazards models to examine the association of socioeconomic status with incident hypertension using race-specific neighborhood socioeconomic status, median household income, and education among 3372 participants (mean age, 61 years) from the Atherosclerosis Risk in Communities Study at Visit 4 (1996-1998). Incident hypertension was defined as self-reported diagnosis or reported use of antihypertensive medications. RESULTS: Over a median follow-up time of 9.4 years, there were 1874 new cases of hypertension (62.1 per 1000 person-years). Overall, being in high as compared with low socioeconomic status categories was associated with a lower risk of developing hypertension in late life, with hazard ratios (95% confidence intervals) of 0.87 (0.77-0.98) for high neighborhood socioeconomic status tertile, 0.79 (0.69-0.90) for high individual income, and 0.75 (0.63-0.89) for college education after adjustment for traditional risk factors. These findings were consistent and robust whenever accounting for competing risks of all-cause mortality. No significant interactions by race and age (dichotomized at age 65) were observed. CONCLUSION: Among participants free of hypertension in midlife, high neighborhood and individual socioeconomic status are associated with a decreased risk of incident hypertension. Our findings support population-level interventions, such as blood pressure screening at senior centers and faith-based organizations, that are tailored to shift the distribution of blood pressure and reduce hypertension health inequalities among older adults.

Introduction: Individual and area-level socioeconomic status (SES) are associated with hypertension incidence and blood pressure changes in midlife. However, examination of the relationship between SES and late-life hypertension incidence are limited. Methods: ARIC Study participants free of hypertension at visit 4 (1996-1998) were followed by annual and semi-annual calls through December 31, 2013 for incidence of hypertension, defined as a self-reported diagnosis or use of antihypertensive medications. Individual and neighborhood SES indicators were assessed at study baseline (using criteria listed in the Table). Among individuals with follow-up and complete data (N=3,374) associations were examined using Cox regression models. Results: Among men and women with a median baseline blood pressure of 118/68 mg Hg, mean age was 61 years (SD ± 5.5), 45% were female, 12% were Black, and 21.7% had an annual household income of Conclusion: Both neighborhood and individual SES are related to late life incidence of hypertension, at least among Whites. Understanding the mechanisms, such as the role of access to care, for these associations can guide prevention strategies.

Despite the importance of continuous care, a large proportion of persons with HIV are not engaged or retained in care at any one time, leading to poor outcomes. Identifying the risk factors associated with lack of engagement and retention in HIV care is needed in order to target patients for interventions. While both engagement and retention in care have been studied using multiple measures, the observation period for the majority of studies is less than one year, few studies have examined both initial engagement and retention, and the effect of comorbidities has typically not been included. This study extends the literature by examining how comorbidities, in addition to demographics, HIV clinical indicators and transmission risk factors, were associated with engagement and retention in a cohort study of 485 HIV-infected persons seen for an initial HIV visit at an urban safety-net hospital. Using the electronic medical record, demographic, risk factor, health status and comorbidity data were gathered at the time of initial visits. To measure engagement and retention, appointment data were obtained for a 24-month period following the initial visit. Key findings were that unknown HIV transmission risk factor and being homeless at initial visit were associated with both lack of engagement and retention. Conversely being diagnosed with a psychiatric disorder was predictive of retention. Our findings have important implications for program structure, including the integration of care, as well as regarding key components to be addressed holistically in early clinic visits.