Background Data are sparse on the association of cardiovascular health (CVH) in younger/middle age with the incidence of dementia later in life. Methods and Results We linked the CHA (Chicago Heart Association Detection Project in Industry) study data, assessed in 1967 to 1973, with 1991 to 2010 Medicare and National Death Index data. Favorable CVH was defined as untreated systolic blood pressure/diastolic blood pressure ≤120/≤80 mm Hg, untreated serum total cholesterol <5.18 mmol/L, not smoking, bone mass index <25 kg/m2, and no diabetes mellitus. International Classification of Diseases, Ninth Revision (ICD‐9) codes and claims dates were used to identify the first dementia diagnosis. Cox models were used to estimate hazard ratios of incident dementia after age 65 years by baseline CVH status. Among 10 119 participants baseline aged 23 to 47 years, 32.4% were women, 9.2% were black, and 7.3% had favorable baseline CVH. The incidence rate of dementia during follow‐up after age 65 was 13.9%. After adjustment, the hazard ratio for incident dementia was lowest in those with favorable baseline CVH and increased with higher risk factor burden (P‐trend<0.001). The hazards of dementia in those with baseline favorable, moderate, and 1‐only high‐risk factor were lower by 31%, 26%, and 20%, respectively, compared with those with ≥2 high‐risk factors. The association was attenuated but remained significant (P‐trend<0.01) when the model was further adjusted for competing risk of death. Patterns of associations were similar for men and women, and for those with a higher and lower baseline education level. Conclusions In this large population‐based study, a favorable CVH profile at younger age is associated with a lower risk of dementia in older age.

It is unclear how long-term medical utilization and costs from diverse care settings and their age-related patterns may differ by cardiovascular health (CVH) status earlier in adulthood. We followed 17,195 participants of the Chicago Heart Association Detection Project Industry (1967-1973) with linked Medicare claims (1992 to 2010). Baseline CVH is a composite measure of blood pressure, body mass index, diabetes, cholesterol, and smoking and includes four mutually exclusive strata: all factors were favorable (5.5%), one or more factors were elevated but none high (20.3%), one factor was high (40.9%), and two or more factors were high (33.2%). We assessed differences in the quantities (using negative binomial models) of and costs (using quantile regressions) for inpatient admissions, ambulatory care, home health care, and others between less favorable and all favorable CVH. All analyses adjusted for baseline age, race, sex, education, age at follow-up, year, state of residence, and death. We found that all favorable CVH in earlier adulthood was associated with lower long-term utilization and costs in all settings and the gap widened with age. Compared to all favorable CVH, the annual number of acute inpatient admissions per person was 79% greater (p-value < 0.001) for poor CVH, the median annual Medicare payment per person was $640 greater (41%, p-value < 0.001), and the mean was $4628 greater (67%, p-value < 0.001). The cost differences were greatest for acute inpatient, followed by ambulatory, post-acute inpatient, home health, and other. Early prevention efforts may potentially result in compressed all-cause morbidity in later years of age, along with reductions in resource use and health care costs for associated conditions.

Introduction: There is limited evidence on the long-term persistence of antihypertensive therapy. Methods: We linked Medicare Part D Event data (2006 - 2012) for participants of the Chicago Heart Association Detection Project Industry Study (1967 - 1972) who were diagnosed with essential hypertension and had at least one drug (any drug) event (N = 5,578). Antihypertensive medications and therapeutic classes were identified using the Medi-Span Electronic Drug File v2. The adherence rate was defined by the proportion of days covered (PDC) in 6-month intervals from the first fill of antihypertensive medication and was calculated separately for each therapeutic class. Additionally, to identify adherence patterns as the number of medications an individual used increased, we calculated adherence rates for time intervals after each subsequent medication was filled. Fractional response generalized linear models were used to identify predictors of the adherence patterns. Results: At 6 months from the first fill, the median adherence rate was 0.72 and the mean was 0.56. Roughly 30% of the individuals in the sample did not fill any antihypertensive medication for the duration of the study. Adherence rates declined substantially over time, but the largest drop occurred within the first 12 months. Compared to individuals with a high school degree or less, individuals with more than a high school degree were on average 8.6% more adherent (p-value <0.001); however, they experienced similar drops in adherence rates over the 6-year duration. Similarly, the adherence patterns were parallel for white and non-white individuals over the study duration although white individuals had higher adherence rates. Moreover, as the number of medications prescribed increased, the overall adherence rates declined at an increasing rate. For example, average adherence rates decreased by 5.2% (p-value <0.001) as the number of medications increased from one to two and by 8.3% (p-value <0.001) as the number of medications increased from two to three. Conclusion: Adherence to antihypertensive therapy decreased significantly over time and with greater medication burden. Interventions are needed to improve persistence in antihypertensive therapy, particularly among those taking multiple medications.

Introduction: We investigate the association between cardiovascular health at young and middle age and medical care costs and utilization in old age. Methods: We linked Chicago Heart Association (CHA) study participants’ baseline cardiovascular health (CVH) (18-59 yrs) to their Medicare claims (1991-2010) for all Part A and Part B services, including inpatient and skilled nursing facility, outpatient, home health, durable medical equipment, and hospice care. Baseline CVH is a composite measure of BP, cholesterol, diabetes, BMI, and smoking and is divided into four strata representing increasing burden. Medical care utilization (e.g., admissions and visits) and costs (in 2010 dollars) were calculated from the claims. We analyzed both the overall costs and the composition of costs among various medical care services and by CVD (non-CVD) morbidity and sex. Conditional quantile regressions were used to estimate the association between increased CVH and costs and negative binomial regressions were used for the number of inpatient admissions and outpatient visits, and the length of inpatient or hospice stay. Results: Among the 22,236 participants (222,816 person-years) 41.7% are female, 5.7% had favorable levels of all factors, 19.6% had 1+ risk factors at elevated levels, 40.9% had 1 high risk factor, and 33.7% had 2+ high risk factors. The median (mean) health care costs over the sample is $12,477 ($189,598) per person year in 2010 dollars, poorer CVH was associated with higher total medical care costs and a greater proportion of spending on home health visits (Figure). A greater CVH burden was associated with greater utilization and length of stay. Individuals with 2+ high risk factors on average have 0.22 more inpatient admissions per year and their inpatient stay is almost 2.91 days longer per year than individuals with favorable CVH. Conclusion: Unfavorable CVH early in life is associated with higher medical care cost burden in old age. Future interventions to improve CVH may result in reduced healthcare costs and utilization.

BACKGROUND: We examined the association of cardiovascular health at younger ages with the proportion of life lived free of morbidity, the cumulative burden of morbidity, and average healthcare costs at older ages.METHODS: The CHA study (Chicago Heart Association Detection Project in Industry) is a longitudinal cohort of employed men and women 18 to 74 years of age at baseline examination in 1967 to 1973. Baseline measurements included blood pressure, cholesterol, diabetes mellitus, body mass index, and smoking. Individuals were classified into 1 of 4 strata of cardiovascular health: favorable levels of all factors, 0 factors high but >= 1 elevated risk factors, 1 high risk factor, and >= 2 high risk factors. Linked Medicare and National Death Index data from 1984 to 2010 were used to determine morbidity in older age. An individual's all-cause morbidity score and cardiovascular morbidity score were calculated from International Classification of Disease, Ninth Revision codes for each year of follow-up.RESULTS: We included 25 804 participants who became >= 65 years of age by 2010, representing 65% of all original CHA participants (43% female; 90% white; mean age, 44 years at baseline); 6% had favorable levels of all factors, 19% had >= 1 risk factors at elevated levels, 40% had 1 high risk factor, and 35% had >= 2 high risk factors. Favorable cardiovascular health at younger ages extended survival by almost 4 years and postponed the onset of all-cause and cardiovascular morbidity by 4.5 and 7 years, respectively, resulting in compression of morbidity in both absolute and relative terms. This translated to lower cumulative and annual healthcare costs for those in favorable cardiovascular health (P<0.001) during Medicare eligibility.CONCLUSIONS: Individuals in favorable cardiovascular health in early middle age live a longer, healthier life free of all types of morbidity. These findings provide strong support for prevention efforts earlier in life aimed at preserving cardiovascular health and reducing the burden of disease in older ages.

Physical function (PF) is a core patient-reported outcome domain in clinical trials in rheumatic diseases. Frequently used PF measures have ceiling effects, leading to large sample size requirements and low sensitivity to change. In most of these instruments, the response category that indicates the highest PF level is the statement that one is able to perform a given physical activity without any limitations or difficulty. This study investigates whether using an item format with an extended response scale, allowing respondents to state that the performance of an activity is easy or very easy, increases the range of precise measurement of self-reported PF.

Background: We examined the association of cardiovascular health at younger ages with the proportion of life lived free of morbidity, the cumulative burden of morbidity, and average healthcare costs at older ages. Methods: The CHA study (Chicago Heart Association Detection Project in Industry) is a longitudinal cohort of employed men and women 18 to 74 years of age at baseline examination in 1967 to 1973. Baseline measurements included blood pressure, cholesterol, diabetes mellitus, body mass index, and smoking. Individuals were classified into 1 of 4 strata of cardiovascular health: favorable levels of all factors, 0 factors high but ≥1 elevated risk factors, 1 high risk factor, and ≥2 high risk factors. Linked Medicare and National Death Index data from 1984 to 2010 were used to determine morbidity in older age. An individual’s all-cause morbidity score and cardiovascular morbidity score were calculated from International Classification of Disease, Ninth Revision codes for each year of follow-up. Results: We included 25 804 participants who became ≥65 years of age by 2010, representing 65% of all original CHA participants (43% female; 90% white; mean age, 44 years at baseline); 6% had favorable levels of all factors, 19% had ≥1 risk factors at elevated levels, 40% had 1 high risk factor, and 35% had ≥2 high risk factors. Favorable cardiovascular health at younger ages extended survival by almost 4 years and postponed the onset of all-cause and cardiovascular morbidity by 4.5 and 7 years, respectively, resulting in compression of morbidity in both absolute and relative terms. This translated to lower cumulative and annual healthcare costs for those in favorable cardiovascular health ( P <0.001) during Medicare eligibility. Conclusions: Individuals in favorable cardiovascular health in early middle age live a longer, healthier life free of all types of morbidity. These findings provide strong support for prevention efforts earlier in life aimed at preserving cardiovascular health and reducing the burden of disease in older ages.

Background: Data are sparse regarding the association of cardiovascular health (CVH) in younger/middle age with the diagnosis of dementia later in life. Methods: We used linked data from the Chicago Heart Association Detection Project in Industry Study assessed in 1967-73 with fee-for-service Medicare claims and National Death Index data from 1991-2010. Participants were ≤65 years old in 1991 and Medicare eligible during 1991-2010. Baseline CVD risk factors included blood pressure, cholesterol, BMI, smoking, and diabetes. Participants were classified into four strata: favorable levels of all factors, 0 factors high but 1+ elevated, 1 high, and ≥2 high risk factors. ICD-9 codes were used to identify date of first dementia diagnosis. We used competing Cox models to estimate hazards for dementia in Medicare data after age 65 with competing event of all-cause mortality prior to dementia diagnosis. Covariates included baseline age, race, sex, and education attainment. Results: This study included 4,273 females and 8,381 males, 10.3% Black, baseline ages 18-48. Dementia was diagnosed in 5.1% of study participants. The prevalence of dementia diagnosis increased with increasing CVH burden from 3.4% to 6.4%. During 1991-2010 in Medicare, the average time from age 65 to the first dementia diagnosis was 7.7 years. Greater CVH in younger age was associated with a reduced risk of being diagnosed with dementia in later life. Hazards ratios of experiencing dementia in those with baseline favorable levels, 0 RF high, and 1 only high RF were lower by 36%, 29%, and 28% respectively as compared to those with 2+ high-risk factors (see Table - Model 1). Similar trends were observed when deaths were treated as competing events although the association was attenuated (Model 2). Patterns were similar when stratified by sex or race. Conclusions: Having a favorable CVH profile at younger age is associated with lower risk of dementia in older age. Improvements in CVH in younger age may translate to increased independence and quality of life later in life.

Objective To present an overview of a series of studies in which the clinical validity of the National Institutes of Health's Patient Reported Outcome Measurement Information System (NIH; PROMIS) measures was evaluated, by domain, across six clinical populations. Study Design and Setting Approximately 1,500 individuals at baseline and 1,300 at follow-up completed PROMIS measures. The analyses reported in this issue were conducted post hoc, pooling data across six previous studies, and accommodating the different designs of the six, within-condition, parent studies. Changes in T-scores, standardized response means, and effect sizes were calculated in each study. When a parent study design allowed, known groups validity was calculated using a linear mixed model. Results The results provide substantial support for the clinical validity of nine PROMIS measures in a range of chronic conditions. Conclusion The cross-condition focus of the analyses provided a unique and multifaceted perspective on how PROMIS measures function in “real-world” clinical settings and provides external anchors that can support comparative effectiveness research. The current body of clinical validity evidence for the nine PROMIS measures indicates the success of NIH PROMIS in developing measures that are effective across a range of chronic conditions.

Background: We sought to determine the association of body-mass index (BMI) in younger adulthood with life lived free of morbidity and cumulative burden of all-cause and cardiovascular (CV) morbidity through older adulthood. Methods: Participants (N=25,930) from the Chicago Heart Association (CHA) study, a longitudinal cohort of employed men and women recruited from 1967-1973, ages 18-59 years at baseline were included. Linked CMS/NDI data from 1984-2010 were used to determine morbidity after age 65 from all participants enrolled in Medicare. Individuals were classified by BMI at baseline and analyses were adjusted for age, sex, race, education, smoking, hypertension, hyperlipidemia, and diabetes. All-cause morbidity was defined using the Gagne score. A CV morbidity score was defined as the sum of coronary heart disease, peripheral vascular disease, stroke, and heart failure diagnoses. Results: Participants were 41% female and 8% African American; mean age was 43±11 years. Two percent were underweight, 43...

OBJECTIVES:To evaluate the validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function measures using longitudinal data collected in six chronic health conditions. STUDY DESIGN AND SETTING:Individuals with rheumatoid arthritis (RA), major depressive disorder (MDD), back pain, chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and cancer completed the PROMIS Physical Function computerized adaptive test or fixed-length short form at baseline and at the end of clinically relevant follow-up intervals. Anchor items were also administered to assess change in physical function and general health. Linear mixed-effects models and standardized response means were estimated at baseline and follow-up. RESULTS:A total of 1,415 individuals participated (COPD n = 121; CHF n = 57; back pain n = 218; MDD n = 196; RA n = 521; cancer n = 302). The PROMIS Physical Function scores improved significantly for treatment of CHF and back pain patients but not for patients with MDD or COPD. Most of the patient subsamples that reported improvement or worsening on the anchors showed a corresponding positive or negative change in PROMIS Physical Function. CONCLUSION:This study provides evidence that the PROMIS Physical Function measures are sensitive to change in intervention studies where physical function is expected to change and able to distinguish among different clinical samples. The results inform the estimation of meaningful change, enabling comparative effectiveness research.

ObjectiveMedications for rheumatoid arthritis (RA) may affect survival. However, studies often include limited followup and do not account for selection bias in treatment allocation. Using a large longitudinal database, we examined the association between prednisone use and mortality in RA, and whether this risk was modified with concomitant disease‐modifying antirheumatic drug (DMARD) use, after controlling for propensity for treatment with prednisone and individual DMARDs.MethodsIn a prospective study of 5,626 patients with RA followed for up to 25 years, we determined the risk of death associated with prednisone use alone and combined treatment of prednisone with methotrexate (MTX) or sulfasalazine. We used the random forests method to generate propensity scores for prednisone use and each DMARD at study entry and during followup. Mortality risks were estimated using multivariate Cox models that included propensity scores.ResultsDuring followup (median 4.97 years), 666 patients (11.8%) died. In a multivariate, propensity‐adjusted model, prednisone use was associated with an increased risk of death (hazard ratio [HR] 2.83 [95% confidence interval (95% CI) 1.03–7.76]). However, there was a significant interaction between prednisone use and MTX use (P = 0.03), so that risk was attenuated when patients were treated with both medications (HR 0.99 [95% CI 0.18–5.36]). However, combination treatment also weakened the protective association of MTX with mortality. Results were similar for sulfasalazine.ConclusionPrednisone use was associated with a significantly increased risk of mortality in patients with RA. This association was mitigated by concomitant DMARD use, but combined treatment also negated the previously reported beneficial association of MTX with survival in RA.

To evaluate the validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function measures in a diverse, population-based cancer sample.

Interpretation of patient-reported outcomes (PROs) requires some definition of an important or meaningful difference. This study aimed to estimate minimally important differences (MIDs) for the Patient-Reported Outcomes Measurement Information System (PROMIS®) Fatigue and Pain Interference scale scores in rheumatoid arthritis (RA). The responsiveness of several PROs was assessed in an observational cohort of 521 RA patients in the Arthritis, Rheumatism and Aging Medical Information Systems (ARAMIS) cohorts. PROMIS Fatigue and Pain Interference instruments were administered at baseline, 6 months, and 12 months. Self-reported retrospective changes in fatigue and pain over the previous 6 months were obtained at the follow-ups (a lot better/worse, a little better/worse, stayed the same). We estimated MIDs using the mean change in PROMIS scores for people who rated their change ‘a little better’ or ‘a little worse.’ At 6 months, 41 patients reported their fatigue was a little better compared to baseline (mean change [SD]: -2.6 [4.8]), 119 a little worse (1.7 [5.6]). Pain was a little better for 60 patients (-1.9 [6.1]) and a little worse for 126 (0.6 [5.7]). At 12 months, fatigue was a little better compared to 6 months prior for 31 patients (-1.3 [6.5]) and a little worse for 133 (0.9 [5.6]). Pain was a little better for 53 patients (-1.8 [5.7]) and a little worse for 122 (1.5 [5.0]). Thus, the MID range was 1-2 points for both Fatigue and Pain Interference. Correlations between change scores and retrospective ratings were low (0.13-0.29), indicating that these analyses may underestimate the MID. The MID for PROMIS Fatigue and PROMIS Pain Interference, estimated from this cohort of RA patients, is roughly 2 points and corresponds to a small effect size. This is consistent with earlier work in this cohort demonstrating an MID of 2 points for PROMIS Physical Functioning.