Behavioral Risk Factors and Regional Variation in Cardiovascular Health Care and Death

Am J Prev Med. 2018 Mar;54(3):376-384. doi: 10.1016/j.amepre.2017.11.011. Epub 2018 Jan 12.


Introduction: Reducing the burden of death from cardiovascular disease includes risk factor reduction and medical interventions.

Methods: This was an observational analysis at the hospital service area (HSA) level, to examine regional variation and relationships between behavioral risks, health services utilization, and cardiovascular disease mortality (the outcome of interest). HSA-level prevalence of cardiovascular disease behavioral risks (smoking, poor diet, physical inactivity) were calculated from the Behavioral Risk Factor Surveillance System; HSA-level rates of stress tests, diagnostic cardiac catheterization, and revascularization from a statewide multi-payer claims data set from Maine in 2013 (with 606,260 patients aged ≥35 years), and deaths from state death certificate data. Analyses were done in 2016.

Results: There were marked differences across 32 Maine HSAs in behavioral risks: smoking (12.4%-28.6%); poor diet (43.6%-73.0%); and physical inactivity (16.4%-37.9%). After adjustment for behavioral risks, rates of utilization varied by HSA: stress tests (28.2-62.4 per 1,000 person-years, coefficient of variation=17.5); diagnostic cardiac catheterization (10.0-19.8 per 1,000 person-years, coefficient of variation=17.3); and revascularization (4.6-6.2 per 1,000 person-years; coefficient of variation=9.1). Strong HSA-level associations between behavioral risk factors and cardiovascular disease mortality were observed: smoking (R2=0.52); poor diet (R2=0.38); and physical inactivity (R2=0.35), and no association between revascularization and cardiovascular disease mortality after adjustment for behavioral risk factors (R2=0.02). HSA-level behavioral risk factors were also strongly associated with all-cause mortality: smoking (R2=0.57); poor diet (R2=0.49); and physical inactivity (R2=0.46).

Conclusions: There is substantial regional variation in behavioral risks and cardiac utilization. Behavioral risk factors are associated with cardiovascular disease mortality regionally, whereas revascularization is not. Efforts to reduce cardiovascular disease mortality in populations should focus on prevention efforts targeting modifiable risk factors.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adult
  • Aged
  • Behavioral Risk Factor Surveillance System
  • Cardiovascular Diseases / epidemiology
  • Cardiovascular Diseases / mortality*
  • Cardiovascular Diseases / therapy
  • Cross-Sectional Studies
  • Female
  • Health Behavior*
  • Health Status
  • Humans
  • Maine / epidemiology
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Prevalence
  • Risk Factors
  • Risk Reduction Behavior*
  • Risk-Taking*