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Abusamaan MS, Marzinke MA, Ashok A, Carroll K, Lane K, Jeun R, Moseley KF, Carson KA, Mathioudakis NN. Hypoglycemic risk exposures in relation to low serum glucose values in ambulatory patients. Medicine (Baltimore) 2020; 99:e18679. [PMID: 31914062 PMCID: PMC6959883 DOI: 10.1097/md.0000000000018679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This study aimed to correlate hypoglycemic risk exposures (HREs) with low blood glucose value (BGV) in ambulatory patients to inform selection of a glucose critical action value (CAV).This was a retrospective study of ambulatory patients with at least 1 serum glucose ≤70 mg/dL obtained at 2 laboratories within the Johns Hopkins Health System over 3.8 years. Multivariable logistic regression was used to evaluate association of BGV cut-offs of <60, <54, <50, and <45 mg/dL with HREs. HREs were classified as "high hypoglycemic risk" (HHR), "moderate hypoglycemic risk" (MHR), "low hypoglycemic risk" (LHR), and "no hypoglycemic risk" (NHR).A total of 5404 patient samples of BG ≤70 mg/dL were analyzed, of which 30.3%, 23.2%, 28.5%, 18.0% occurred in NHR, LHR, MHR, and HHR groups, respectively. An inverse relationship was noted between BGV cut-offs and HHR, but no association was observed for LHR or MHR. After adjusting for age, sex, and race, there was an inverse association between BG thresholds and the odds of HHR. For classification of HHR, BGV cut-offs of <60, <54, <50, and <45 mg/dL correctly classified 71.2%, 69.8%, 68.8%, and 67.2% of BG samples, achieved false-positive rates of 13.6%, 4.7%, 1.7%, and 0.5% and positive likelihood ratios of 3.3, 6.0, 11.2, and 23.4, respectively.Nearly 70% of low BGVs occurred in patients with at least 1 HRE, but only ∼20% occurred in HHR patients. Given their high positive likelihood ratios, BGVs <54 or <50 mg/dL are reasonable candidates for CAVs that would allow sufficient clinician response time while minimizing false-positive alerts.
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Boulware LE, Ephraim PL, Hill-Briggs F, Roter DL, Bone LR, Wolff JL, Lewis-Boyer L, Levine DM, Greer RC, Crews DC, Gudzune KA, Albert MC, Ramamurthi HC, Ameling JM, Davenport CA, Lee HJ, Pendergast JF, Wang NY, Carson KA, Sneed V, Gayles DJ, Flynn SJ, Monroe D, Hickman D, Purnell L, Simmons M, Fisher A, DePasquale N, Charleston J, Aboutamar HJ, Cabacungan AN, Cooper LA. Hypertension Self-management in Socially Disadvantaged African Americans: the Achieving Blood Pressure Control Together (ACT) Randomized Comparative Effectiveness Trial. J Gen Intern Med 2020; 35:142-152. [PMID: 31705466 PMCID: PMC6957583 DOI: 10.1007/s11606-019-05396-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 05/15/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Effective hypertension self-management interventions are needed for socially disadvantaged African Americans, who have poorer blood pressure (BP) control compared to others. OBJECTIVE We studied the incremental effectiveness of contextually adapted hypertension self-management interventions among socially disadvantaged African Americans. DESIGN Randomized comparative effectiveness trial. PARTICIPANTS One hundred fifty-nine African Americans at an urban primary care clinic. INTERVENTIONS Participants were randomly assigned to receive (1) a community health worker ("CHW") intervention, including the provision of a home BP monitor; (2) the CHW plus additional training in shared decision-making skills ("DoMyPART"); or (3) the CHW plus additional training in self-management problem-solving ("Problem Solving"). MAIN MEASURES We assessed group differences in BP control (systolic BP (SBP) < 140 mm Hg and diastolic BP (DBP) < 90 mmHg), over 12 months using generalized linear mixed models. We also assessed changes in SBP and DBP and participants' BP self-monitoring frequency, clinic visit patient-centeredness (i.e., extent of patient-physician discussions focused on patient emotional and psychosocial concerns), hypertension self-management behaviors, and self-efficacy. KEY RESULTS BP control improved in all groups from baseline (36%) to 12 months (52%) with significant declines in SBP (estimated mean [95% CI] - 9.1 [- 15.1, - 3.1], - 7.4 [- 13.4, - 1.4], and - 11.3 [- 17.2, - 5.3] mmHg) and DBP (- 4.8 [- 8.3, - 1.3], - 4.0 [- 7.5, - 0.5], and - 5.4 [- 8.8, - 1.9] mmHg) for CHW, DoMyPART, and Problem Solving, respectively). There were no group differences in BP outcomes, BP self-monitor use, or clinic visit patient-centeredness. The Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 18.7 [4.0, 87.3]) and self-efficacy scores (OR [95% CI] 4.7 [1.5, 14.9]) at 12 months compared to baseline, while other groups did not. Compared to DoMyPART, the Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 5.7 [1.3, 25.5]) at 12 months. CONCLUSION A context-adapted CHW intervention was correlated with improvements in BP control among socially disadvantaged African Americans. However, it is not clear whether improvements were the result of this intervention. Neither the addition of shared decision-making nor problem-solving self-management training to the CHW intervention further improved BP control. TRIAL REGISTRY ClinicalTrials.gov Identifier: NCT01902719.
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Murphy KA, Greer RC, Roter DL, Crews DC, Ephraim PL, Carson KA, Cooper LA, Albert MC, Boulware LE. Awareness and Discussions About Chronic Kidney Disease Among African-Americans with Chronic Kidney Disease and Hypertension: a Mixed Methods Study. J Gen Intern Med 2020; 35:298-306. [PMID: 31720962 PMCID: PMC6957584 DOI: 10.1007/s11606-019-05540-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/09/2019] [Accepted: 10/09/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Routine primary care visits provide an educational opportunity for African-Americans with chronic kidney disease (CKD) and CKD risk factors such as hypertension. The nature of patient-physician discussions about CKD and their impact on CKD awareness in this population have not been well explored. OBJECTIVE To characterize patient CKD awareness and discussions about CKD between patients and primary care physicians (PCPs). DESIGN Mixed methods study. PATIENTS African-American patients with uncontrolled hypertension (≥ 140/90 mmHg) and CKD (albuminuria or eGFR < 60 ml/min/1.73 m2) recruited from an urban primary care clinic. MAIN MEASURES We assessed patient CKD awareness with questionnaires and audio-recorded patients-PCP discussions during a routine visit. We characterized discussions and used multivariate regression analysis to identify independent patient and visit predictors of CKD awareness or CKD discussions. RESULTS Among 48 African-American patients with uncontrolled hypertension and CKD, 29% were aware of their CKD. After adjustment, CKD awareness was associated with moderate-severe CKD (stages 3-4) (vs. mild CKD [stages 1-2]) (prevalence ratio [PR] 2.82; 95% CI 1.18-6.78) and inversely associated with diabetes (vs. without diabetes) (PR 0.28; 95% CI 0.10-0.75). CKD discussions occurred in 30 (63%) visits; most focused on laboratory assessment (n = 23, 77%) or risk factor management to delay CKD progression (n = 19, 63%). CKD discussions were associated with moderate-severe CKD (vs. mild CKD) (PR 1.57; 95% CI 1.04-2.36) and diabetes (vs. without diabetes) (PR 1.42; 95% CI 1.09-1.85), and inversely associated with uncontrolled hypertension (vs. controlled) (PR 0.58; 95% CI 0.92-0.89). In subgroup analysis, follow-up CKD awareness did not change by presence or absence of CKD discussion (10.5% vs. 7.7%, p = 0.8). CONCLUSIONS In patients at risk of CKD progression, few were aware of CKD, and CKD discussions were not associated with CKD awareness. More resources may be needed to enhance the clarity of clinical messages regarding CKD and its significance for patients' health. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01902719.
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Salas J, Reddy N, Carson KA, Northington FJ, Huisman TA. Ultrasound Predicts White Matter Integrity after Hypothermia Therapy in Neonatal Hypoxic-Ischemic Injury. J Neuroimaging 2019; 29:743-749. [PMID: 31206969 PMCID: PMC6814495 DOI: 10.1111/jon.12644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/01/2019] [Accepted: 06/06/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Hypoxic-ischemic injury (HII) is a major cause of neonatal death and neurodevelopmental disability. Head ultrasounds (HUS) in neonates with HII often show enhanced gray/white matter differentiation. We assessed the significance of this finding in predicting white matter structural integrity measured by diffusion tensor imaging (DTI) in neonates with HII. METHODS We performed a quantitative region of interest-based analysis of white and gray matter echogenicity within the cingulate gyrus on pre- and posthypothermia HUS. We also completed a quantitative analysis of fractional anisotropy (FA) and mean (MD), axial (AD), and radial (RD) diffusivity within the bilateral anterior and posterior centrum semiovale (CSO) on posthypothermia brain magnetic resonance imaging. For HUS studies, we calculated a white-to-gray matter echogenicity ratio (WGR) and subsequently correlated it to DTI measurements. RESULTS Forty-two term neonates with HII who underwent hypothermia therapy were included. Significant correlation was found between prehypothermia WGR and MD, AD, and RD values in the left anterior CSO (r = .38-.40, P = .02). Prehypothermia WGR also correlated with the following: MD and RD in the right anterior CSO (r = .35-.36, P = .04), MD and AD in the right posterior CSO (r = .32-.45, P = .008-.03), and AD in the left posterior CSO (r = .47, P = .005). No significant correlation was found either between prehypothermia WGR and FA values in the bilateral anterior and posterior CSO or between posthypothermia WGR and all DTI scalars in the bilateral anterior and posterior CSO. CONCLUSIONS Prehypothermia HUS WGR may predict posthypothermia white matter structural integrity and is potentially an early and easily obtainable biomarker of severity in neonatal HII.
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Falomo E, Adejumo C, Carson KA, Harvey S, Mullen L, Myers K. Variability in the Management Recommendations Given for High-risk Breast Lesions Detected on Image-guided Core Needle Biopsy at U.S. Academic Institutions. Curr Probl Diagn Radiol 2019; 48:462-466. [DOI: 10.1067/j.cpradiol.2018.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/01/2018] [Accepted: 06/20/2018] [Indexed: 11/22/2022]
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Chisholm JF, Shenoy SK, Shade JK, Kim V, Putcha N, Carson KA, Wise R, Hansel NN, Hanes JS, Suk JS, Neptune E. Nanoparticle diffusion in spontaneously expectorated sputum as a biophysical tool to probe disease severity in COPD. Eur Respir J 2019; 54:13993003.00088-2019. [PMID: 31164433 DOI: 10.1183/13993003.00088-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/26/2019] [Indexed: 01/20/2023]
Abstract
Perturbations in airway mucus properties contribute to lung function decline in patients with chronic obstructive pulmonary disease (COPD). While alterations in bulk mucus rheology have been widely explored, microscopic mucus properties that directly impact on the dynamics of microorganisms and immune cells in the COPD lungs are yet to be investigated.We hypothesised that a tightened mesh structure of spontaneously expectorated mucus (i.e. sputum) would contribute to increased COPD disease severity. Here, we investigated whether the mesh size of COPD sputum, quantified by muco-inert nanoparticle (MIP) diffusion, correlated with sputum composition and lung function measurements.The microstructure of COPD sputum was assessed based on the mean squared displacement (MSD) of variously sized MIPs measured by multiple particle tracking. MSD values were correlated with sputum composition and spirometry. In total, 33 samples collected from COPD or non-COPD individuals were analysed.We found that 100 nm MIPs differentiated microstructural features of COPD sputum. The mobility of MIPs was more hindered in sputum samples from patients with severe COPD, suggesting a tighter mucus mesh size. Specifically, MSD values inversely correlated with lung function.These findings suggest that sputum microstructure may serve as a novel risk factor for COPD progression and severity.
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Gipson TT, Poretti A, Kelley SA, Carson KA, Johnston MV, Huisman TAGM. Characterization of the Basal Ganglia Using Diffusion Tensor Imaging in Children with Self-Injurious Behavior and Tuberous Sclerosis Complex. J Neuroimaging 2019; 29:506-511. [PMID: 31056796 PMCID: PMC6618151 DOI: 10.1111/jon.12628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 04/24/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Tuberous sclerosis complex (TSC) is a rare, genetic disease that is associated with multiple manifestations including epilepsy and autism. Self‐injurious behaviors (SIBs) also occur in a subset of patients. This study used diffusion tensor imaging (DTI) in children with TSC for quantitative and volumetric analysis of brain regions that have been associated with SIB in other genetic conditions. METHODS We used DTI to compare 6 children with TSC‐associated SIB and 10 children with TSC without SIB. Atlas‐based analysis of DTI data and calculation of number of voxels; fractional anisotropy (FA); and mean, axial, and radial diffusivity were performed for multiple regions; DTI measures were summarized using medians and interquartile ranges and were compared using Wilcoxon rank sum tests and false discovery rates (FDRs). RESULTS Analysis showed that children with TSC and SIB had reduced numbers of voxels (median) in the bilateral globus pallidus (right: 218 vs. 260, P = .008, FDR = .18; left: 222 vs. 274, P = .002, FDR = .12) and caudate nucleus (right: 712 vs. 896, P = .01, FDR = .26; left: 702 vs. 921, P = .03, FDR = .44) and reduced FA in the bilateral globus pallidus (right: .233 vs. .272, P = .003, FDR = .12; left: .223 vs. .247, P = .004, FDR = .12) and left caudate nucleus (.162 vs. .186, P = .03, FDR = .39) versus children without SIB. No other statistically significant differences were found. CONCLUSIONS These data support a correlation between lower volumes of the globus pallidus and caudate with SIB in children with TSC.
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Ibe CA, Bowie J, Carson KA, Bone L, Monroe D, Roter D, Cooper LA. Patient-level Predictors of Extent of Exposure to a Community Health Worker Intervention in a Randomized Controlled Trial. Ethn Dis 2019; 29:261-266. [PMID: 31057311 DOI: 10.18865/ed.29.2.261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective Community health worker (CHW) interventions have been cited as a best practice for reducing health disparities, but patient-level attributes may contribute to differential uptake. We examined patient characteristics associated with the extent of exposure to a CHW coaching intervention among a predominantly low-income, African American population participating in a randomized controlled trial of hypertension interventions. Design We conducted a within-group longitudinal analysis of those receiving a CHW intervention from a study conducted between September 2003 and August 2005. We employed mixed effects models to ascertain relationships between patients' characteristics, length of time spent with the CHW, and the number of topics discussed during the intervention. Setting Baltimore, MD. Participants 140 patients with a diagnosis of hypertension in the CHW intervention arm. Results Marital status, stress, depression symptomology, and having multiple comorbid conditions were each independently and positively related to the length of time patients spent with CHWs. An indirect relationship between higher perceived physical health and time spent with the CHW was observed. Patients with multiple comorbid conditions discussed more intervention-related topics, while patients who perceived themselves as being healthier discussed fewer topics. Marital status and extreme poverty were the strongest predictors of the length of time spent with the CHW, while having multiple comorbid conditions was the strongest predictor of the number of coaching topics discussed. Conclusions Differential exposure to a CHW intervention is influenced by patients' physical, psychosocial, and sociodemographic characteristics.
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Laube BL, Carson KA, Sharpless G, Paulin LM, Hansel NN. Mucociliary Clearance in Former Tobacco Smokers with Both Chronic Obstructive Pulmonary Disease and Chronic Bronchitis and the Effect of Roflumilast. J Aerosol Med Pulm Drug Deliv 2019; 32:189-199. [PMID: 30964381 DOI: 10.1089/jamp.2018.1459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Little is known of the repeatability and reliability of mucociliary clearance (MCC) in former tobacco smokers who have both chronic obstructive pulmonary disease (COPD) and chronic bronchitis (CB). Less is known of the effect of roflumilast, a selective inhibitor of PDE4, on MCC in these patients. Methods: Former tobacco smokers with COPD and CB were treated for 4 weeks with either roflumilast, or placebo, in a randomized, crossover trial. The following were measured on two baseline and two posttreatment visits: MCC values through 90 minutes, following inhalation of 99mtechnetium sulfur colloid and gamma camera imaging; outer:inner (O:I) deposition ratio; forced expiratory volume in 1 second (FEV1); and symptom scores. Comparisons included: MCC measures through 30 minutes (MCC30), 60 minutes (MCC60), and 90 minutes (MCC90) on the two baseline visits (n = 9) and mean change [(roflumilast - baseline)-(placebo - baseline)] for MCC30, MCC60, MCC90, and FEV1 (n = 8). Associations between MCC measurements, FEV1 and O:I ratio with symptom scores were also examined. Results: Pearson correlation tests indicated good repeatability for baseline measures of MCC30, MCC60, and MCC90 and intraclass correlation coefficients indicated good reliability. Only FEV1 (percent predicted) improved significantly following roflumilast treatment. There were no statistically significant correlations between MCC measures and symptom scores. Lower FEV1 values were significantly associated with increased shortness of breath (dyspnea), and lower O:I ratios (more inner region deposition) were significantly associated with increased cough and sputum. Conclusions: Measurements of MCC30, MCC60, and MCC90 are repeatable and reliable in former tobacco smokers with both COPD and CB. One month of treatment with roflumilast did not improve MCC in this limited study. Airway narrowing in the larger, central airways of these subjects could lead to decreased FEV1, increased inner region deposition of the radiolabeled particles, and the associated increase in symptoms of dyspnea, cough, and sputum.
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Riedel S, Boire N, Carson KA, Vadlamudi A, Khuvis J, Vadlamudi V, Atukorale V, Riedel VAA, Parrish NM. A survey of antimicrobial resistance in Enterobacteriaceae isolated from the Chesapeake Bay and adjacent upper tributaries. Microbiologyopen 2019; 8:e00839. [PMID: 30950215 PMCID: PMC6741119 DOI: 10.1002/mbo3.839] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 02/06/2023] Open
Abstract
In recent years, the rise in antimicrobial resistance (AR) in the healthcare setting as well as the environment has been recognized as a growing public health problem. The Chesapeake Bay (CB) and its upper tributaries (UT) is a large and biologically diverse estuary. This pilot study evaluated the presence of AR of gram‐negative bacteria isolated from water samples collected at various sites of the Chesapeake Bay. Bacterial organisms were identified and antimicrobial susceptibility testing was performed by phenotypic and genotypic methods. Ninety‐two distinctly different gram‐negative bacteria were identified; Klebsiella pneumoniae, Enterobacter cloacae, Enterobacter aerogenes, Serratia marcescens, and Escherichia coli were most often isolated. Serratia marcescens was more frequently isolated in samples from the UT compared to the CB. Antimicrobial resistance was more frequently detected in organisms from the CB by phenotypic and genotypic methods. Antimicrobial resistance to ampicillin, imipenem, tetracycline, and chloramphenicol were the most frequently observed resistance patterns. ACT‐1, CMY, and SHV genes were the most frequently detected resistance genes, with predominance in organism isolated from the CB. The results from this study emphasize the importance for further developing comprehensive surveillance programs of AR in bacterial isolates in the various environments, such as recreational and other water systems.
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Song AY, Crews DC, Ephraim PL, Han D, Greer RC, Boyér LL, Ameling J, Gayles DJ, Sneed V, Carson KA, Albert M, Liu Y, Cooper LA, Boulware LE. Sociodemographic and Kidney Disease Correlates of Nutrient Intakes Among Urban African Americans With Uncontrolled Hypertension. J Ren Nutr 2019; 29:399-406. [PMID: 30709714 DOI: 10.1053/j.jrn.2018.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 11/18/2018] [Accepted: 12/12/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The objective of this study was to determine the association between sociodemographic factors and intakes of 4 nutrients and associations between intakes and markers of kidney disease to identify opportunities to improve outcomes among clinically high-risk African Americans. DESIGN AND METHODS We conducted a cross-sectional study of baseline data from the Achieving Blood Pressure Control Together study, a randomized controlled trial of 159 African Americans (117 females) with uncontrolled hypertension in Baltimore MD. To determine the association between sociodemographic factors and nutrient intakes, we constructed linear and logistic regression models. Using logistic regression, we determined the association between below-median nutrient intakes and kidney disease. Our outcomes of interest were daily intakes of vitamin C, magnesium, dietary fiber, and potassium as estimated by the Block Fruit-Vegetable-Fiber Screener and kidney disease defined as estimated glomerular filtration rate <60 mL/min per 1.73 m2 or urinary albumin-to-creatinine ratio >=30 mg/g. SETTING AND SUBJECTS Baseline data from the Achieving Blood Pressure Control Together study, a randomized controlled trial of 159 African Americans (117 females) with uncontrolled hypertension, were obtained. METHODS To determine the association between sociodemographic factors and nutrient intakes, we constructed linear and logistic regression models. Using logistic regression, we determined the association between below-median nutrient intakes and kidney disease. MAIN OUTCOME MEASURES Our outcomes of interest were daily intakes of vitamin C, magnesium, dietary fiber, and potassium as estimated by the Block Fruit-Vegetable-Fiber Screener and kidney disease defined as estimated glomerular filtration rate <60 mL/min per 1.73 m2 or urinary albumin-to-creatinine ratio ≥30 mg/g. RESULTS Overall, compared to Institute of Medicine recommendations, participants had lower intakes of magnesium, fiber, and potassium but higher vitamin C intakes. For females, sociodemographic factors that significantly associated with lower intake of the 4 nutrients were older age, obesity, lower health numeracy, and lesser educational attainment. For males, none of the sociodemographic factors were significantly associated with nutrient intakes. Below-median intake was significantly associated with albumin-to-creatinine ratio ≥30 (adjusted odds ratio [95% confidence interval]: 3.4 [1.5, 7.8] for vitamin C; 3.6 [1.6, 8.4] for magnesium; 2.9 [1.3, 6.5] for fiber; 3.6 [1.6, 8.4] for potassium), but not with estimated glomerular filtration rate <60. CONCLUSION African Americans with uncontrolled hypertension may have low intakes of important nutrients, which could increase their risk of chronic kidney disease. Tailored dietary interventions for African Americans at high risk for chronic kidney disease may be warranted.
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Mogul DB, Brereton N, Carson KA, Pittarelli M, Daniel H, Torbenson M, Schwarz KB. Development of a Dietary Methyl Donor Food Frequency Questionnaire to Assess Folate and Vitamin B 12 Status in Children with Chronic Hepatitis B Virus Infection. J Pediatr 2018; 203:41-46.e2. [PMID: 30243534 DOI: 10.1016/j.jpeds.2018.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/10/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To develop a dietary methyl donor food frequency questionnaire (DMD-FFQ) that is validated in a cohort of US children and to determine whether the consumption of folate and vitamin B12, principal DMDs, correlates with HBV DNA levels and its methylation density. STUDY DESIGN We developed a semiquantitative DMD-FFQ to estimate intake of folate and vitamin B12 and validated this instrument against a 24-hour dietary recall and biomarkers-red blood cell folate, serum vitamin B12, and homocysteine-in 35 children with chronic HBV infection without other medical comorbidities. Estimates of DMD, as well as the serum biomarkers, were correlated with the methylation density of HBV CpG island 2 and HBV DNA levels. RESULTS Folate per kilogram of body weight by the DMD-FFQ correlated positively with 24-hour recall (r = 0.60; P < .001) and red blood cell folate (r = 0.40; P = .02), and negatively with homocysteine (r = -0.54; P < .001). Vitamin B12 per kilogram by DMD-FFQ also correlated positively with 24-hour recall (r = 0.57; P < .001) and serum vitamin B12 (r = 0.36, P = .04), and negatively with homocysteine (r = -0.44; P = .008). Neither DMD intake (from DMD-FFQ or 24-hour recall) nor serum biomarkers correlated with HBV DNA levels or its methylation density. CONCLUSIONS Our DMD-FFQ correlates well with a 24-hour recall and circulating biomarkers. Although little evidence existed that consumption of these micronutrients correlated with HBV replication, this tool could prove useful for investigating epigenetic modification by diet for several pediatric diseases.
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Mobula LM, Sarfo FS, Carson KA, Burnham G, Arthur L, Ansong D, Sarfo-Kantanka O, Plange-Rhule J, Ofori-Adjei D. Predictors of glycemic control in type-2 diabetes mellitus: Evidence from a multicenter study in Ghana. TRANSLATIONAL METABOLIC SYNDROME RESEARCH 2018. [DOI: 10.1016/j.tmsr.2018.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Tang O, Juraschek SP, Appel LJ, Cooper LA, Charleston J, Boonyasai RT, Carson KA, Yeh HC, Miller ER. Comparison of automated clinical and research blood pressure measurements: Implications for clinical practice and trial design. J Clin Hypertens (Greenwich) 2018; 20:1676-1682. [PMID: 30403006 DOI: 10.1111/jch.13412] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/13/2018] [Accepted: 09/07/2018] [Indexed: 11/30/2022]
Abstract
Discrepancies between clinic and research blood pressure (BP) measurements lead to uncertainties in translating hypertension management guidelines into practice. We assessed the concordance between standardized automated clinic BP, from a primary care clinic, and research BP, from a randomized trial conducted at the same site. Mean single-visit clinic BP was higher by 4.4/3.8 mm Hg (P = 0.007/<0.001). Concordance in systolic BP (SBP) improved with closer proximity of measurements (difference = 2.5 mm Hg, P = 0.21 for visits within 7 days), but not averaging across multiple visits (difference =5.1(9.2) mm Hg; P < 0.001). This discrepancy was greater among female participants. Clinic-based difference in SBP between two visits was more variable than research-based change (SD = 19.6 vs 14.0; P = 0.002); a 2-arm trial using clinic measurements would need 95% more participants to achieve comparable power. Implementation of a bundled standardization intervention decreased discrepancies between clinic and research BP, compared to prior reports. However, clinic measurements remained higher and more variable, suggesting treatment to research-based targets may lead to overtreatment and using clinic BP approximately halves power in trials.
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Salas J, Reddy N, Orru E, Carson KA, Chavez-Valdez R, Burton VJ, Stafstrom CE, Northington FJ, Huisman TAGM. The Role of Diffusion Tensor Imaging in Detecting Hippocampal Injury Following Neonatal Hypoxic-Ischemic Encephalopathy. J Neuroimaging 2018; 29:252-259. [PMID: 30325083 DOI: 10.1111/jon.12572] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/12/2018] [Accepted: 10/03/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Neonatal hypoxic-ischemic injury of the brain and resultant encephalopathy (HIE) leads to major developmental impairments by school age. Conventional/anatomical MRI often fails to detect hippocampal injury in mild cases. We hypothesize that diffusion tensor imaging (DTI) has greater sensitivity for identifying subtle hippocampal injury. METHODS We retrospectively analyzed DTI data collected from a cohort of neonates with HIE and controls. Conventional MRI sequences were classified qualitatively according to severity using a modified Barkovich scale. Using multivariate linear regression, we compared hippocampal DTI scalars of HIE patients and controls. Spearman correlation was used to test the association of DTI scalars in the hippocampal and thalamic regions. A multiple regression analysis tested the association of the DTI scalars with short-term outcomes. RESULTS Fifty-five neonates with HIE (42% males) and 13 controls (54% males) were included. Hippocampal DTI scalars were similar between HIE and control groups, even when restricting the HIE group to those with moderate-to-severe injury (8 subjects). DTI scalars of the thalamus were significantly lower in the moderate-to-severely affected patients compared to controls (right fractional anisotropy [FA] .148 vs. .182, P = .01; left FA .147 vs. .181, P = .03). Hippocampal and thalamic DTI scalars were correlated (P < .001). Hippocampal DTI scalars were not associated with short-term outcomes. CONCLUSIONS Quantitative DTI analysis of the hippocampus in neonates following HIE is a feasible technique to examine neuronal injury. Although DTI scalars were useful in identifying thalamic injury in our cohort, hippocampal DTI analysis did not provide additional information regarding hippocampal injury following HIE.
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Falomo E, Myers K, Reichel KF, Carson KA, Mullen L, Di Carlo P, Harvey S. Impact of insurance coverage and socioeconomic factors on screening mammography patients' selection of digital breast tomosynthesis versus full-field digital mammography. Breast J 2018; 24:1091-1093. [PMID: 30240094 DOI: 10.1111/tbj.13129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/06/2017] [Accepted: 11/07/2017] [Indexed: 11/28/2022]
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Waldman M, Han JC, Reyes-Capo DP, Bryant J, Carson KA, Turkbey B, Choyke P, Naggert JK, Gahl WA, Marshall JD, Gunay-Aygun M. Alström syndrome: Renal findings in correlation with obesity, insulin resistance, dyslipidemia and cardiomyopathy in 38 patients prospectively evaluated at the NIH clinical center. Mol Genet Metab 2018; 125:181-191. [PMID: 30064963 PMCID: PMC7984722 DOI: 10.1016/j.ymgme.2018.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 07/19/2018] [Accepted: 07/19/2018] [Indexed: 12/15/2022]
Abstract
Alström Syndrome is a ciliopathy associated with obesity, insulin resistance/type 2 diabetes mellitus, cardiomyopathy, retinal degeneration, hearing loss, progressive liver and kidney disease, and normal cognitive function. ALMS1, the protein defective in this disorder, localizes to the cytoskeleton, microtubule organizing center, as well as the centrosomes and ciliary basal bodies and plays roles in formation and maintenance of cilia, cell cycle regulation, and endosomal trafficking. Kidney disease in this disorder has not been well characterized. We performed comprehensive multisystem evaluations on 38 patients. Kidney function decreased progressively; eGFR varied inversely with age (p = 0.002). Eighteen percent met the definition for chronic kidney disease (eGFR < 60 mL/min/1.73 m2 and proteinuria); all were adults with median age of 32.8 (20.6-37.9) years. After adjusting for age, there were no significant associations of kidney dysfunction with type 2 diabetes mellitus, dyslipidemia, hypertension, cardiomyopathy or portal hypertension suggesting that kidney disease in AS is a primary manifestation of the syndrome due to lack of ALMS1 protein. Approximately one-third of patients had hyperechogenicity of the renal parenchyma on imaging. While strict control of type 2 diabetes mellitus may decrease kidney-related morbidity and mortality in Alström syndrome, identification of novel targeted therapies is needed.
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Vivas-Buitrago TGM, Rigamonti A, Pinilla-Monsalve GD, Carson KA, Sharkey P, Robison J, Jusué-Torres I, Clemens G, Sanyal A, Hoffberger J, Sankey EW, Lu J, Adams A, Rigamonti D. 160 Normal Pressure Hydrocephalus Medicare Expenditures (2006-2010). Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Akhuemonkhan E, Parian A, Carson KA, Hutfless S. Adverse Reactions After Intravenous Iron Infusion Among Inflammatory Bowel Disease Patients in the United States, 2010-2014. Inflamm Bowel Dis 2018; 24:1801-1807. [PMID: 29669068 PMCID: PMC6241641 DOI: 10.1093/ibd/izy063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Indexed: 12/12/2022]
Abstract
Background Anemia is a frequent complication of Crohn's disease (CD) and ulcerative colitis (UC), collectively known as inflammatory bowel disease (IBD). Intravenous (IV) iron is recommended as the initial therapy for patients with clinically active IBD, severe anemia, and intolerance to oral iron. IV iron is associated with serious adverse effects including a black box warning for anaphylaxis with iron dextran and ferumoxytol. We aimed to examine the occurrence of adverse reactions including anaphylaxis after IV iron infusions in a large database of US IBD patients. Methods We performed a retrospective analysis for encounters occurring between 2010 and 2014 in MarketScan, a US commercial claims database. We assessed the following adverse events: anaphylactic shock, bronchospasm, and hypotension among IBD patients receiving ferumoxytol, iron dextran, ferric gluconate, iron sucrose, and ferric carboxymaltose. We calculated the adverse event rate per 1000 infusions within 7 days of IV iron infusion. Results In our study cohort of 6151 IBD patients (38.4% UC), 37 168 IV iron infusions were given (median, 3 infusions). There were very few adverse events; only 1.3% of IBD patients experienced any adverse reaction. The incident rate per 1000 infusions for any adverse event among IBD patients was highest among those receiving ferumoxytol (2.54, 95% confidence interval [CI], 1.26-5.11), ferric gluconate (1.85; 95% CI, 1.03-3.35), iron sucrose (1.74; 95% CI, 1.09-2.78), and iron dextran (0.96; 95% CI, 0.43-2.13). There were 0.24 anaphylactic shock events per 1000 IV iron infusions. Conclusions About 1.3 of 100 IBD patients ever developed any adverse event. Because adverse reactions are rare, physicians should be encouraged to adhere to recommended guidelines for iron replacement among anemic IBD patients. 10.1093/ibd/izy063_video1izy063.video15768853346001.
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Lin DM, Carson KA, Lubomski LH, Wick EC, Pham JC. Statewide Collaborative to Reduce Surgical Site Infections: Results of the Hawaii Surgical Unit-Based Safety Program. J Am Coll Surg 2018; 227:189-197.e1. [PMID: 29782913 DOI: 10.1016/j.jamcollsurg.2018.04.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) after colorectal surgery are common, lead to patient harm, and are costly to the healthcare system. This study's purpose was to evaluate the effectiveness of the AHRQ Safety Program for Surgery in Hawaii. STUDY DESIGN This pre-post cohort study involved 100% of 15 hospitals in Hawaii from January 2013 through June 2015. The intervention was a statewide implementation of the Comprehensive Unit-Based Safety Program and individualized bundles of interventions to reduce SSIs. Primary end point was colorectal SSIs. Secondary end point was safety culture measured by the AHRQ Hospital Survey on Patient Safety Culture. RESULTS The most common interventions implemented were reliable chlorhexidine wash, wipe before operation, and surgical preparation; appropriate antibiotic choice, dose, and timing; standardized post-surgical debriefing; and differentiating clean-dirty-clean with anastomosis tray and closing tray. From January 2013 (quarter 1) through June 2015 (quarter 2), the collaborative colorectal SSI rate decreased (from 12.08% to 4.63%; p < 0.01). The SSI rate exhibited a linear decrease during the 10-quarter period (p = 0.005). Safety culture increased in 10 of 12 domains: Overall Perception/Patient Safety (from 49% to 53%); Teamwork Across Units (from 49% to 54%); Management-Support Patient Safety (from 53% to 60%); Nonpunitive Response to Error (from 36% to 40%); Communication Openness (from 50% to 55%); Frequency of Events Reported (from 51% to 60%); Feedback/Communication about Error (from 52% to 59%); Organizational Learning/Continuous Improvement (from 59% to 70%); Supervisor/Manager Expectations and Actions Promoting Safety (from 58% to 64%); and Teamwork Within Units (from 68% to 75%) (all p < 0.05). CONCLUSIONS Participation in the national AHRQ Safety Program for Surgery in the state of Hawaii was associated with a 61.7% decrease in colorectal SSI rate and an increase in patient safety culture.
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Thakur KT, Vareta J, Carson KA, Kampondeni S, Potchen MJ, Birbeck GL, MacCormick I, Taylor T, Sullivan DJ, Seydel KB. Cerebrospinal fluid Plasmodium falciparum histidine-rich protein-2 in pediatric cerebral malaria. Malar J 2018; 17:125. [PMID: 29566695 PMCID: PMC5865338 DOI: 10.1186/s12936-018-2272-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 03/14/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Cerebral malaria (CM) causes a rapidly developing coma, and remains a major contributor to morbidity and mortality in malaria-endemic regions. This study sought to determine the relationship between cerebrospinal fluid (CSF) Plasmodium falciparum histidine rich protein-2 (PfHRP-2) and clinical, laboratory and radiographic features in a cohort of children with retinopathy-positive CM. METHODS Patients included in the study were admitted (2009-2013) to the Pediatric Research Ward (Queen Elizabeth Central Hospital, Blantyre, Malawi) meeting World Health Organization criteria for CM with findings of malarial retinopathy. Enzyme-linked immunosorbent assay was used to determine plasma and CSF PfHRP-2 levels. Wilcoxon rank-sum tests and multivariable logistic regression analysis assessed the association of clinical and radiographic characteristics with the primary outcome of death during hospitalization. RESULTS In this cohort of 94 patients, median age was 44 (interquartile range 29-62) months, 53 (56.4%) patients were male, 6 (7%) were HIV-infected, and 10 (11%) died during hospitalization. Elevated concentrations of plasma lactate (p = 0.005) and CSF PfHRP-2 (p = 0.04) were significantly associated with death. On multivariable analysis, higher PfHRP-2 in the CSF was associated with death (odds ratio 9.00, 95% confidence interval 1.44-56.42) while plasma PfHRP-2 was not (odds ratio 2.05, 95% confidence interval 0.45-9.35). CONCLUSIONS Elevation of CSF, but not plasma PfHRP-2, is associated with death in this paediatric CM cohort. PfHRP-2 egress into the CSF may represent alteration of blood brain barrier permeability related to the sequestration of parasitized erythrocytes in the cerebral microvasculature.
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Rock C, Curless MS, Carson KA, Nowakowski E, Scheeler V, Maragakis LL. Patient and health care worker perceptions of daily use of ultraviolet-C technology as an adjunct to daily cleaning in an academic hospital: Secondary study of Ultra Violet-C Light Evaluation as an Adjunct to Removing Multi-Drug Resistant Organisms. Am J Infect Control 2018; 46:348-349. [PMID: 29056329 DOI: 10.1016/j.ajic.2017.08.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 11/30/2022]
Abstract
A cluster randomized crossover trial is in progress at The Johns Hopkins Hospital to investigate the impact of daily ultraviolet (UV)-C light disinfection on the acquisition of health care-associated pathogens. To understand perceptions and challenges to daily use of UV-C, we surveyed health care workers (HCWs) and patients. Most HCWs think daily UV-C decreases the patients' risk of acquiring infection. Daily UV-C is acceptable to patients and may enhance their overall hospital experience.
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Hines AL, Roter D, Ghods Dinoso BK, Carson KA, Daumit GL, Cooper LA. Informed and patient-centered decision-making in the primary care visits of African Americans with depression. PATIENT EDUCATION AND COUNSELING 2018; 101:233-240. [PMID: 28779910 PMCID: PMC5785566 DOI: 10.1016/j.pec.2017.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 07/21/2017] [Accepted: 07/24/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We examined the prevalence and extent of informed decision-making (IDM) and patient-centered decision-making (PCDM) in primary care visits of African Americans with depression. METHODS We performed a cross-sectional analysis of audiotaped clinical encounters and post-visit surveys of 76 patients and their clinicians. We used RIAS to characterize patient-centeredness of visit dialogue. IDM entailed discussion of 3 components: the nature of the decision, alternatives, and pros/cons. PCDM entailed discussion of: lifestyle/coping strategies, knowledge/beliefs, or treatment concerns. We examined the association of IDM and PCDM with visit duration, overall patient-centeredness, and patient/clinician interpersonal ratings. RESULTS Approximately one-quarter of medication and counseling decisions included essential IDM elements and 40% included at least one PCDM element. In high patient-centered visits, IDM was associated with patients feeling respected in counseling and liking clinicians in medication decisions. IDM was not related to clinician ratings. In low patient-centered visits, PCDM in counseling decisions was positively associated with patients feeling respected and clinicians respecting patients. CONCLUSIONS The associations between IDM and PCDM with interpersonal ratings was moderated by overall patient-centeredness of the visit, which may be indicative of broader cross-cultural communication issues. PRACTICE IMPLICATIONS Strengthening partnerships between depressed African Americans and their clinicians may improve patient-engaged decision-making.
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Abu H, Aboumatar H, Carson KA, Goldberg R, Cooper LA. Hypertension knowledge, heart healthy lifestyle practices and medication adherence among adults with hypertension. EUROPEAN JOURNAL FOR PERSON CENTERED HEALTHCARE 2018; 6:108-114. [PMID: 32405420 DOI: 10.5750/ejpch.v6i1.1416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective To assess patients' knowledge about hypertension and its association with heart healthy lifestyle practices and medication adherence. Methods We conducted a cross sectional survey of 385 adults with hypertension treated at 2 primary care clinics in Baltimore, Maryland, USA. We used an 11-item measure to assess hypertension knowledge and obtained self-reports on dietary changes, engagement in aerobic exercise and medication adherence. Results Approximately 85% of patients properly identified high blood pressure, but more than two-thirds were unaware that hypertension lasts a lifetime once diagnosed; one-third were unaware that hypertension could lead to renal disease. Patients with low hypertension knowledge were less likely to reduce their salt intake (OR=0.44 [95% CI: 0.24-0.72]) and eat less to lose weight (OR=0.48 [95% CI: 0.26-0.87]) than patients with high hypertension knowledge. Conclusion In general, patients were knowledgeable about hypertension, but most were unaware that hypertension is a lifelong condition and could lead to kidney disease. High knowledge of hypertension was associated with healthy lifestyle practices including eating less to lose weight and dietary salt reduction. Practice Implications Intensifying education strategies to improve patients' knowledge of hypertension may enhance their engagement in heart healthy lifestyle practices for optimal blood pressure control.
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Boonyasai RT, Carson KA, Marsteller JA, Dietz KB, Noronha GJ, Hsu YJ, Flynn SJ, Charleston JM, Prokopowicz GP, Miller ER, Cooper LA. A bundled quality improvement program to standardize clinical blood pressure measurement in primary care. J Clin Hypertens (Greenwich) 2017; 20:324-333. [PMID: 29267994 DOI: 10.1111/jch.13166] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/28/2017] [Accepted: 09/30/2017] [Indexed: 12/17/2022]
Abstract
We evaluated use of a program to improve blood pressure measurement at 6 primary care clinics over a 6-month period. The program consisted of automated devices, clinical training, and support for systems change. Unannounced audits and electronic medical records provided evaluation data. Clinics used devices in 81.0% of encounters and used them as intended in 71.6% of encounters, but implementation fidelity varied. Intervention site systolic and diastolic blood pressure with terminal digit "0" decreased from 32.1% and 33.7% to 11.1% and 11.3%, respectively. Improvement occurred uniformly, regardless of sites' adherence to the measurement protocol. Providers rechecked blood pressure measurements less often post-intervention (from 23.5% to 8.1% of visits overall). Providers at sites with high protocol adherence were less likely to recheck measurements than those at low adherence sites. Comparison sites exhibited no change in terminal digit preference or repeat measurements. This study demonstrates that clinics can apply a pragmatic intervention to improve blood pressure measurement. Additional refinement may improve implementation fidelity.
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