Provision of Lifestyle Counseling and the Prescribing of Pharmacotherapy for Hyperlipidemia Among US Ambulatory Patients: A National Assessment of Office-Based Physician Visits

Atherosclerotic Cardiovascular Disease Primary and Secondary Prevention in Latino Subgroups

BACKGROUND

Studies assessing equity in the prevention of atherosclerotic cardiovascular disease (ASCVD) for Latinos living in the USA collectively yield mixed results. Latino persons are diverse in many ways that may influence cardiovascular health. The intersection of Latino nativity and ASCVD prevention is understudied.

OBJECTIVE

To determine whether disparities in ASCVD screening, detection, and prescribing differ for US Latinos by country of birth.

DESIGN

A retrospective cohort design utilizing 2014-2020 electronic health record data from a network of 320 community health centers across 12 states. Analyses occurred October 1, 2022, to September 30, 2023.

PARTICIPANTS

Non-Hispanic White and Latino adults age 20-75 years, born in Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, and the USA.

EXPOSURES

Ethnicity and country of birth.

MAIN MEASURES

Outcome measures included prevalence of statin eligibility, of having insufficient data to establish eligibility, odds of having a documented statin prescription, and rates of statin prescriptions and refills. We used covariate-adjusted logistic and generalized estimating equations logistic and negative binomial regressions to generate absolute and relative measures.

KEY RESULTS

Among 108,672 adults, 23% (n = 25,422) were statin eligible for primary or secondary prevention of ASCVD using American College of Cardiology/American Heart Association guidelines. Latinos, born in and outside the USA were more likely eligible than Non-Hispanic White patients were (US-born Latino OR = 1.55 (95% CI = 1.37-1.75); non-US-born Latino OR = 1.63 (95% CI = 1.34-1.98)). The eligibility criteria that was met differed by ethnicity and nativity. Latinos overall were less likely missing data to establish eligibility and differences were again observed by specific non-US country of origin. Among those eligible, we observed no statistical difference in statin prescribing between US-born Latinos and non-Hispanic White persons; however, disparities varied by specific non-US country of origin.

CONCLUSION

Efforts to improve Latino health in the USA will require approaches for preventing and reversing cardiovascular risk factors, and statin initiation that are Latino subgroup specific.

Knowledge and attitudes of lower Michigan primary care physicians towards dietary interventions: A cross-sectional survey

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Physicians rarely counsel patients about dietary interventions despite the proven efficacy of such interventions.

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Physicians both over- and under-estimated their knowledge on different dietary interventions.

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>90% of participating physicians expressed interest in continuing education on dietary interventions.

Background

Dietary interventions are first-line therapies for the prevention and management of many chronic diseases, yet primary care physicians prescribe these interventions infrequently.

Objectives

This study investigates primary care physicians’ current knowledge and opinions regarding the delivery of dietary interventions. This work aims to identify modifiable barriers to prescribing dietary interventions to prevent and treat diet-related diseases.

Methods

We designed and fielded an anonymous, cross-sectional survey of faculty and resident physicians across the Internal Medicine, Family Medicine, and Pediatrics departments in three academic and community hospitals in lower Michigan. Data were collected between January 15 and April 15, 2019. Self-rated knowledge and attitudes were measured on a 5-point Likert scale. Objective scores were calculated for each question as percentage answered correctly among all respondents. Objective knowledge scores were compared based on participants’ years in practice.

Results

Response rate was 23% (356 responses). The sample was 62.3% female and 75.3% non-Hispanic White, and 56.7% were age 40 or younger. Average objective knowledge score was 70.3% (±17.2) correct. Mean self-rated knowledge score was 2.51 (±0.96) on a scale of 1(Poor) − 5(Excellent). Overall agreement with a statement of importance of dietary interventions was 3.99 (±0.40) on a scale of 1 (strongly disagree) to 5 (strongly agree). A majority (91.7%) of respondents indicated they would like more opportunities to learn about the evidence supporting dietary interventions.

Conclusions

Physicians desire to incorporate dietary interventions into their practice. Findings encourage the development of educational strategies to support dietary intervention use among primary care physicians.

Association of healthy lifestyle and all-cause mortality according to medication burden

BACKGROUND

Healthy lifestyle is associated with reduced all-cause mortality, but it is not known whether this association persists for individuals with high medication burden. We examined the association between healthy lifestyle behaviors and all-cause mortality across different degrees of polypharmacy.

METHODS

This was a secondary analysis of 20,417 adults aged ≥45 years from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study. The primary exposure was healthy lifestyle (adherence to Mediterranean diet, physical activity, smoking abstinence, sedentary behavior avoidance, and composite healthy behavior score [HBS]). The primary outcome was all-cause mortality. Strata of medication burden were based on the number of medications taken (no polypharmacy: 0-4, polypharmacy: 5-9, hyperpolypharmacy: ≥10). We used Cox proportional hazards regression models to examine the association between healthy lifestyle behaviors and mortality within each medication burden stratum and examined for interactions with age.

RESULTS

The healthiest category of each lifestyle behavior, except sedentary behavior avoidance among the hyperpolypharmacy group, was associated with lower all-cause mortality (hazard ratio [HR]) regardless of medication burden: Mediterranean diet (no polypharmacy: HR 0.77, polypharmacy: HR 0.78, hyperpolypharmacy: HR 0.85), physical activity (no polypharmacy: HR 0.87, polypharmacy: HR 0.82, hyperpolypharmacy: HR 0.79), smoking abstinence (no polypharmacy: HR 0.40, polypharmacy: HR 0.45, hyperpolypharmacy: HR 0.52), and sedentary behavior avoidance (no polypharmacy: HR 0.88, polypharmacy: HR 0.86, hyperpolypharmacy: HR 0.95). Higher HBS was inversely associated with all-cause mortality within each medication burden stratum (no polypharmacy: HR 0.52, polypharmacy: HR 0.55, hyperpolypharmacy: HR 0.69). Although there was an interaction with age among those with no polypharmacy and those with polypharmacy, point estimates for HBS followed a graded pattern whereby higher HBS was incrementally associated with improved mortality across all age strata.

CONCLUSION

Greater adherence to a healthy lifestyle was associated with lower all-cause mortality irrespective of medication burden and age.

Lifestyle Counseling for Patients with Type 2 Diabetes in the Southwest of Saudi Arabia: An Example of Healthcare Delivery Inequality Between Different Healthcare Settings

Purpose

Adherence to a healthy lifestyle can have a positive impact on the course of diabetes management. This investigation aims to study lifestyle counseling provision among patients with type 2 diabetes in Saudi Arabia and the delivery of lifestyle counseling within different healthcare settings.

Methods

This cross-sectional investigation was conducted in the Jazan region in Saudi Arabia. Data were collected using a semi-structured questionnaire during phone interviews. The questionnaire measured items related to the demographics of the patients, diabetes diagnoses, and follow-up locations. The items pertaining to lifestyle counseling were related to whether the patients were given an assessment of dietary and physical activity levels, receipt of a personalized lifestyle change plan, and smoking cessation therapy among smokers. Odds ratios (ORs) were calculated to estimate the probability of receiving the lifestyle counseling items in primary healthcare centers (PHCs) compared to other healthcare facilities.

Results

A total of 461 patients diagnosed with diabetes were identified. The development of symptoms or complications related to diabetes was the main cause of diagnosis (63%). Sixty-six patients reported not attending a follow-up at any healthcare facility. The ORs of receiving a lifestyle plan and having daily caloric needs calculated were higher among patients who followed up at hospitals, diabetes centers or within the private sector compared to those who went to PHCs (ORs: 1.8 [1.1–2.8] and 2.7 [1.2–5.9] respectively). In all the identified healthcare settings, health education was mostly provided by the treating physicians, indicating the limited role of nutritionists or health educationists.

Conclusion

This study suggests a limited receipt of lifestyle counseling services for patients with type 2 diabetes in PHCs compared to other healthcare facilities. The majority of counseling services were provided by physicians, which indicates the limited inter-disciplinary involvement of other health professionals, such as nutritionists and health educationists.

How the National Ambulatory Medical Care Survey has been used to identify health disparities in the care of patients in the United States

BACKGROUND

Healthcare disparities negatively impact patient health outcomes; addressing disparities could improve quality of life and decrease overall healthcare cost. The National Ambulatory Medical Care Survey (NAMCS) is an objective and reliable source for collecting information on United States (U.S.) ambulatory medical care service visits and may be a useful tool for identifying potential disparities in care.

OBJECTIVE

The purpose of this literature review is to describe studies utilizing NAMCS to capture U.S. healthcare disparities.

METHODS

PubMed was searched for scientific articles that utilized NAMCS to determine health disparities in the U.S. The keywords queried included "NAMCS" or "National Ambulatory Medical Care Survey" and "disparity" or "disparities" as a pair or additionally paired with one of the following: "race", "ethnicity", "age", "gender", "geography", or "insurance".

RESULTS

66 studies were found that incorporated NAMCS data from 1980-2016 into their methods to measure outcomes relating to health disparities. Disparities were found in the following categories: race/ethnicity, geographic location, age, insurance type, gender, specialist care versus primary care, body habitus, and preexisting conditions affecting patient outcomes. Disparities were identified in pain management, neurology, dermatology, psychiatry, patient communication access, and non-specialty specific or primary care visits related to disease conditions, screening, and treatment plans.

LIMITATIONS

Only PubMed was utilized as a search engine and may not encompass all studies on NAMCS and health disparities. NAMCS is a cross-sectional database and does not allow for longitudinal analyses.

CONCLUSIONS

NAMCS may be an underused tool given the limited number of articles that identify health disparities using it. Research studies utilizing NAMCS may identify potential disparities ultimately leading to better healthcare outcomes.

Tobacco Screening and Treatment of Patients With a Psychiatric Diagnosis, 2012-2015

INTRODUCTION

Smoking disproportionately affects individuals with psychiatric diagnoses. Providers can play a role in reducing tobacco-related morbidity among people with a psychiatric diagnosis by routinely screening and treating all patients for tobacco use. This study seeks to identify rates of tobacco screening, counseling, and medication orders during outpatient visits with adults who have a psychiatric diagnosis.

METHODS

Data from the 2012-2015 National Ambulatory Medical Care Survey were examined to calculate the proportion of visits with people who have a psychiatric diagnosis that included tobacco screening, counseling, or smoking-cessation medications. Logistic regression was used to identify patient and visit factors associated with tobacco screening and treatment. All analyses were conducted in 2018.

RESULTS

Seventy-two percent of visits included tobacco screening, 23% of visits with tobacco users included cessation counseling, and 4% of visits with tobacco users included a cessation medication order. Visits were more likely to include tobacco screening if they were for a nonpsychiatric condition, were >30 minutes, or were with a primary care physician (p<0.05). Visits were less likely to include tobacco screening if they were with a black, non-Hispanic patient or patient with Medicaid (p<0.05). Visits were more likely to include cessation counseling if they were for a nonpsychiatric condition (p<0.05), and were less likely to include counseling if they were with a Hispanic or self-pay patient (p<0.05).

CONCLUSIONS

There is still room for improvement in providing equitable treatment for people with psychiatric conditions for smoking, particularly in nonprimary settings.