Deaths preventable in the U.S. by improvements in use of clinical preventive services

Exploration of understanding of impactibility analysis and application through workshops to inform model design for population health management policy: a qualitative assessment

OBJECTIVES

Assess understanding of impactibility modelling definitions, benefits, challenges and approaches.

DESIGN

Qualitative assessment.

SETTING

Two workshops were developed. Workshop 1 was to consider impactibility definitions and terminology through moderated open discussion, what the potential pros and cons might be, and what factors would be best to assess. In workshop 2, participants appraised five approaches to impactibility modelling identified in the literature.

PARTICIPANTS

National Health Service (NHS) analysts, policy-makers, academics and members of non-governmental think tank organisations identified through existing networks and via a general announcement on social media. Interested participants could enrol after signing informed consent.

OUTCOME MEASURES

Descriptive assessment of responses to gain understanding of the concept of impactibility (defining impactibility analysis), the benefits and challenges of using this type of modelling and most relevant approach to building an impactibility model for the NHS.

RESULTS

37 people attended 1 or 2 workshops in small groups (maximum 10 participants): 21 attended both workshops, 6 only workshop 1 and 10 only workshop 2. Discussions in workshop 1 illustrated that impactibility modelling is not clearly understood, with it generally being viewed as a cross-sectional way to identify patients rather than considering patients by iterative follow-up. Recurrent factors arising from workshop 2 were the shortage of benchmarks; incomplete access to/recording of primary care data and social factors (which were seen as important to understanding amenability to treatment); the need for outcome/action suggestions as well as providing the data and the risk of increasing healthcare inequality.

CONCLUSIONS

Understanding of impactibility modelling was poor among our workshop attendees, but it is an emerging concept for which few studies have been published. Implementation would require formal planning and training and should be performed by groups with expertise in the procurement and handling of the most relevant health-related real-world data.

The Chicagoland Free Clinics Consortium: A Model for Student-Run Free Clinic Collaboration

BACKGROUND

While student-run free clinics (SRFCs) play an important role in care for underserved populations, few mechanisms exist to promote collaboration among regional SRFCs.

AIMS

To address this gap, the Chicagoland Free Clinics Consortium (CFCC) was formed to (1) facilitate collaboration between Chicagoland SRFCs, (2) provide innovation grant funding, and (3) host an annual conference.

SETTING AND PARTICIPANTS

In 2018, students from the Pritzker School of Medicine founded the CFCC and partnered with peers from area schools to implement programming.

PROGRAM DESCRIPTION

Between 2018 and 2022, CFCC engaged 23 SRFCs representing all 6 Chicagoland schools, held 4 annual conferences, and distributed $15,423 in grants to 19 projects at 14 SRFC sites.

PROGRAM EVALUATION

A total of 176 students from 5 schools attended the 4 conferences. In 2022, 82 unique participants were surveyed, and 66% (54/82) responded. Eighty percent (43/54) reported they were "more likely to collaborate with other Chicagoland free clinics." In 2022, all grant sites were surveyed and 84% (16/19) responded. Most (87%,14/16) agreed the grant "allowed them to implement a project that would not have otherwise been accomplished" and 21% (4/19) were inter-institutional collaborations.

DISCUSSION

To our knowledge, CFCC is the first student-led organization to promote sustained collaboration across SRFCs in a metropolitan area.

Leveraging Electronic Health Records to Construct a Phenotype for Hypertension Surveillance in the United States

BACKGROUND

Hypertension is an important risk factor for cardiovascular diseases. Electronic health records (EHRs) may augment chronic disease surveillance. We aimed to develop an electronic phenotype (e-phenotype) for hypertension surveillance.

METHODS

We included 11,031,368 eligible adults from the 2019 IQVIA Ambulatory Electronic Medical Records-US (AEMR-US) dataset. We identified hypertension using three criteria, alone or in combination: diagnosis codes, blood pressure (BP) measurements, and antihypertensive medications. We compared AEMR-US estimates of hypertension prevalence and control against those from the National Health and Nutrition Examination Survey (NHANES) 2017-18, which defined hypertension as BP ≥130/80 mm Hg or ≥1 antihypertensive medication.

RESULTS

The study population had a mean (SD) age of 52.3 (6.7) years, and 56.7% were women. The selected three-criteria e-phenotype (≥1 diagnosis code, ≥2 BP measurements of ≥130/80 mm Hg, or ≥1 antihypertensive medication) yielded similar trends in hypertension prevalence as NHANES: 42.2% (AEMR-US) vs. 44.9% (NHANES) overall, 39.0% vs. 38.7% among women, and 46.5% vs. 50.9% among men. The pattern of age-related increase in hypertension prevalence was similar between AEMR-US and NHANES. The prevalence of hypertension control in AEMR-US was 31.5% using the three-criteria e-phenotype, which was higher than NHANES (14.5%).

CONCLUSIONS

Using an EHR dataset of 11 million adults, we constructed a hypertension e-phenotype using three criteria, which can be used for surveillance of hypertension prevalence and control.

Development of a Hypertension Electronic Phenotype for Chronic Disease Surveillance in Electronic Health Records: Key Analytic Decisions and Their Effects

INTRODUCTION

Modernizing chronic disease surveillance with electronic health record (EHR) data may provide better data to improve hypertension prevention and control, but no consensus exists for an EHR-based surveillance definition for hypertension. The Multi-State EHR-Based Network for Disease Surveillance (MENDS) pilot surveillance system was used to develop and test an electronic phenotype for hypertension.

METHODS

We used MENDS data from 1,671,279 patients in Louisiana to examine the effect of different analytic decisions on estimates of hypertension prevalence. Decisions included 1) whether to restrict surveillance to patients with recent blood pressure measurements, 2) varying the number and recency of encounters to define the population at risk of hypertension, 3) how to define hypertension (diagnosis codes, antihypertensive medication, blood pressure measurements, or combinations of these), and 4) how to handle multiple blood pressure measurements on the same day. Results were compared with independent estimates of hypertension prevalence in Louisiana from the Behavioral Risk Factor Surveillance System (BRFSS).

RESULTS

Applying varying criteria resulted in hypertension prevalence estimates ranging from 19.7% to 59.3%. A hypertension surveillance strategy that includes a population with at least 1 clinical encounter with measured blood pressure in the previous 2 years and identifies hypertension using all available data (≥1 diagnosis code, ≥1 antihypertensive medication, and ≥2 elevated blood pressure values ≥140/90 mm Hg on separate days) generated estimates in line with population-based survey data. This definition estimated the crude 2019 hypertension prevalence in the state of Louisiana as 43.4% (age-adjusted, 41.0%), comparable with the crude BRFSS estimate of 39.7% (age adjusted, 37.1%).

CONCLUSION

Applying different criteria to define hypertension using EHR data has a large effect on hypertension prevalence estimates. The proposed electronic phenotype generates hypertension prevalence estimates that align with independent estimates from BRFSS.

Digitally Based Blood Pressure Self-Monitoring Program That Promotes Hypertension Self-Management and Health Education Among Patients With Low-Income: Usability Study

BACKGROUND

According to evidence-based clinical guidelines, adults with hypertension are advised to self-monitor their blood pressure (BP) twice daily. Self-measured BP monitoring is a recommended strategy for improving hypertension management.

OBJECTIVE

We aimed to determine the feasibility and acceptability of a digitally based BP self-monitoring program that promotes hypertension self-management and health education among low-income patients. We hypothesized that the program would be highly feasible and acceptable and that at least 50% of the patients would use the monitor at the rate required for the reimbursement of the device's cost (16 days of measurements in any 30-day period).

METHODS

Withings BPM Connect was deployed to patients at Family Health Centers of San Diego. Program elements included training, SMS text message reminders, and physician communication. Compliance, use, mean BP, and BP control status were calculated. A Kaplan-Meier time-to-event analysis was conducted to compare time to compliance between a strict definition (≥16 days in any rolling 30-day window) and a lenient definition (≥1 day per week for 4 consecutive weeks). A log-rank test was performed to determine whether the difference in time to compliance between the definitions was statistically significant. Mean systolic BP (SBP) and diastolic BP (DBP) before the intervention and after the intervention and mean change in SBP and DBP across patients were calculated. Paired sample t tests (2-tailed) were performed to assess the changes in SBP and DBP from before to after the intervention.

RESULTS

A total of 179 patients received the monitors. The mean changes in SBP and DBP from before to after the intervention were +2.62 (SE 1.26) mm Hg and +3.31 (SE 0.71) mm Hg, respectively. There was a statistically significant increase in both SBP and DBP after the intervention compared with before the intervention (P=.04 and P<.001). At the first and last measurements, 37.5% (63/168) and 48.8% (82/168) of the patients had controlled BP, respectively. During the observation period, 83.3% (140/168) of the patients had at least 1 controlled BP measurement. Use decreased over time, with 53.6% (90/168) of the patients using their monitor at week 2 and only 25% (42/168) at week 11. Although only 25.6% (43/168) achieved the strict definition of compliance, 42.3% (71/168) achieved the lenient definition of compliance. The median time to compliance was 130 days for the strict definition and 95 days for the lenient definition. The log-rank test showed a statistically significant difference in time to compliance between the compliance definitions (P<.001). Only 26.8% (45/168) complied with the measurement rate that would result in device cost reimbursement.

CONCLUSIONS

Few patients used the monitors at a rate that would result in reimbursement, raising financial feasibility concerns. Plans for sustaining costs among low-income patients need to be further evaluated.

Comparing the Evidence from Observational Studies and Randomized Controlled Trials for Nonskeletal Health Effects of Vitamin D

Although observational studies of health outcomes generally suggest beneficial effects with, or following, higher serum 25-hydroxyvitamin D [25(OH)D] concentrations, randomized controlled trials (RCTs) have generally not supported those findings. Here we review results from observational studies and RCTs regarding how vitamin D status affects several nonskeletal health outcomes, including Alzheimer’s disease and dementia, autoimmune diseases, cancers, cardiovascular disease, COVID-19, major depressive disorder, type 2 diabetes, arterial hypertension, all-cause mortality, respiratory tract infections, and pregnancy outcomes. We also consider relevant findings from ecological, Mendelian randomization, and mechanistic studies. Although clear discrepancies exist between findings of observational studies and RCTs on vitamin D and human health benefits these findings should be interpreted cautiously. Bias and confounding are seen in observational studies and vitamin D RCTs have several limitations, largely due to being designed like RCTs of therapeutic drugs, thereby neglecting vitamin D’s being a nutrient with a unique metabolism that requires specific consideration in trial design. Thus, RCTs of vitamin D can fail for several reasons: few participants’ having low baseline 25(OH)D concentrations, relatively small vitamin D doses, participants’ having other sources of vitamin D, and results being analyzed without consideration of achieved 25(OH)D concentrations. Vitamin D status and its relevance for health outcomes can usefully be examined using Hill’s criteria for causality in a biological system from results of observational and other types of studies before further RCTs are considered and those findings would be useful in developing medical and public health policy, as they were for nonsmoking policies. A promising approach for future RCT design is adjustable vitamin D supplementation based on interval serum 25(OH)D concentrations to achieve target 25(OH)D levels suggested by findings from observational studies.

Examining rural-urban disparities in perceived need for health care services among adults with disabilities

Purpose

The purpose of this study is to parse out differences between unmet need and perceived need for health care services among rural and urban adults with disabilities in the United States. While unmet need focuses primarily on environmental factors such as access to health insurance or provider availability, perceived need relates to personal choice. This distinction between unmet and perceived need is largely ignored in prior studies, but relevant to public health strategies to improve access and uptake of preventive care.

Methods

Using Wave 2 data from the National Survey on Health and Disability, we explored rural and urban differences in unmet and perceived health care needs among working-age adults with disabilities for acute and preventive services.

Findings

Although we found no significant differences in unmet needs between rural and urban respondents, we found that perceived needs for dental care and mental health counseling varied significantly across geography. Using logistic regression analysis and controlling for observable participant characteristics, we found that respondents living in noncore counties relative to metropolitan counties were more likely to report not needing dental care (OR 1.89, p = 0.028), and not needing mental health counseling services (OR 2.15, p ≤ 0.001).

Conclusion

These findings suggest additional study is warranted to understand perceived need for preventive services and the levers for addressing rural disparities.

Preventive health therapy and behavior outcomes from a brown bag medication review for older adults

BACKGROUND

Morbidity and mortality associated with preventable diseases can be reduced with the use of preventive health services. We evaluated the uptake and retention of preventive health behaviors and management of accidental medication poisonings in older adults after a health prevention educational component was combined with a brown bag medication review.

METHODS

This study used a cohort design and was conducted in six urban senior centers and three independent senior living communities in Detroit, Michigan. Participants included 85 older adults (>60 years old) taking five or more medications with 63 participants returning follow up materials. Pharmacy personnel conducted brown bag medication reviews that were combined with a preventive health education component. Information was collected on medications, vaccinations, supplement use, and accidental medication poisoning management. Participants were given written recommendations on prescription medications and preventive health therapies to improve health and medication use. An investigator developed program satisfaction survey was administered immediately after the review. An investigator-developed follow-up preventive health implementation survey was conducted at least 3 months later to assess recommendation implementation.

RESULTS

Participants' mean age was 75.9 ± 8.5 years. Fifty-six older adults had 124 recommendations in preventive health in total (1-5/participant). Eleven participants had no recommendations. Sixty-three participants (74%) returned follow-up preventive health surveys. Twenty-three percent of recommendations were already implemented with 34% planned to be done in the future. Poisoning management knowledge increased for 13 participants, reporting they would call the poison control center. The program was well received, with participants reporting high satisfaction scores (4.8 ± 0.7 out of 5).

CONCLUSIONS

Brown bag medication reviews can be an effective method to promote the uptake of preventive health behaviors among older adults, but additional accidental medication poisoning management education is still needed.

Student-Run Free Clinics Stand at a Critical Junction Between Undergraduate Medical Education, Clinical Care, and Advocacy

Student-run free clinics (SRFCs) act as primary care providers that bring health care to populations in need and are an important source of undergraduate medical education (UME), guiding trainees through the art of history taking and physical examination. However, they are also social justice and advocacy initiatives-addressing disparity in access to care and educating medical trainees with firsthand exposure to socioeconomic determinants of health as well as language and medical illiteracy barriers. Here, the authors review academic literature examining the impact of SRFCs in their 3 roles: as medical care providers, as components of medical education, and as advocacy organizations. Based on the evidence of that literature and decades of direct SRFC leadership experience, the authors make the case that SRFCs are an undersupported means by which UME institutions contribute to correcting health care disparities and to serving social justice reform.

Priorities among effective clinical preventive services in British Columbia, Canada

BACKGROUND

Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing.

METHODS

We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a 'strong or conditional (weak) recommendation for' by the Canadian Task Force on Preventive Health Care or an 'A' or 'B' rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained.

RESULTS

Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services.

CONCLUSIONS

These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Inferring medication adherence from time-varying health measures

Medication adherence is a problem of widespread concern in clinical care. Poor adherence is a particular problem for patients with chronic diseases requiring long-term medication because poor adherence can result in less successful treatment outcomes and even preventable deaths. Existing methods to collect information about patient adherence are resource-intensive or do not successfully detect low-adherers with high accuracy. Acknowledging that health measures recorded at clinic visits are more reliably recorded than a patient's adherence, we have developed an approach to infer medication adherence rates based on longitudinally recorded health measures that are likely impacted by time-varying adherence behaviors. Our framework permits the inclusion of baseline health characteristics and socio-demographic data. We employ a modular inferential approach. First, we fit a two-component model on a training set of patients who have detailed adherence data obtained from electronic medication monitoring. One model component predicts adherence behaviors only from baseline health and socio-demographic information, and the other predicts longitudinal health measures given the adherence and baseline health measures. Posterior draws of relevant model parameters are simulated from this model using Markov chain Monte Carlo methods. Second, we develop an approach to infer medication adherence from the time-varying health measures using a sequential Monte Carlo algorithm applied to a new set of patients for whom no adherence data are available. We apply and evaluate the method on a cohort of hypertensive patients, using baseline health comorbidities, socio-demographic measures, and blood pressure measured over time to infer patients' adherence to antihypertensive medication.

Precision Medicine and Physical Therapy: A Healthy Living Medicine Approach for the Next Century

There is a reciprocal relationship between common health conditions encountered in physical therapist practice, disability, and healthy living factors, such as physical inactivity, blood pressure, sleep quality, diet, and obesity. This relationship is apparent across all practice settings. Physical therapists are well positioned in the health care system to mitigate chronic disease by routinely screening and addressing healthy living factors to improve overall health and lower the risk for chronic disease (healthy living medicine). However, there are several challenges to the successful implementation of this framework in physical therapist practice. This Perspective will elucidate this relationship between healthy living behaviors and physical therapist practice, review the current state of practice regarding screening and intervention of 5 key healthy living behaviors, and outline future steps the profession can take toward implementing precision medicine using a healthy living medicine approach.

Bridging the impactibility gap in population health management: a systematic review

OBJECTIVES

Assess whether impactibility modelling is being used to refine risk stratification for preventive health interventions.

DESIGN

Systematic review.

SETTING

Primary and secondary healthcare populations.

PAPERS

Articles published from 2010 to 2020 on the use or implementation of impactibility modelling in population health management, reported with the terms 'intervenability', 'amenability', and 'propensity to succeed' (PTS) and associated with the themes 'care sensitivity', 'characteristic responders', 'needs gap', 'case finding', 'patient selection' and 'risk stratification'.

INTERVENTIONS

Qualitative synthesis to identify themes for approaches to impactibility modelling.

RESULTS

Of 1244 records identified, 20 were eligible for inclusion. Identified themes were 'health conditions amenable to care' (n=6), 'PTS modelling' (n=8) and 'comparison or combination with clinical judgement' (n=6). For the theme 'health conditions amenable to care', changes in practice did not reduce admissions, particularly for ambulatory care sensitive conditions, and sometimes increased them, with implementation noted as a possible issue. For 'PTS modelling', high costs and needs did not necessarily equate to high impactibility and targeting a larger number of individuals with disorders associated with lower costs had more potential. PTS modelling seemed to improve accuracy in care planning, estimation of cost savings, engagement and/or care quality. The 'comparison or combination with clinical judgement' theme suggested that models can reach reasonable to good discriminatory power to detect impactable patients. For instance, a model used to identify patients appropriate for proactive multimorbid care management showed good concordance with physicians (c-statistic 0.75). Another model employing electronic health record scores reached 65% concordance with nurse and physician decisions when referring elderly hospitalised patients to a readmission prevention programme. However, healthcare professionals consider much wider information that might improve or impede the likelihood of treatment impact, suggesting that complementary use of models might be optimum.

CONCLUSIONS

The efficiency and equity of targeted preventive care guided by risk stratification could be augmented and personalised by impactibility modelling.

Cognitive impairment as a barrier to utilizing preventive health services among older adults

OBJECTIVES

This study aimed to examine the influence of cognitive impairment on preventive health services utilization among older adults.

METHODS

The study sample came from 1995 to 2014 waves of the Health and Retirement Study (HRS), consisting of 19,644 adults aged 51 years or older. Mixed-effects logistic regression was used to analyze the influence of cognitive impairment, measured using the Telephone Interview for Cognitive Status, on the utilization of four types of preventive health care services, including flu shots, cholesterol tests, mammography for women, and prostate cancer screening for men.

RESULTS

Persons with cognitive impairment with no dementia were less likely to receive cholesterol tests (OR=0.68, 95% CI=0.64-0.73, p<.001), flu shots (OR=0.86, CI=0.80-0.92, p<.001), mammograms (OR=0.88, CI=0.78-0.99, p<.05), and prostate cancer screenings (OR=0.71, CI=0.71-0.98, p<.05) compared with those without cognitive impairment. Having dementia was associated with a lower odds of receiving cholesterol tests (OR=0.42, CI=0.38-0.47, p<.001), flu shots (OR=0.65, CI=0.57-0.74, p<.001), mammograms (OR=0.70, CI=0.55-0.89, p<.01), and prostate cancer screening (OR=0.68, CI=0.47-0.99, p<.05).

CONCLUSIONS

Cognitive impairment with or without dementia is a significant barrier to utilizing preventive health services among older adults. Targeted health promotion prevention and intervention strategies and caregiver education are warranted to improve preventive services among older adults with cognitive impairment.

An intensive follow-up in subjects with cardiometabolic high-risk

BACKGROUND AND AIM

Addressing chronic problems requires a model of care that promotes self-management of the disease and facilitates adherence to treatment. This project was designed to enhance patient's clinical and functional outcomes through a Comprehensive Model to be implemented in our health system and to evaluate the results.

METHODS AND RESULTS

Different population stratification tools were tested and designed to classify subjects according to different variables. We have developed a program to detect and screen cardiometabolic risk by integrating most of the Chronic Care Model recommendations through in-house developed management software (MoviHealth®). From the results, 1317 subjects were evaluated (27% of the whole population) during the first year of follow-up which significantly improved for all variables along the follow-up period. The blood pressure of the hypertensive population in 2010 and 2015 showed the importance of enrollment of subjects and the optimization of the blood pressure control. The result of HbA1c observed in 2010 decreased progressively to 7.1 ± 1.4% in 2015, and dyslipidemia levels improved gradually. The number of cardiovascular events requiring hospitalization decreased significantly (48%), from 1.9 events per 100 subjects in 2011 to 0.98 in 2015.

CONCLUSION

Our program has combined strategies for the prevention and control of non-communicable diseases, incorporating interventions to control risk factors and to reduce morbidity and mortality. It also had improvements in life quality, accessibility to health-care services, and the promotion of self-care.

Harm reduction for smokers living with HIV

Tobacco use is now a leading cause of death in people living with HIV in the USA. Increasing cessation rates in this group is a public health priority, yet the results of clinical trials aimed at optimising tobacco treatment strategies have been largely disappointing. Combinations of behavioural and pharmacological cessation therapies in people living with HIV have yielded increases in short-term quit rates, but few have shown long-term efficacy. Even with aggressive therapy combining intensive behavioural treatment with pharmacological agents, most smokers living with HIV continue to smoke. The generalised approach to tobacco treatment that prevails in guidelines and in clinical practices might do a disservice to these individuals, who represent a sizable segment of the population of people living with HIV. Harm reduction is a sensible and needed approach for smokers living with HIV who are unable or unwilling to quit. In this Viewpoint, we take an expansive view of harm reduction to include not only cutting down on cigarette intake for persistent smokers, but also reducing smoking's downstream health effects by increasing lung cancer screening and by controlling concurrent cardiovascular risk factors, especially hypertension and hyperlipidaemia.

Sustaining Successful Clinical-community Partnerships in Medically Underserved Urban Areas: A Qualitative Case Study

Clinical-community partnerships can improve access and receipt of preventive health services in community settings. Understanding how to sustain their potential benefits is warranted. Qualitative case-study of the Faith Community Health Partnership (FCHP), a collaboration between faith-community nurses and community organizations sustained over 25 years. We used content analysis principles to report on partnership sustainability themes identified through semi-structured interviews with FCHP partners (n = 18). Factors supporting partnership sustainability: Maintaining partners' commitment over time; strategic resource-sharing; facilitating engagement; and preserving partnership flexibility. Sustaining clinical-community partnerships is a dynamic and continuous process requiring significant time, effort, and resources on behalf of partners.

Characterizing Health Care Delays and Interruptions in the United States During the COVID-19 Pandemic: Internet-Based, Cross-sectional Survey Study

Background

The COVID-19 pandemic has broader geographic spread and potentially longer lasting effects than those of previous disasters. Necessary preventive precautions for the transmission of COVID-19 has resulted in delays for in-person health care services, especially at the outset of the pandemic.

Objective

Among a US sample, we examined the rates of delays (defined as cancellations and postponements) in health care at the outset of the pandemic and characterized the reasons for such delays.

Methods

As part of an internet-based survey that was distributed on social media in April 2020, we asked a US–based convenience sample of 2570 participants about delays in their health care resulting from the COVID-19 pandemic. Participant demographics and self-reported worries about general health and the COVID-19 pandemic were explored as potent determinants of health care delays. In addition to all delays, we focused on the following three main types of delays, which were the primary outcomes in this study: dental, preventive, and diagnostic care delays. For each outcome, we used bivariate statistical tests (t tests and chi-square tests) and multiple logistic regression models to determine which factors were associated with health care delays.

Results

The top reported barrier to receiving health care was the fear of SARS-CoV-2 infection (126/374, 33.6%). Almost half (1227/2570, 47.7%) of the participants reported experiencing health care delays. Among those who experienced health care delays and further clarified the type of delay they experienced (921/1227, 75.1%), the top three reported types of care that were affected by delays included dental (351/921, 38.1%), preventive (269/921, 29.2%), and diagnostic (151/921, 16.4%) care. The logistic regression models showed that age (P<.001), gender identity (P<.001), education (P=.007), and self-reported worry about general health (P<.001) were significantly associated with experiencing health care delays. Self-reported worry about general health was negatively related to experiencing delays in dental care. However, this predictor was positively associated with delays in diagnostic testing based on the logistic regression model. Additionally, age was positively associated with delays in diagnostic testing. No factors remained significant in the multiple logistic regression for delays in preventive care, and although there was trend between race and delays (people of color experienced fewer delays than White participants), it was not significant (P=.06).

Conclusions

The lessons learned from the initial surge of COVID-19 cases can inform systemic mitigation strategies for potential future disruptions. This study addresses the demand side of health care delays by exploring the determinants of such delays. More research on health care delays during the pandemic is needed, including research on their short- and long-term impacts on patient-level outcomes such as mortality, morbidity, mental health, people’s quality of life, and the experience of pain.

Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context

PURPOSE

We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care.

METHODS

We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes.

RESULTS

In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes.

CONCLUSIONS

There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.

The prediction of mortality influential variables in an intensive care unit: a case study

The intensive care units (ICUs) are among the most expensive and essential parts of all hospitals for extremely ill patients. This study aims to predict mortality and explore the crucial factors affecting it. Generally, in the health care systems, having a fast and precise ICU mortality prediction for patients plays a key role in care quality, resulting in reduced costs and improved survival chances of the patients. In this study, we used a medical dataset, including patients' demographic details, underlying diseases, laboratory disorder, and LOS. Since accurate estimates are required to have optimal results, various data pre-processings as the initial steps are used here. Besides, machine learning models are employed to predict the risk of mortality ICU discharge. For AdaBoost model, these measures are considered AUC= 0.966, sensitivity (recall) = 87.88%, Kappa=0.859, F-measure = 89.23% making it, AdaBoost, accounts for the highest rate. Our model outperforms other comparison models by using various scenarios of data processing. The obtained results demonstrate that the high mortality can be caused by underlying diseases such as diabetes mellitus and high blood pressure, moderate Pulmonary Embolism Wells Score risk, platelet blood count less than 100000 (mcl), hypertension (HTN), high level of Bilirubin, smoking, and GCS level between 6 and 9.

Predictors of Use of Preventative Health Services for People with Disabilities in Taiwan

People with disabilities display less use of preventive health services, such as health examinations, flu vaccinations, Pap smears and breast screening, but evidence has shown that preventive health services can detect or even prevent serious diseases and medical problems. Therefore, identifying the factors associated with the use of preventive health services is important for people with disabilities. This study examined the use of preventive health services by people with disabilities and identified other associated factors for people with disabilities. The research used social demographics and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) 12 items to measure activity and participation (AP) and other factors; there were 742 people with disabilities recruited with stratified proportional sampling. The data were collected through face-to-face interviews. The findings revealed that the common types of preventive services accessed by people with disabilities were health examinations and flu vaccinations; most of them had only used one preventive health service in the past year. The factors of having caregivers of spouses (OR = 1.74), perceived good health (OR = 1.26), and less limitation of AP (OR = 0.99) were significantly associated with the use of preventive services (p < 0.01). The study found a significant association between having children as caregivers and the non-use of Pap smears and breast screening services among women, providing valuable evidence for the distribution of the use of preventive health services for people with disabilities. Furthermore, the study highlighted the present status of disparities in the use of preventive services for people with disabilities and should encourage a boost in the adjustment of the medical environment and service resource allocation by the Taiwanese government for people with disabilities.

The Development and Pilot Testing of an Evidence-Based Cardiovascular Disease Risk-Prevention Program to Promote Healthy Lifestyle Behaviors Among African-American College Students - Rams Have HEART

OBJECTIVES

Cardiovascular disease (CVD) is the leading cause of death in the United States. Among the risk factors for college students, obesity and physical inactivity are disproportionately high among African Americans (AAs), and while studies of the obesity epidemic have increased in recent years, few target AA college-aged students. This study developed and piloted an evidence-based, 15-week, 3-credit hour, CVD risk-prevention and intervention course, Rams Have HEART that used e-learning, web-based technologies, and a mobile application and compared its effects against a control course.

METHODS

Two cohorts were recruited in a two-year period; 124 AA college students voluntarily consented to participate in the study, with n = 63 representing the control group and n = 61 representing the intervention. CVD risk factors were assessed by examining blood markers and anthropometric measurements. Demographic, clinical, and survey data (physical measures, blood marker investigation, and self-report surveys) were collected at baseline, post-intervention, and follow-up over the academic year.

RESULTS

The mean blood markers for lipid panel and glucose results were within the established optimal range. Intake of fruits and vegetables increased along with knowledge of CVD risk factors; 86% of students enrolled in the intervention passed the course; 100% (n = 61) would recommend it to future students.

CONCLUSION

Developing and offering a healthy lifestyle-behavior CVD intervention course to AA college students is feasible and effective in optimizing their awareness of chronic disease risk factors and prompting behavior change.

Erectile dysfunction and adherence to antihypertensive therapy: Focus on β-blockers

The management of arterial hypertension is very challenging in everyday clinical practice. Blood pressure control rates remain disappointingly low, despite intense efforts. Poor adherence to antihypertensive treatment is among the main causes of inadequate blood pressure control. Among the various parameters leading to poor adherence, medication adverse events seem to be the prevailing cause of treatment discontinuation. Β-blockers are a class of drugs commonly used in the management of hypertension. However, β-blockers use has been associated with various adverse events, among which, erectile dysfunction is a prevalent one. Accumulating evidence supports the detrimental role of β-blockers on erectile function. Older studies have shown contradictory findings, which however may be attributed to methodological errors related with the assessment of erectile function. More recent studies, however, unveiled the negative impact of this drug category on erectile function. Nevertheless, β-blockers represent a class of drugs with substantial within class heterogeneity. Nebivolol presents a unique mode of action through enhanced nitric oxide bioavailability that may be associated with benefits on erectile function. Indeed, studies of nebivolol have shown improvement in erectile function, suggesting that nebivolol represents the only exception in this class of drugs in terms of erectile function.

Validation of the wrist blood pressure measuring device Omron RS6 (HEM-6221-E) among obese Sudanese patients according to the European Society of Hypertension International Protocol Revision 2010

Background: Electronic devices for measuring blood pressure (BP) need to go through independent clinical validation as recommended by different authorities, both in general and specific populations. The aim of this study was to assess the validity of the Omron RS6 (HEM-6221-E) wrist oscillometric devices in obese Sudanese patients. Methods: Of 90 obese individuals invited for recruitment, 33 were included in the study, and had their BP at the level of the wrist measured using Omron RS6 and standard mercury sphygmomanometer. Two observations were made and the mean was taken. BP differences between the two methods for the 33 participants were classified into three categories (≤5, ≤10, and ≤15 mmHg), according to the European Society of Hypertension-International Protocol revision 2010 (ESH-IP2) criteria. This was then used to assess the validity of the tested Omron RS6 device. Results: Participants had a mean age of 56.97 years (standard deviation (SD), 8.75; range, 36-79). Average systolic blood pressure (SBP) was 146.21 mmHg (SD, 23.07; range, 107-182), and average diastolic blood pressure (DBP) was 93.82 mmHg (SD, 16.06; range, 67-128). There was a good agreement between the two observations using the OMRON RS6 and the standard sphygmomanometer: -4 to + 3 mmHg for SBP and -4 to +4 mmHg for DBP, with the mean difference of 1.73±1.11 mmHg for SBP and 1.49±1.02 mmHg for DBP. Conclusion: Thus, the Omron RS6 (HEM-6221-E) is a valid and suitable measure of BP according to ESH-IP2.

Organizational Costs and Benefits of a Health System Quality Improvement Intervention to Increase Aspirin Use for Primary Prevention of Heart Attack and Stroke

Performance improvement on clinical quality outcomes typically requires significant effort by personnel in health care organizations. Understanding the cost of quality improvement is important given diffusion of value-based contracting. This study investigates the organizational costs and benefits associated with planning and implementing the Ask about Aspirin intervention to increase use of low-dose aspirin in clinically recommended patient populations. Data from 4 health systems in Minnesota were used to estimate personnel effort and labor resource costs as well as corresponding benefits, measured as the change in aspirin use among eligible candidates during the study period. Overall personnel effort across the 4 systems was approximately 3900 hours with corresponding resource costs estimated to be $214,385. Aspirin use increased 4.7% overall, corresponding to roughly 1530 new users in the aspirin candidate population. Significant variation was observed by system in total hours reported, distribution of effort by activity type, and in benefits realized from the intervention.

Preventing Breast, Cervical, and Colorectal Cancer Deaths: Assessing the Impact of Increased Screening

Introduction

The US Preventive Services Task Force (USPSTF) recommends select preventive clinical services, including cancer screening. However, screening for cancers remains underutilized in the United States. The Centers for Disease Control and Prevention leads initiatives to increase breast, cervical, and colorectal cancer (CRC) screening. We assessed the number of avoidable deaths from increased screening, according to USPSTF recommendations, for CRC and female breast and cervical cancers.

Methods

We used model-based estimates of avoidable deaths for the lifetime of single-year age cohorts under the current and increased use of screening scenarios (data year 2016; analysis, 2018). We calculated prevented cancer deaths for each 1% increase in screening uptake and extrapolated to current level of screening (2016), current level plus 10 percentage points, and increasing screening to 90% and 100% of the eligible population.

Results

Increased use of screening from current levels to 100% would prevent an additional 2,821 deaths from breast cancer, 6,834 deaths from cervical cancer, and 35,530 deaths from CRC over a lifetime of the respective single-year cohort. Increasing use of CRC screening would prevent approximately 8.5 times as many deaths as the equivalent increase in use of breast cancer screening (women only), although twice as many people (men and women) would have to be screened for CRC.

Conclusions

A large number of deaths could be avoided by increasing breast, cervical, and CRC screening. Public health programs incorporating strategies shown to be effective can help increase screening rates.

Effects of allergic airway inflammation and chronic intermittent hypoxia on systemic blood pressure

Asthma and obstructive sleep apnea (OSA) are highly prevalent chronic conditions, and both are associated with systemic hypertension. Additionally, asthma and OSA reciprocally interact, mutually exacerbating each other. In this study, we tested the effect of allergen-induced lower airway inflammation and concurrent chronic intermittent hypoxia (CIH) on systemic blood pressure (BP), pulmonary function, and proinflammatory cytokines, in a rat model. Brown Norway rats were exposed to 43 days of normoxia (NORM) or CIH, concurrent with weekly house dust mite (HDM) challenges. BP was measured 1 day after the last HDM challenge. On day 44, pulmonary function was tested, and blood for Th-2 and Th-1 cytokine levels was collected. HDM significantly increased mean (P = 0.002), systolic (P = 0.003), and diastolic (P = 0.004) BP compared with saline-challenged controls. Higher mean BP significantly correlated to increased total respiratory system resistance (R² = 0.266, P = 0.002), driven by an association with parenchymal tissue dampening (R² = 0.166, P = 0.016). HDM relative to saline-challenged controls increased the expression of serum IL-6 (P = 0.008), but no relationships of systemic BP with IL-6 or any other cytokines were found. CIH did not alter the allergen-induced responses on BP, although it tended to increase the expression of serum IL-6 (P = 0.06) and monocyte chemoattractant protein-1 (MCP-1, P = 0.09), regardless of HDM challenge. Chronic allergen-induced airway inflammation results in systemic hypertension that is correlated to the degree of distal airway obstruction induced by the allergen. These effects do not appear to be explained by the associated systemic inflammation.

Preventive Cardiology and Risk Assessment: Beyond LDL

PURPOSE OF REVIEW

Risk assessment is the foundational cornerstone for cardiovascular prevention. The goal of this review is to apprise the reader of the latest evidence and guideline-based stepwise method for clinical risk assessment for future atherosclerotic events. We also discuss caveats to the current approach and review future directions including the promise of precision medicine.

RECENT FINDINGS

The most recent cholesterol and prevention guidelines improve upon the widely used pooled cohort equations by incorporating risk-enhancing factors to further personalize risk assessment. For those in whom uncertainty remains, there is mounting evidence for using the coronary calcium score to uncover subclinical disease to either up- or down-classify risk. Although still in its infancy, progress in high-throughput molecular analysis is edging the field closer to more precise risk stratification. Atherosclerosis is the leading cause of global morbidity and mortality. Emphasis on cardiovascular prevention is essential to mitigate the burden of disease. Here, we introduce a "4 + 2" paradigm for approaching preventive cardiology based on recent guidelines. Risk stratification is performed in four steps: qualitative risk approximation to initiate counseling and education, quantitative risk estimation based on a validated model, personalization with risk-enhancing factors, and measurement of coronary artery calcium score in select patients. The two foundational principles of preventive management are to promote a healthy lifestyle in all and to escalate preventive pharmacotherapy based on increasing risk. Shared decision-making remains central throughout this process.

Reducing Premature Mortality from Cardiovascular and Other Non-Communicable Diseases by One Third: Achieving Sustainable Development Goal Indicator 3.4.1

Non-communicable diseases (NCDs) are the world's leading causes of death and disability, with cardiovascular disease (CVD) accounting for half of NCD deaths. An ambitious global target established by the United Nations Sustainable Development Goals - indicator 3.4.1 - aims to reduce the risk of premature death among people aged 30-69 years from CVD, cancer, diabetes, and chronic lung disease by one third by 2030. This article reviews the science and practice informing what is required to achieve this target, identifying seven interventions that can accelerate progress: 1) tobacco control; 2) treatment to reduce cardiovascular risk; 3) reduction of dietary sodium; 4) reduction of household air pollution; 5) elimination of artificial trans fat; 6) reduction of alcohol use; and 7) prevention, detection, and treatment of cancers. Achieving the target is possible - there has already been progress in some areas, particularly related to CVD reduction - but only if there is faster, more concerted action.

A perspective of private health care providers in the state of Madhya Pradesh on adopting key strategies of the India hypertension control initiative

The India Hypertension Control Initiative (IHCI) has been implemented in public health facilities. This study assessed the perspective of private physicians (PPs) on adopting the core strategies of the IHCI in Bhopal district of Madhya Pradesh. A semi-structured interview was purposely applied to 30 PPs to obtain their opinions on standardized hypertension treatment protocols, patient-centered services, and easy-to-use information system in their private practices. Verbatim data were recorded and analyzed thematically. Only 11 PPs followed the state hypertension treatment protocol. Among the remaining 19 PPs, the major reasons for not adopting protocol were (1) limited availability of single component hypertension drugs, (2) preferences for fixed dose combinations (FDCs), and (3) fear of either losing patients due to a lack of immediate blood pressure control or causing drug-related adverse effects. None of the interviewed doctors had resources to provide patient-centered care and use a digital health information system. Overall, the interviewed doctors identified that free supply of hypertension treatment protocol drugs, inclusion of FDCs in treatment protocol, increasing number of staff for follow-up visits, and patient education, IT-based solutions for patient records, employee incentives, and need for national data sharing policies are the key actions to accelerate the adoption of IHCI strategies in the private sector. This exploratory qualitative study suggests that engagement of private sector in the IHCI is feasible. Plans to expand the IHCI to the private sector should consider ensuring the wider availability of hypertension treatment protocol drugs and developing a simple user-friendly digital platform for patient monitoring.

Network-Based Delivery and Sustainment of Evidence-Based Prevention in Community-Clinical Partnerships Addressing Health Equity: A Qualitative Exploration

Background: Increased delivery of evidence-based preventive services can improve population health and increase health equity. Community-clinical partnerships offer particular promise, but delivery and sustainment of preventive services through these systems face several challenges related to service integration and collaboration. We used a social network analysis perspective to explore (a) the range of contributions made by community-clinical partnership network members to support the delivery of evidence-based preventive services and (b) important influences on the ability of these partnerships to sustain service delivery. Methods: Data come from an implementation evaluation of the Prevention and Wellness Trust Fund initiative, which supported nine Massachusetts communities to coordinate delivery of evidence-based prevention and address inequities in hypertension, pediatric asthma, falls among older adults, or tobacco use. In 2016, we conducted semi-structured interviews with (a) leadership teams representing nine community-level partnerships and (b) practitioners from four high-implementation partnerships (n = 23). We managed data using NVivo11 and utilized a framework analysis approach. Results: Key network contributions for delivery of evidence-based preventive services included creating referrals, delivering services, providing links to community members, and administration and leadership. Less emphasized contributions included wraparound services, technical assistance, and venue provision. Implementers from high-implementation partnerships also highlighted contributions such as program adaptation, creating buy-in, and sharing information to improve service delivery. Expected drivers of program sustainability included the ability to develop a business case, ongoing network facilitation, technology support, continued integrated action, and sufficient staffing to maintain programming. Conclusion: The study highlights the need to take a long-term, infrastructure-focused approach when designing community-clinical partnerships. Strategic partnership composition, including identifying sources of necessary network contributions, in conjunction with efforts from the outset to link systems, align effort, and build a long-term funding structure can support the required coordinated action around preventive services needed to improve health equity.

Blood Pressure Screening by Outpatient Physical Therapists: A Call to Action and Clinical Recommendations

Hypertension (HTN) is among the leading global preventable risk factors for cardiovascular disease and premature mortality. Early detection and effective management of HTN have demonstrated significant reductions in mortality, morbidity rate, and health care costs. Furthermore, screening for HTN by nonphysician health care providers improves detection rates and medical management. As physical therapist practice advances to a more independent care model, physical therapists may serve as the first point of contact into the health care system, thereby necessitating a need for routine blood pressure (BP) monitoring. This is especially relevant in the outpatient physical therapist practice setting, where there is evidence for elevated BP measures among patients, yet omission of routine screening in this setting is well documented. Leading physical therapy professional organizations include statements in their guidelines that suggest that physical therapists have a duty to provide a standard of care that protects the safety and optimizes the overall health of patients under their care. Therefore, it is imperative not only that physical therapists include BP examination into routine practice protocols but that the knowledge and skills to accurately measure and interpret BP at rest and during exercise be integrated into the standard of care. The authors suggest that the profession of physical therapy proactively embrace their potential to address the national and worldwide HTN epidemic through routine assessment of BP, appropriate referral for elevated BP measures, and exploration of HTN management by physical therapists.

Psychological and neighborhood factors associated with urban women's preventive care use

Women are more likely than men to forego care-including preventive care. Understanding which factors influence women's preventive care use has the potential to improve health. This study focuses on the largely understudied areas of psychological barriers (depression) and neighborhood factors (support and stressors) that may be associated with women's preventive care use through secondary analysis of the Chicago Community Adult Health Study. Across models, 30-40% of the variance in preventive care adherence was explained by the neighborhood. Depressive symptoms were not associated with preventive care use when neighborhood factors were included. However, stratified models showed that associations varied by race/ethnicity. Previous research has tended to focus on individual determinants of care, but this study suggests that barriers to care are far more complex. Efforts aimed at improving care utilization need to be multipronged and interventions need to take an individual's demographics, mental health, and context into account.

Molecular Regulation of the RhoGAP GRAF3 and Its Capacity to Limit Blood Pressure In Vivo

Anti-hypertensive therapies are usually prescribed empirically and are often ineffective. Given the prevalence and deleterious outcomes of hypertension (HTN), improved strategies are needed. We reported that the Rho-GAP GRAF3 is selectively expressed in smooth muscle cells (SMC) and controls blood pressure (BP) by limiting the RhoA-dependent contractility of resistance arterioles. Importantly, genetic variants at the GRAF3 locus controls BP in patients. The goal of this study was to validate GRAF3 as a druggable candidate for future anti-HTN therapies. Importantly, using a novel mouse model, we found that modest induction of GRAF3 in SMC significantly decreased basal and vasoconstrictor-induced BP. Moreover, we found that GRAF3 protein toggles between inactive and active states by processes controlled by the mechano-sensing kinase, focal adhesion kinase (FAK). Using resonance energy transfer methods, we showed that agonist-induced FAK-dependent phosphorylation at ^Y376GRAF3 reverses an auto-inhibitory interaction between the GAP and BAR-PH domains. Y376 is located in a linker between the PH and GAP domains and is invariant in GRAF3 homologues and a phosphomimetic ^E376GRAF3 variant exhibited elevated GAP activity. Collectively, these data provide strong support for the future identification of allosteric activators of GRAF3 for targeted anti-hypertensive therapies.

Improving blood pressure screening and control at an academic health system

The goal of the University of California Davis Health Blood Pressure (BP) Quality Improvement Initiative was to improve the diagnosis, management and control of high BP. Patients aged 18-85 years were included in the initiative. Lean A3 problem solving was used to implement the following evidence-based interventions based on stakeholder interviews, value stream mapping and the Centers for Disease Control and Prevention's Million Hearts Initiative: staff training on accurate BP measurement, visual cues and reminders for BP screening, virtual case-based videoconferences, standardised clinical management algorithm, academic detailing visits, clinical decision support tools, access to pharmacists for medication comanagement, clinician workflow modification, patient education and access to home BP monitors. Following implementation of interventions, accurate screening of BP increased from 14% to 87% and BP control increased from 62% to 75%. Strategies that contributed the most to improvements were using a team-based approach, adjusting clinic workflow and frequent communication of results to staff.

Dedicated Workforce Required to Support Large-Scale Practice Improvement

BACKGROUND

Facilitation is an effective approach for helping practices implement sustainable evidence-based practice improvements. Few studies examine the facilitation infrastructure and support needed for large-scale dissemination and implementation initiatives.

METHODS

The Agency for Health care Research and Quality funded 7 Cooperatives, each of which worked with over 200 primary care practices to rapidly disseminate and implement improvements in cardiovascular preventive care. The intervention target was to improve primary care practice capacity for quality initiative and the ABCS of cardiovascular disease prevention: aspirin in high-risk individuals, blood pressure control, cholesterol management, and smoking cessation. We identified the organizational elements and infrastructures Cooperatives used to support facilitators by reviewing facilitator logs, online diary data, semistructured interviews with facilitators, and fieldnotes from facilitator observations. We analyzed these data using a coding and sorting process.

RESULTS

Each Cooperative partnered with 2 to 16 organizations, piecing together 16 to 35 facilitators, often from other quality improvement projects. Quality assurance strategies included establishing initial and ongoing training, processes to support facilitators, and monitoring to assure consistency and quality. Cooperatives developed facilitator toolkits, implemented initiative-specific training, and developed processes for peer-to-peer learning and support.

CONCLUSIONS

Supporting a large-scale facilitation workforce requires creating an infrastructure, including initial training, and ongoing support and monitoring, often borrowing from other ongoing initiatives. Facilitation that recognizes the need to support the vital integrating functions of primary care might be more efficient and effective than this fragmented approach to quality improvement.

Connecting Rheumatology Patients to Primary Care for High Blood Pressure: Specialty Clinic Protocol Improves Follow-up and Population Blood Pressures

OBJECTIVE

Recognizing high blood pressure (BP) as the most prevalent cardiovascular risk factor in patients with rheumatic diseases and all adults, experts recommend clinic protocols to improve BP control. The aim of this study was to adapt and implement a specialty clinic protocol, "BP Connect," to improve timely primary care follow-up after high BP measurements in rheumatology clinics.

METHODS

We examined BP Connect in a 6-month preimplementation and postimplementation quasi-experimental design with 24-month follow-up in 3 academic rheumatology clinics. Medical assistants and nurses were trained to 1) check (re-measuring BPs ≥140/90 mm Hg), 2) advise (linking rheumatic and cardiovascular diseases), and 3) connect (timely [<4 weeks] primary care follow-up using protocoled electronic health record [EHR] orders). We used EHR data and multivariable logistic regression analysis to examine the primary outcome of timely primary care follow-up for patients with in-network primary care. Staff surveys were used to assess perceptions. Interrupted time series analysis was performed to examine sustainability and BP trends in the clinic populations.

RESULTS

Across both 4,683 preimplementation and 689 postimplementation rheumatology visits by patients with high BP, 2,789 (57%) encounters were eligible for in-network primary care follow-up. Postimplementation, the odds of timely primary care BP measurement follow-up doubled (odds ratio 2.0, 95% confidence interval 1.4-2.9). Median time to follow-up decreased from 71 days to 38 days. Moreover, rheumatology visits by patients with high BP decreased from 17% to 8% over 24 months, suggesting significant population-level declines (P < 0.01).

CONCLUSION

Implementing the BP Connect specialty clinic protocol in rheumatology clinics improved timely follow-up and demonstrated reduced population-level rates of high BP. These findings highlight a timely strategy to improve BP follow-up amid new guidelines and quality measures.

Is preventive care utilization associated with lower outpatient and inpatient health-care expenses among Chinese older adults? A longitudinal analysis

BACKGROUND

China has made major improvements to its health-care system since the early 21st century. However, the effectiveness of preventive care utilization on health-care costs remains limited. This study seeks to understand the effect of preventive care utilization on outpatient and inpatient health-care expenses.

METHODS

With the use of the Chinese Longitudinal Healthy Longevity Survey with older adults who were 65 years old or above (n = 2828), Tobit regression models were estimated to examine the association of preventive care utilization and expenses with medical treatments. Preventive care utilization in the previous wave was used to predict health-care costs for treatments in the next wave. Propensity score matching was used to reduce potentially confounding factors.

FINDINGS

Results indicated that preventive care utilization was positively associated with outpatient health care among Chinese older adults (β = 231.8, standard error [SE] = 71.5, P < .01). The association between preventive care utilization and inpatient health-care expenses was not significant.

CONCLUSIONS

Despite the results from previous studies suggesting that preventive care utilization can help reduce health-care expenses, this study does not support such a claim among Chinese older adults. The long-term association between preventive care utilization and health-care expenses for treatment should be studied further.

Self-efficacy for managing hypertension and comorbid conditions

BACKGROUND

Self-efficacy is defined an individual’s belief in completing necessary actions to achieve the desired goal. For individuals with hypertension and other chronic conditions, self-efficacy has been an essential factor to predict adherence to treatment behaviors.

AIM

To examine self-efficacy for managing chronic conditions in individuals with hypertension.

METHODS

A total of 1087 individuals with chronic conditions in two groups (hypertension and non-hypertension groups) were selected in this study. The two groups’ self-efficacy for managing chronic conditions were investigated using the five domains of patient reported outcomes measurement information system self-efficacy for managing chronic conditions measures (PROMIS-SE); daily activities, emotions, medication and treatment, social interactions, and symptoms. Also, the relationships between self-efficacy and other health-related outcomes for the hypertension group were examined using structural equation modeling.

RESULTS

Among 1087 participants, 437 reported having hypertension. The hypertension and non-hypertension groups were statistically different in self-efficacy for managing daily activities [F (1, 598) = 5.63, P < 0.05]. Structural equation modeling indicated that for individuals with hypertension, two domains of PROMIS-SE (managing daily activities and emotions) significantly predict global physical health (P < 0.001 and P < 0.01 sequentially), and one domain (managing emotions) significantly predicts mental health (P < 0.001). Hypertension patients’ general quality of life was significantly predicted by global physical health (P < 0.001) and mental health (P < 0.001).

CONCLUSION

The hypertension group reported deficits in self-efficacy in managing daily activities as compared to the non-hypertension group. In this hypertension group, self-efficacy functioned as an indirect predictor of general quality of life, mediated by global physical and mental health.

Low-Level Cumulative Lead and Resistant Hypertension: A Prospective Study of Men Participating in the Veterans Affairs Normative Aging Study

Background

Bone lead offers a better method over blood lead measurement to discern long‐term lead exposure and accumulation. We examined the risk of resistant hypertension based on bone lead levels in a prospective cohort study of NAS (Normative Aging Study).

Methods and Results

Participants had clinic data on hypertension (systolic blood pressure, diastolic blood pressure, and antihypertension medication), lead (blood, bone‐patella, bone‐tibia), and demographic and confounding variables. Cases of resistant hypertension were identified by meeting criteria for: (1) inadequate systolic blood pressure (>140 mm Hg) or diastolic blood pressure (>90 mm Hg) while taking 3 medications or (2) requiring >4 medications for blood pressure control. A modified Poisson regression was used for model analysis. Of the 475 participants, 97 cases of resistant hypertension (20.4%) were identified. Among the cases of resistant hypertension, the median tibia and patella lead levels were 20 μg/g and 25 μg/g, respectively, while median tibia and patella lead levels were 20 μg/g and 27.5 μg/g, respectively, in participants without resistant hypertension. Tibia lead demonstrated a significant association with resistant hypertension (relative risk, 1.19; 95% confidence interval, 1.01–1.41 [P=0.04]) per interquartile range increase in tibia lead (13–28.5 μg/g). Patella lead was not associated with resistant hypertension (relative risk, 1.10; 95% confidence interval, 0.92–1.31 [P=0.31]) per interquartile range increase in patella lead (18–40 μg/g). Blood lead levels were not significantly associated with resistant hypertension (relative risk, 1.11; 95% confidence interval, 0.88–1.40 [P=0.38]).

Conclusions

Tibia lead represents a novel risk factor for resistant hypertension. Our study demonstrates an increased association between tibia lead and resistant hypertension status, with an increased risk of 19% per 1 interquartile range increase in tibia lead.

Call to Action: Urgent Challenges in Cardiovascular Disease: A Presidential Advisory From the American Heart Association

Although advances in care have spurred improvements in cardiovascular outcomes, cardiovascular disease remains the leading cause of death in the United States and around the world. Previous declines in cardiovascular disease mortality have slowed and even reversed for certain demographics. Further concerns exist with regard to cardiovascular drug innovation, quality of care, and healthcare costs. The Value in Healthcare Initiative-Transforming Cardiovascular Care, a collaboration of the American Heart Association and Duke University, Robert J. Margolis, MD, Center for Health Policy, aims to increase access to and affordability of cardiovascular treatment and to decrease barriers to care. The following Call to Action describes trends in cardiovascular care, identifies gaps in areas of cardiovascular disease prevention and treatment, highlights challenges with medical product innovation, and finally, outlines a series of learning collaboratives that will aid in the development of road maps for transforming cardiovascular care.

Lower 24-h urinary sodium excretion is associated with hypertension control: the 2010 Heart Follow-Up Study

Among individuals with hypertension, controlling high blood pressure (BP) reduces the risk for cardiovascular events and death. Reducing dietary sodium can help achieve BP control. The study aim was to use a population-based sample utilizing the gold-standard for urinary sodium to quantify the degree with which sodium was independently associated with BP control among individuals with hypertension. Participants included 1 568 adults from the Heart Follow-Up Study, a New York City population-based representative study conducted in 2010. Participants collected urine for 24 hours and had BP and other anthropometrics measured. Hypertension was defined as systolic BP ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, or being on BP lowering medication. Sodium intake (mg/day) was measured from a single 24-hour urine collection. Hypertension prevalence was 30.8%. Among those with hypertension, 64.6% were aware, 56.3% were treated, and 40.3% were controlled. Among those treated for hypertension, 73.0% were controlled. Mean sodium intake among those with hypertension was 3 564 mg/day. From multivariable adjusted logistic regression models, each 500mg decrease in 24-hour urinary sodium excretion was associated with a 18% higher odds of hypertension control among those with hypertension (1.18, 95% CI: 1.07, 1.30). In New York City, approximately one in three people has hypertension with a majority uncontrolled. Sodium intake among those with hypertension was 55% greater than recommended upper limit of 2 300 mg per day. Among individuals with hypertension, lower sodium intake was associated with hypertension control.