Hypertension management in patients with diabetes: the need for more aggressive therapy

Digital Twin in Managing Hypertension Among People With Type 2 Diabetes: 1-Year Randomized Controlled Trial

Background

Digital twin (DT)-guided lifestyle changes induce type 2 diabetes (T2D) remission but effects on hypertension (HTN) in this population are unknown.

Objectives

The purpose of this study was to assess effects of DT vs standard of care (SC) on blood pressure (BP), anti-HTN medication, HTN remission, and microalbuminuria in participants with T2D.

Methods

This is a secondary analysis of a randomized controlled trial in India of 319 participants with T2D. Participants were randomized to DT group (N = 233), which used artificial intelligence-enabled DT technology, or SC group (N = 86). A Home Blood Pressure Monitoring system guided anti-HTN medication adjustments. BP, anti-HTN medications, HTN remission rates, and microalbuminuria were compared between groups.

Results

Among the 319 participants, 44 in DT and 15 in SC group were on anti-HTN medications, totaling 59 (18.4%) participants. DT group achieved significant reductions in systolic blood pressure (-7.6 vs -3.2 mm Hg; P < 0.007) and diastolic blood pressure (-4.3 vs -2.2 mm Hg; P = 0.046) after 1 year compared with SC group. 68.2% of DT group remained off anti-HTN medications compared to none in SC group. Among participants with HTN, DT subgroup achieved higher rates of normotension (40.9% vs 6.7%; P = 0.0009) and HTN remission (50% vs 0%; P < 0.0001) than SC subgroup. DT group had a higher rate of achieving normoalbuminuria (92.4% vs 83.1%; P = 0.018) at 1 year compared with SC group.

Conclusions

Artificial intelligence -enabled DT technology is more effective than SC in reducing BP and anti-HTN medications and inducing HTN remission and normoalbuminuria in participants with HTN and T2D. (A Novel WholeBody Digital Twin Enabled Precision Treatment for Reversing Diabetes; CTRI/2020/08/027072).

Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care

In this article, we demonstrate first how the term "aggressive care," used loosely by clinicians to denote care that can negatively impact quality of life in serious illness, is often used to inappropriately label the preferences of African American patients, and discounts, discredits, and dismisses the deeply held beliefs of African American Christians. This form of biased communication results in a higher proportion of African Americans than whites receiving care that is non-goal-concordant and contributes to the prevailing lack of trust the African American community has in our healthcare system. Second, we invite clinicians and health care centers to make the perspectives of socially marginalized groups (in this case, African American Christians) the central axis around which we find solutions to this problem. Based on this, we provide insight and understanding to clinicians caring for seriously ill African American Christian patients by sharing their beliefs, origins, and substantive importance to the African American Christian community. Third, we provide recommendations to clinicians and healthcare systems that will result in African Americans, regardless of religious affiliation, receiving equitable levels of goal-concordant care if implemented. KEY MESSAGE: Labeling care at end-of-life as "aggressive" discounts the deeply held beliefs of African American Christians. By focusing on the perspectives of this group clinicians will understand the importance of respecting their religious values. The focus on providing equitable goal-concordant care is the goal.

Association between Systolic Blood Pressure and Diabetic Retinopathy in Both Hypertensive and Normotensive Patients with Type 2 Diabetes: Risk Factors and Healthcare Implications

A common diabetes-related microvascular complication is diabetic retinopathy (DR), yet associations between blood pressure (BP) and risks for DR in diabetic patients with normal BP received inadequate attention. This may lead to 'clinical inertia' in early DR prevention. We aimed to assess whether the extent to which systolic BP levels were associated with DR in patients with type 2 diabetes (T2DM) and normal BP were similar to that in those with concurrent hypertension. Data were collected from patients with T2DM attending ophthalmic check-up with primary care referral (n = 2510). BP measurements, clinical laboratory tests, and dilated fundus examination were conducted according to gold standard of diagnosis and routine clinical procedure. Of all subjects, over 40% were normotensive and one fifth were clinically diagnosed with DR. Systolic BP levels increased across DR categories of escalated severity irrespective of the coexistence of hypertension. Ordinal logistic regression analysis showed that an increased systolic BP was independently and significantly associated with DR (adjusted odds ratio [aOR] = 1.020, p < 0.001 for hypertensives; aOR = 1.019, p = 0.018 for normotensives), after adjusting for diabetes duration, sex, lifestyles, and haemoglobin A1c levels. Regular monitoring of systolic BP should not be neglected in routine diabetes management even when BP falls within the normal range. (200 words).

Real-World Hypertension Prevalence, Awareness, Treatment, and Control in Adult Diabetic Individuals: An Italian Nationwide Epidemiological Survey

Introduction

Hypertesion is the leading cause of morbidity and mortality, worldwide, and its prevalence has been increasing in several countries, including Italy.

Aims

To assess hypertension prevalence, awareness, treatment, and control in a real-world sample of adults with self-reported diabetes compared with nondiabetic individuals.

Methods

Following the 2018 World Hypertension Day, a nationwide, cross-sectional epidemiological survey on cardiovascular risk factors (“Abbasso la Pressione!”) in 3956 Italian pharmacies enrolled 47217 self-presenting volunteers (≥ 18 years). Participants underwent standardized blood pressure (BP) measurements and answered a questionnaire on cardiovascular risk factors and lifestyle habits. Questions included if they had an established diagnosis of diabetes, hypertension or were on a BP medication. Hypertension prevalence was defined as systolic BP ≥ 140 and/or diastolic BP ≥ 90 mmHg. A double definition for hypertension control based on the recent European and US guidelines on hypertension was applied.

Results

Diabetic individuals (N = 5695, 12%) had higher rates of hypertension prevalence (80% vs. 54.7%, p < 0.001), awareness (85.6% vs 77.3%, p < 0.001) and treatment (85.8% vs. 76.7%, p < 0.001), but lower hypertension control rates (36.1% vs. 39.6% according to the 2018 European guidelines, p < 0.001; 25.4% vs 30.8% according to the 2017 US guidelines, p < 0.001) than nondiabetics. Diabetic participants tended to be older, sedentary, overweight/obese, dyslipidemic men, with higher 10-years cardiovascular risk than nondiabetics (p < 0.001). Uncontrolled hypertension was associated with male gender, diabetes, body mass index, unhealthy lifestyle habits, and older age.

Conclusions

Elevated hypertension awareness and treatment rates in diabetic adults do not translate into adequate BP control in the real world. Concomitant unfavorable metabolic features and unhealthy lifestyle habits might contribute to this observation.

An example of clinical inertia in geriatrics

Background

As we know that close contact is the main reason of the contagious diseases, caregivers are at higher risk for diseases that we can prevent by vaccines. In present study, we aim at revealing an example of clinical inertia in geriatrics, which shows us the status of vaccination both in a group of older patients and their caregivers.

Materials and Methods

Both the caregivers and their dependent geriatric patients were included, and the selection of the participants was designed on a random and volunteer basis. We performed the study with a phenomenological design and asked the participants their vaccination status. For the participants that were not vaccinated, the reasons were questioned with a demographic form. Correlations between parameters were analyzed with an independent t-test and analysis of variance. SPSS (IBM SPSS for Windows, ver.24) was used to analyze the data, which were saved in excel files.

Results

A total of 144 caregivers with 21 men (14.6%) and 123 female (85.4%) were included in the study. A total of 111(77.1%) caregivers had never been vaccinated before, while 21 (14.6%) caregivers were vaccinated occasionally, and finally, 12 (8.3%) caregivers were vaccinated on a regular base. The vaccination status of the older adults was as follows: 42 patients (29.2%) had never been vaccinated before, 60 (41.7%) had been vaccinated occasionally, and 42 (29.2%) patients had been vaccinated regularly.

Conclusion

The vaccination rates of caregivers and older patients were lower than we expected, so primary-care providers need to plan more vaccination awareness studies in social media and communities. Clinical inertia might be an essential reason in the lower vaccination rates of the caregivers and older adults' population.

Risk Factors of Hypertension among Diabetic Patients from Yaoundé Central Hospital and Etoug-Ebe Baptist Health Centre, Cameroon

Uncontrolled blood pressure is a threat to diabetic patients' life. The aim of this study was to identify risk factors of hypertension among diabetic patients at different stages from Yaoundé Central Hospital and Etoug-Ebe Baptist Health Center of Cameroon. A hospital-based cross-sectional study was conducted for 6 months, and 109 participants (types 1 and 2), aged 24-81 years, were enrolled using simple random sampling. A pretested structured questionnaire was used to collect sociodemographic data, habitual behaviors, clinical history blood pressure, and anthropometric measures. The prevalence of hypertension was 86.2%. Of the total, 13.8% participants were normotensive, 32.1% stage 1 hypertensive, and 54.1% stage 2 hypertensive. Being a male (p = 0.046) and not smoking (p = 0.036) were negatively associated with stage 1 hypertension whereas eating less than 3 times (p = 0.046) and duration of diabetes greater than 9 years among women (p = 0.039) were positively associated. Age above 40 years (p = 0.002) was negatively associated with stage 2 hypertension. However, age above 40 years had a negative effect among Christian, less educated diabetics, people having diabetes for more than 9 years, and those on medical treatment (5.556 ≤ specific OR ≤ 10.278). Duration of diabetes (age-adjusted OR = 1.155; p = 0.003) and abnormal waist circumference (crude OR = 4.074; p = 0.024) were positively associated with stage 2. Abnormal waist-to-hip ratio (crude OR = 3.773; p = 0.028) and feeding rate greater than 2 times a day (WHR-adjusted OR = 3.417; p = 0.046) were positively associated with hypertension (stages 1 and 2). This study suggests that hypertension, present at its two stages, is a serious health issue among diabetic patients. Thus, appropriate intervention should be put in place to prevent and control hypertension by managing identified risk factors.

Impact of a "Chart Closure" Hard Stop Alert on Prescribing for Elevated Blood Pressures Among Patients With Diabetes: Quasi-Experimental Study

BACKGROUND

University of California at Los Angeles Health implemented a Best Practice Advisory (BPA) alert for the initiation of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) for individuals with diabetes. The BPA alert was configured with a "chart closure" hard stop, which demanded a response before closing the chart.

OBJECTIVE

The aim of the study was to evaluate whether the implementation of the BPA was associated with changes in ACEI and ARB prescribing during primary care encounters for patients with diabetes.

METHODS

We defined ACEI and ARB prescribing opportunities as primary care encounters in which the patient had a diabetes diagnosis, elevated blood pressure in recent encounters, no active ACEI or ARB prescription, and no contraindications. We used a multivariate logistic regression model to compare the change in the probability of an ACEI or ARB prescription during opportunity encounters before and after BPA implementation in primary care sites that did (n=30) and did not (n=31) implement the BPA. In an additional subgroup analysis, we compared ACEI and ARB prescribing in BPA implementation sites that had also implemented a pharmacist-led medication management program.

RESULTS

We identified a total of 2438 opportunity encounters across 61 primary care sites. The predicted probability of an ACEI or ARB prescription increased significantly from 11.46% to 22.17% during opportunity encounters in BPA implementation sites after BPA implementation. However, in the subgroup analysis, we only observed a significant improvement in ACEI and ARB prescribing in BPA implementation sites that had also implemented the pharmacist-led program. Overall, the change in the predicted probability of an ACEI or ARB prescription from before to after BPA implementation was significantly greater in BPA implementation sites compared with nonimplementation sites (difference-in-differences of 11.82; P<.001).

CONCLUSIONS

A BPA with a "chart closure" hard stop is a promising tool for the treatment of patients with comorbid diabetes and hypertension with an ACEI or ARB, especially when implemented within the context of team-based care, wherein clinical pharmacists support the work of primary care providers.

An evaluation of empagliflozin and it's applicability to hypertension as a therapeutic option

INTRODUCTION

Sodium-glucose cotransporter 2 (SGLT2) inhibitors such as Empagliflozin are novel antihyperglycemic drugs approved for the treatment of type 2 diabetes (T2D). In addition to its glucose-lowering effects, Empagliflozin promotes weight loss, blood pressure reduction, and other beneficial metabolic benefits.

AREAS COVERED

This review outlines the pharmacokinetics, pharmacodynamics, safety, and tolerability of Empagliflozin and discusses its role in diabetes-associated hypertension.

EXPERT OPINION

Empagliflozin was the first in class to not only demonstrate safety of SGLT2 inhibition but also cardio- and reno-protective effects in an adequately powered cardiovascular outcome trial. The EMPA-REG study showed significant reductions in mortality from cardiovascular causes, hospitalization for heart failure, and progression of diabetic kidney disease. These benefits cannot be attributed to glycemic control alone, suggesting the involvement of other SGLT2 inhibition-mediated mechanisms. Recent data suggests the potential utility of SGLT2 inhibition in other conditions including type 1 diabetes (T1D) and non-diabetic heart failure patients with clinical trials currently being conducted. In concert with ongoing pre-clinical investigations to unravel the mechanisms contributing to cardiorenal protection, the full therapeutic potential of SGLT2 inhibition will become apparent over the next few years and promises to be one of the major success stories in clinical medicine.

ABBREVIATIONS

T1D: type 1 diabetes; T2D: type 2 diabetes; SGLT2: sodium-glucose cotransporter 2; CVD: cardiovascular disease; SBP: systolic blood pressure; DBP: diastolic blood pressure; SNS: sympathetic nervous system; BP: blood pressure; CV: cardiovascular; ZDF: Zucker diabetic fatty; CKD: chronic kidney disease; FDA: Food and Drug Administration.

Primary care provider adherence to an alert for intensification of diabetes blood pressure medications before and after the addition of a "chart closure" hard stop

Objective

To evaluate provider responses to a narrowly targeted "Best Practice Advisory" (BPA) alert for the intensification of blood pressure medications for persons with diabetes before and after implementation of a "chart closure" hard stop, which is non-interruptive but demands an action or dismissal before the chart can be closed.

Materials and Methods

We designed a BPA that fired alerts within an electronic health record (EHR) system during outpatient encounters for patients with diabetes when they had elevated blood pressures and were not on angiotensin receptor blocking medications. The BPA alerts were implemented in eight primary care practices within UCLA Health. We compared data on provider responses to the alerts before and after implementing a "chart closure" hard stop, and we conducted chart reviews to adjudicate each alert's appropriateness.

Results

Providers responded to alerts more often after the "chart closure" hard stop was implemented (P < .001). Among 284 alert firings over 16 months, we judged 107 (37.7%) to be clinically unnecessary or inappropriate based on chart review. Among the remainder, which represent clear opportunities for treatment, providers ordered the indicated medication more often (41% vs 75%) after the "chart closure" hard stop was implemented (P = .001).

Discussion

The BPA alerts for diabetes and blood pressure control achieved relatively high specificity. The "chart closure" hard stop improved provider attention to the alerts and was effective at getting patients treated when they needed it.

Conclusion

Targeting specific omitted medication classes can produce relatively specific alerts that may reduce alert fatigue, and using a "chart closure" hard stop may prompt providers to take action without excessively disrupting their workflow.

Risk factors for self-reported diabetes among Bhutanese adults: A nationally representative survey data analysis

Background

Bhutan, a small land-locked country in the eastern Himalayas has been undergoing an epidemiological and nutritional transition in the last two decades. The objective of this paper was to determine the prevalence and explore the risk factors of self-reported diabetes among Bhutanese adults.

Methods

We conducted a secondary data analysis among adults 18 years and older Bhutanese using the data from the National Health Survey 2012 (NHS, 2012) of Bhutan. The self-reported information on risk factors was obtained using standard protocols of the WHO STEPwise approach to Surveillance. The outcome of interest was self-reported diabetes on medication. Adjusted and unadjusted logistic regression analyses were performed to identify the risk factor of diabetes.

Results

A total of 31,066 participants aged 18 years and older were included for the analysis. The prevalence of self-reported hypertension was 1.8% (491). Risk factors for diabetes were: age groups: 35–44 years adjusted odds ratio (AOR) = 2.82 (95% CI, 1.07, 7.41), 45–54 years AOR = 6.02 (95% CI, 2.29, 15.83), 55–64 year AOR = 15.7 (95% CI 5.93, 41.55) and >65 years AOR = 19.60 (95% CI, 6.93, 55.71); high school and diploma/certificate education AOR = 2.57, (95% CI 1.62, 4.07) and AOR = 3.92 (95% CI 1.70, 9.07); and urban dwellers AOR = 2.37, (95% 1.58, 3.57); hypertension AOR = 3.3, (95% CI 2.47, 4.41); and fruit servings of 1–3 per week AOR = 1.63 (95% CI 1.15, 2.31).

Conclusion

The number of Bhutanese adults with diabetes and co-morbidities associated with it is likely to increase with the ageing of the population, nutrition transition, and high rural-urban migration in the near future. This calls for an urgent need to implement strategies to prevent diabetes in the Bhutanese population targeting risk factors including healthy lifestyle with increased physical activities and reduced smoking. At the same time treating other chronic morbidities including hypertension.

Blood glucose and pressure controls in diabetic kidney disease: Narrative review of adherence, barriers and evidence of achievement

AIMS

To review the epidemiology and the clinical evidence regarding achieving blood pressure (BP) and blood glucose control in patients with chronic kidney disease (CKD) and diabetes mellitus (DM), with emphasis on adherence and barriers within the context of Australian clinical guidelines. This article then considers Australian services aimed at BP, DM, and CKD, guideline adherence and control.

METHODS

Evidence from PubMed-listed articles published between 1994 and 2016 is considered, including original research, focusing on randomised controlled trials and prospective studies, review articles, meta- analyses, expert and professional bodies' guidelines as well as our experience.

RESULTS

There have been no Australian studies that consider adherence to BP control in DM and CKD patients. This is a major limitation in preventing DM and renal disease progression. It is possible that Australian clinicians are not adhering to DM, hypertension (HT), and glucose recommendations, thus resulting in reduced patient outcomes.

CONCLUSIONS

It is hoped that future studies ascertain the extent to which the required BP and glucose control in patients is achieved, and the potential barriers to adherence. The significance of this is immense since the impact of failure to control blood glucose levels and BP leads to renal damage.

Blood pressure control and its determinants among diabetes mellitus co-morbid hypertensive patients at Jimma University medical center, South West Ethiopia

BACKGROUND

Hypertension is the major contributor to cardiovascular diseases related morbidity and mortality. Blood pressure is not well controlled in the majority of patients with both diabetes and hypertension. The main objective of this study was to assess blood pressure control and its determinants among diabetes mellitus co- morbid hypertensive ambulatory patients.

METHODS

Hospital based cross sectional study was conducted among diabetes mellitus co-morbid hypertensive ambulatory adult patients based on the inclusion criteria. Patient specific data was collected using structured data collection tool. Data was analyzed using statistical software package, SPSS version 20.0. To identify the independent predictors of blood pressure control, multiple stepwise backward logistic regression analysis was done. Statistical significance was considered at p-value <0.05. Patient's written informed consent was obtained after explaining the purpose of the study. Patients were informed about confidentiality of the information obtained.

RESULTS

From a total of 131 study participants 51.14% were males with the mean (SD) age of the 50.69 ± 13.71. The mean duration of time since the diagnosis of hypertension was 7.44 ± 5.11 years. The mean (SD) SBP was 149.79 ± 16.32 mmHg, while the mean (SD) DBP was 89.77 ± 9.34 mmHg. More than one fourth (25.20%) of study participants had a controlled SBP, while about 27.48% had a controlled DBP. The overall control of BP was achieved in about 57 (43.51%) of the study participants. Older age (≥50 years) (AOR = 2.06; 95% CI: 2.65-7.79; P = 0.002), female gender (AOR = 1.42; 95% CI: 1.19-2.14; P = 0.042), duration of hypertension (AOR = 2.88, 95% CI: 1.27, 8.31, P = 0.02), non-adherence (AOR 2.05; 95% CI: 2.61-9.33; P = 0.01) and uncontrolled blood sugar(AOR = 1.65; 95% CI: 2.14-3.32; P = 0.04) are independent predictors for uncontrolled blood pressure.

CONCLUSIONS

Blood pressure control to target goal was suboptimal in the study area. Diabetic patients who were older, female, live longer duration with hypertension, non-adherent to their medications and poor glycemic control were more likely to have uncontrolled BP. Therefore, more effort should be dedicated to control the blood pressure in diabetics.

Hypertension in Non-Type 2 Diabetes in Isfahan, Iran: Incidence and Risk Factors

Objective

To estimate the incidence of and risk factors for the development of hypertension (HTN) in people with T1D using routinely collected data.

Method

The mean 16-year incidence of HTN was measured among 1,167 (557 men and 610 women) nonhypertensive patients with T1D from Isfahan Endocrine and Metabolism Research Center outpatient clinics, Iran. HTN was defined as a systolic blood pressure (BP) of 140 mm Hg or higher and/or a diastolic BP 90 mm Hg or higher and/or use of antihypertensive medications. The mean (standard deviation [SD]) age of participants was 20.6 years (10.5 years) with a mean (SD) duration of diabetes of 3.6 years (4.8 years) at registration.

Results

The prevalence of HTN at baseline was 9.7% (95% CI: 8.2, 11.5). Among the 1,167 patients free of HTN at registration who attended the clinic at least twice in the period 1992–2016, the incidence of HTN was 9.6 (8.0 women and 11.3 men) per 1000 person-years based on 18,870 person-years of follow-up. Multivariate analyses showed that male gender, older age, higher triglyceride, and higher systolic BP were significantly and independently associated with the development of HTN in this population.

Conclusion

These findings will help the identification of those patients with T1D at particular risk of HTN and strongly support the case for vigorous control of BP in patients with T1D.

Services aimed at achieving desirable clinical outcomes in patients with chronic kidney disease and diabetes mellitus: A narrative review

There is a large number of patients with chronic kidney disease (CKD), diabetes mellitus (DM), and hypertension (HT) but whether the targets on blood pressure (BP) control in patients with DM and/or CKD are met is not clear. This narrative review therefore investigated evidence on services aimed at achieving desirable clinical results in patients with CKD and DM, and HT in Australia. Literature pertaining to pathology diagnosis and management of these patients as well as the complexities in management were considered. This involved evidence from PubMed-listed articles published between 1993 and 2016 including original research studies, focusing on randomised controlled trials and prospective studies where possible, systematic and other review articles, meta- analyses, expert consensus documents and specialist society guidelines, such as those from the National Heart Foundation of Australia, American Diabetes Association, the Department of Health, The Royal College of Pathologists of Australasia, and The Australasian College of Emergency Medicine. Based on the literature reviewed, it is yet unknown as to how effective programs, such as diabetes inpatient services, endocrine out-patient services, and cardiac rehabilitation services, are at achieving guideline recommendations. It is also not clear how or whether clinicians are encumbered by complexities in their efforts of adhering to DM, HT, and glucose control recommendations, and the potential reasons for clinical inertia. Future studies are needed to ascertain the extent to which required BP and glucose control in patients is achieved, and whether clinical inertia is a barrier.

Synergistic Interaction of Hypertension and Diabetes in Promoting Kidney Injury and the Role of Endoplasmic Reticulum Stress

Diabetes mellitus and hypertension are major risk factors for chronic kidney injury, together accounting for >70% of end-stage renal disease. In this study, we assessed interactions of hypertension and diabetes mellitus in causing kidney dysfunction and injury and the role of endoplasmic reticulum (ER) stress. Hypertension was induced by aorta constriction (AC) between the renal arteries in 6-month-old male Goto-Kakizaki (GK) type 2 diabetic and control Wistar rats. Fasting plasma glucose averaged 162±11 and 87±2 mg/dL in GK and Wistar rats, respectively. AC produced hypertension in the right kidney (above AC) and near normal blood pressure in the left kidney (below AC), with both kidneys exposed to the same levels of glucose, circulating hormones, and neural influences. After 8 weeks of AC, blood pressure above the AC (and in the right kidney) increased from 109±1 to 152±5 mm Hg in GK rats and from 106±4 to 141±5 mm Hg in Wistar rats. The diabetic-hypertensive right kidneys in GK-AC rats had much greater increases in albumin excretion and histological injury compared with left kidneys (diabetes mellitus only) of GK rats or right kidneys (hypertension only) of Wistar-AC rats. Marked increases in ER stress and oxidative stress indicators were observed in diabetic-hypertensive kidneys of GK-AC rats. Inhibition of ER stress with tauroursodeoxycholic acid for 6 weeks reduced blood pressure (135±4 versus 151±4 mm Hg), albumin excretion, ER and oxidative stress, and glomerular injury, while increasing glomerular filtration rate in hypertensive-diabetic kidneys. These results suggest that diabetes mellitus and hypertension interact synergistically to promote kidney dysfunction and injury via ER stress.

Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme

Background

Electronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.

Objective

To evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.

Design

Epidemiological cohort, health informatics, health economics and ethnographic approaches were used.

Setting

230 NHS hospitals and 226 general practices in England and Wales.

Participants

Up to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.

Main outcome measures

Quality of care, fatal and non-fatal cardiovascular disease (CVD) events.

Data platform and methods

We created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.

Results

CALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.

Conclusions

Emerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.

Future work

The vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.

Study registration

CALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).

Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting

Purpose

The purpose of this study was to determine whether “clinical inertia”—inadequate intensification of therapy by the provider—could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site.

Methods

In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured.

Results

Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001).

Conclusions

Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.

Changes in blood-pressure control among patients with hypertension from 2008 through 2011: surveys of actual clinical practice

We performed cross-sectional surveys to investigate changes in clinical practices regarding blood-pressure control in patients with hypertension from 2008 through 2011. Questionnaires regarding the care of patients with hypertension were mailed to members of the Kanagawa Physicians Association in Kanagawa Prefecture, Japan. Data were obtained on 675 patients in 2008, 332 in 2009, and 1,076 in 2011. The mean systolic blood pressure (BP) was significantly lower in 2011 than in 2008 (132.2±11.9 mm Hg versus 134.6±10.6 mm Hg). The office-measured target BP, according to the 2009 guidelines of the Japanese Society of Hypertension for the management of patients with hypertension, was achieved in 53.9% of patients in 2008, 55.1% in 2009, and 57.1% in 2011. In nonelderly patients (younger than 65 years), the achievement rate was significantly greater in 2011 (41.2%) than in 2008 (23.6%). This analysis showed that the factor most significantly associated with a decrease in office-measured BP was treatment with a larger number and higher doses of antihypertensive agents. To investigate changes in clinical practices according to the guidelines, further follow-up surveys are necessary.

Status of hypertension and coronary stenosis in asymptomatic type 2 diabetic patients: analysis from Coronary Computed Tomographic Angiography Registry

BACKGROUND

Limited data exist regarding the prevalence of coronary artery disease (CAD) as well as clinical outcomes in asymptomatic diabetic patients with normotension, controlled hypertension, and uncontrolled hypertension.

METHODS

We enrolled 935 consecutive asymptomatic type 2 diabetic patients without known CAD. Coronary computed tomography angiography was used to evaluate the prevalence and severity of CAD. Blood pressure was measured at baseline. Patients were assigned to one of the three groups: normotension (n=314), controlled hypertension (systolic blood pressure (SBP)< 140 mm Hg with treatment, n=458), or uncontrolled hypertension (SBP ≥ 140 mm Hg with or without treatment, n=163).

RESULTS

Obstructive CAD (≥ 50% stenosis) increased from the prevalence in normotensive patients (33%) to that in patients with controlled (40%) or uncontrolled hypertension (52%) (p=0.003). The incidence of obstructive CAD in multivessel or left main CAD also increased across the three groups (13%, 21%, 32%, respectively, p<0.001). A multivariate logistic regression analysis showed that uncontrolled hypertension was an independent predictor of obstructive CAD (adjusted odds ratio, 2.13; 95% confidence interval (CI), 1.42 to 3.21, p<0.001). During a median follow-up of 3.1 years, uncontrolled hypertension was associated with increased risk of cardiac death or myocardial infarction compared to the risk in normotensive patients (hazard ratio, 6.11; 95% CI, 1.65 to 22.6, p=0.007).

CONCLUSION

In asymptomatic type 2 diabetic patients, uncontrolled hypertension was associated with increased risk of CAD and poor clinical outcomes.

Trends in hypertension prevalence, awareness, treatment and control in an adult type 2 diabetes Spanish population between 2003 and 2009

In patients with type 2 diabetes, the prevalence of hypertension is higher than in non-diabetic subjects. Despite the high cardiovascular risk involving hypertension in these patients, its prevalence and control are not well known. The aims of this study were: to estimate the hypertension prevalence, awareness, treatment and control in Spanish adults with type 2 diabetes attended in Primary Care; and to analyse its time trend from 2003 to 2009. A serial cross-sectional study from 2003 to 2009 was performed in 21 Primary Care Centres in Madrid. The study population comprised all patients with diagnosed type 2 diabetes in their computerised medical history. Overall annual prevalence during the period 2003-2009 was calculated from and according to sex and age groups. Linear trend tests, regression lines and coefficients of determination were used. In 2003 89.78% (CI 87.92-91.64) of patients with type 2 diabetes suffered hypertension and 94.76% (CI: 92.85-96.67) in 2009. This percentage was greater for women and for patients over 65 years old. 30% of patients suffered previously undiagnosed hypertension in 2003 and 23.1% in 2009. 97% of diagnosed patients received pharmacological treatment and 28.79% reached the blood pressure objective in 2009. The average number of antihypertensive drugs taken was 2.72 in 2003 and 3.27 in 2009. Only 5.2% of patients with type 2 diabetes show blood pressure levels below 130/80 mmHg. Although significant improvements have been achieved in the diagnosis and control of hypertension in people with type 2 diabetes, these continue to remain far from optimum.

Overcoming challenges integrating patient-generated data into the clinical EHR: lessons from the CONtrolling Disease Using Inexpensive IT--Hypertension in Diabetes (CONDUIT-HID) Project

INTRODUCTION

The CONDUIT-HID intervention integrates patients' electronic blood pressure measurements directly into the clinical EHR using Microsoft HealthVault as an intermediary data store. The goal of this paper is to describe generalizable categories of patient and technical challenges encountered in the development and implementation of this inexpensive, commercial off-the-shelf consumer health informatics intervention, examples of challenges within each category, and how the example challenges were resolved prior to conducting an RCT of the intervention.

METHODS

The research team logged all challenges and mediation strategies during the technical development of the intervention, conducted home visits to observe patients using the intervention, and conducted telephone calls with patients to understand challenges they encountered. We then used these data to iteratively refine the intervention.

RESULTS

The research team identified a variety of generalizable categories of challenges associated with patients uploading data from their homes, patients uploading data from clinics because they did not have or were not comfortable using home computers, and patients establishing the connection between HealthVault and the clinical EHR. Specific challenges within these categories arose because: (1) the research team had little control over the device and application design, (2) multiple vendors needed to coordinate their actions and design changes, (3) the intervention use cases were not anticipated by the device and application designers, (4) PHI accessed on clinic computers needed to be kept secure, (5) the research team wanted the data in the clinical EHR to be valid and reliable, (6) patients needed the ability to share only the data they wanted, and (7) the development of some EHR functionalities were new to the organization. While these challenges were varied and complex, the research team was able to successfully resolve each one prior to the start of the RCT.

CONCLUSIONS

By identifying these generalizable categories of challenges, we aim to help others proactively search for and remedy potential challenges associated with their interventions, rather than reactively responding to problems as they arise. We posit that this approach will significantly increase the likelihood that these types of interventions will be successful.

Getting the message across: opportunities and obstacles in effective communication in hypertension care

Effective communication is a prerequisite for any successful encounter between patient and provider. Nevertheless, it is unclear how/where communication can impact/affect adherence to antihypertensive medication, and maintenance of lifestyle changes to control blood pressure targets. Poor physician communication is correlated with a higher risk of treatment nonadherence. Given the high rates of hypertension globally, this review serves to enlighten aspects of the communication exchange from a provider, context, and patient perspective. Relevant articles were analyzed to assess barriers, solutions, and optimizations for communication with hypertensive patients. To support the findings, a model of communication in the context of hypertension treatment is presented, which comprises three phases: comprehension and acceptance, translation into action, and long-term retention. Secondly, an analysis of care providers (bedside manner, verbal/nonverbal communication, empathy and sex, time, knowledge base), context (format and tailoring of the message, and physical environment), and patient-related factors (sex, socio-economic status, language and health literacy, culture, age, psychological factors) were assessed in relation to hypertension. Current literature is limited regarding reciprocal communication, adaptive packaging of messages, and active verification of effective communication. To improve communication, hypertension care programs could benefit from better communication training, more team-based approaches, and flexible tools based on information technology.

Prevalence, awareness, treatment and control of hypertension in adults with diagnosed diabetes: the Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV)

We evaluated the prevalence, awareness, treatment and control of hypertension in Korean adults with diagnosed diabetes using nationally representative data. Among subjects aged ≥30 years who participated in the Fourth Korea National Health and Nutrition Examination Survey in 2007 and 2008, a total of 745 subjects (336 men and 409 women) with a previous diagnosis of diabetes mellitus were analyzed. The prevalence of hypertension in adults with diagnosed diabetes was 55.5%. The rates of awareness, treatment and control were 88.0, 94.2, and 30.8%, respectively. Compared with the general population, the prevalence of hypertension in adults with diagnosed diabetes was higher in all age groups in both genders. Factors independently associated with a high prevalence of hypertension included being male, increasing age, single, <9 years of education, the presence of chronic kidney disease risk, hypercholesterolemia (≥240 mg dl(-1)) and high body mass index (≥25 kg m(-2)). Regular medical screening was positively associated with hypertension control, whereas a high triglyceride level (≥150 mg dl(-1)) was inversely associated. A high prevalence and a low control rate of hypertension in adults with diagnosed diabetes suggest that stringent efforts are needed to control blood pressure in diabetic patients.

Electronic health record identification of prediabetes and an assessment of unmet counselling needs

RATIONALE, AIMS AND OBJECTIVES

Large clinical trials demonstrate that lifestyle modification can prevent or delay the onset of diabetes in those with prediabetes. However, recent National Health and Nutrition Survey data suggest that prediabetes often goes unrecognized, and the majority of prediabetic individuals do not report having received lifestyle advice from physicians. We explored whether electronic health record (EHR) query of glucose measurements can identify prediabetic patients, and we estimated rates of prediabetic lifestyle counselling in a large, urban, primary care practice.

METHODS

Electronic search identified patients with plasma glucose levels of 100 to 199 mg dL(-1) between 1 June 2007 and 1 June 2009, excluding those with diabetes or diabetic medications/supplies. From these 5366 patients, 100 randomly selected patients underwent classification into provisional categories based on available EHR data: likely prediabetes, likely diabetes, glucose abnormality in the setting of acute illness, or normal glucose metabolism. In those likely to have prediabetes, we assessed lifestyle modification counselling.

RESULTS

Fifty-eight per cent (95% CI 48% to 68%) of patients sampled were likely to have prediabetes. Fourteen per cent of those sampled were likely to have diabetes. Thirty-one per cent of prediabetics (95% CI 22% to 42%) had documented lifestyle counselling. Counselled patients had a significantly higher baseline mean body mass index compared to those not counselled (34.1 versus 29.9, P = 0.037).

CONCLUSIONS

EHR query using glucose measurements can identify prediabetic patients and those requiring further glucose metabolism evaluation, including those with undiagnosed diabetes. Future research should investigate EHR-based, population-level interventions to facilitate prediabetes recognition and counselling.

Discontinuation of statins among patients with type 2 diabetes

BACKGROUND

Statins play an important role in the prevention of cardiovascular disease in type 2 diabetes. Several studies have reported low adherence with statins among patients with type 2 diabetes. Studies comparing discontinuation of statins compared with discontinuation of oral anti-diabetics within the same individuals before and after initiation of oral anti-diabetic drugs are not available. The aim of this study was to describe discontinuation among patients with type 2 diabetes prescribed statins prior to and after initiation of oral anti-diabetics and to compare statin discontinuation with discontinuation of oral anti-diabetics.

METHODS

We report an observational cohort study among patients initiating treatment with statins prior to or after initiation of oral anti-diabetics between 1999 and 2007. Patients were classified as starting statins prior to initiation (Prior users) or after initiation (After users) of anti-diabetics. Discontinuation was defined as an interval of 180 days or more between the theoretical end date of a statin/anti-diabetic prescription and the dispensing date of the next statin/anti-diabetic prescription.

RESULTS AND CONCLUSIONS

We included 3323 starters with oral anti-diabetic drugs in our study; 2072 patients initiated statins in the period of observation. Discontinuation rates for statins were higher compared with oral anti-diabetics (52.1 vs 15.0%). After users discontinued statin therapy more frequently compared to prior users (62.8 vs 48.2%). Discontinuation of statins is higher compared with anti-diabetic discontinuation. Patients starting statins after the initiation of oral anti-diabetic treatment are more likely to discontinue treatment than patients who initiate statins before the start of oral anti-diabetics.

A role for regulatory focus in explaining and combating clinical inertia

RATIONALE, AIMS AND OBJECTIVES

It is well established that clinical inertia generates suboptimal care in patients with chronic diseases, and policies and interventions have yet to satisfactorily address the problem.

METHODS

This paper integrates the relevant literatures on clinical inertia and Regulatory Focus Theory (RFT) from psychology to identify an actionable explanatory mechanism.

RESULTS

We review RFT and show that it provides a mechanism that may explain key provider contributions to clinical inertia. We then identify two general intervention strategies based on RFT: one that changes individual sensitivity to positive/negative outcomes and another that maintains the sensitivity to positive/negative outcome but frames how information is provided to match the sensitivity.

CONCLUSIONS

We conclude that RFT is a plausible explanation to guide the development of policies and interventions for mitigating clinical inertia.

Diabetes Disease Management in a Home Care Setting

The purpose of this Orem’s Self-Care Deficit Theory of Nursing guided project was to extend a program evaluation project to examine the effects of three different approaches to home health care diabetes care on patient self-care behaviors. Group 1 (n = 64) received an experimental Diabetes Disease Management Program, group 2 (n = 167) received a Diabetes Learning Collaborative program, and group 3 (n = 132) received standard diabetes home care. No statistically significant group differences were found for self-care behaviors. Statistically significant associations in group 2 between emergent care and patients who met American Diabetes Association criteria for glucose control regarding discharge management of injectable medication management were found. A significant clinical finding was that 46% of patients (n = 117) did not meet the glucose criteria.

Hypertension and type 2 diabetes: what family physicians can do to improve control of blood pressure--an observational study

BACKGROUND

The prevalence of type 2 diabetes is rising, and most of these patients also have hypertension, substantially increasing the risk of cardiovascular morbidity and mortality. The majority of these patients do not reach target blood pressure levels for a wide variety of reasons. When a literature review provided no clear focus for action when patients are not at target, we initiated a study to identify characteristics of patients and providers associated with achieving target BP levels in community-based practice.

METHODS

We conducted a practice-based, cross-sectional observational and mailed survey study. The setting was the practices of 27 family physicians and nurse practitioners in 3 eastern provinces in Canada. The participants were all patients with type 2 diabetes who could understand English, were able to give consent, and would be available for follow-up for more than one year. Data were collected from each patient's medical record and from each patient and physician/nurse practitioner by mailed survey. Our main outcome measures were overall blood pressure at target (< 130/80), systolic blood pressure at target, and diastolic blood pressure at target. Analysis included initial descriptive statistics, logistic regression models, and multivariate regression using hierarchical nonlinear modeling (HNLM).

RESULTS

Fifty-four percent were at target for both systolic and diastolic pressures. Sixty-two percent were at systolic target, and 79% were at diastolic target. Patients who reported eating food low in salt had higher odds of reaching target blood pressure. Similarly, patients reporting low adherence to their medication regimen had lower odds of reaching target blood pressure.

CONCLUSIONS

When primary care health professionals are dealing with blood pressures above target in a patient with type 2 diabetes, they should pay particular attention to two factors. They should inquire about dietary salt intake, strongly emphasize the importance of reduction, and refer for detailed counseling if necessary. Similarly, they should inquire about adherence to the medication regimen, and employ a variety of patient-oriented strategies to improve adherence.

Prevalence of hypertension, control of blood pressure and treatment in hypertensive with type 2 diabetes in Hospital University Sains Malaysia

AIMS

To determine the prevalence of hypertension, control of hypertension and patterns of antihypertensive medications in Malaysian type 2 diabetic patients who attended diabetes clinics in Hospital University Sains Malaysia (Tertiary Hospital).

MATERIALS AND METHODS

The study design was observational prospective longitudinal follow-up study; the study was conducted with sample of 1077 type 2 diabetes mellitus outpatient recruited whom attended the diabetes clinics at Hospital Universiti Sains Malaysia (HUSM) in Kelantan. The study period was from January till December 2008. Blood pressure was defined as >130/80 or use of antihypertension medications. Demographic characteristics of patients, level of blood pressure control, use of antihypertensive medications and patterns of antihypertensive therapy.

RESULTS

The prevalence of hypertension in Malaysian type 2 diabetic patients was 998 (92.7%),antihypertensive drugs were prescribed in 940 (94.2%) of hypertensive patients with type 2 diabetic mellitus. The achievement of blood pressure control (≤130/80 mmHg) was 471 (47.2%) %. The percentage of patients receiving one, two, three, and four drugs were 253 (25.3%), 311 (31.3%), 179 (17.9%), and 197 (19.7%) respectively. Calcium channel blockers were the most commonly prescribed antihypertensive agents 757 (75.7%) followed by Angiotensin-converting enzyme inhibitors 446 (44.6%), and Angiotensin receptor blockers 42.4 (42.4%).

CONCLUSION

The prevalence of hypertension is high in Malaysian type 2 diabetic patients, hypertension was not controlled to the recommended levels of blood pressure in about one-half (52.8%) of diabetes patients. Calcium channel blockers were the most commonly prescribed antihypertensive agents. There is an urgent need to educate both patients and health care providers of importance of achieving target of treatment in order to reduce morbidity and mortality due to diabetes with hypertension.

Alterations in arterial pressure in patients with Type 1 diabetes are associated with long-term poor metabolic control and a more atherogenic lipid profile

AIM

To determine the prevalence of alterations in blood pressure (BP) in patients with Type 1 diabetes who are normoalbuminuric and normotensive; and to evaluate the association with genetic, clinical and metabolic factors. MATERIAL/ METHODS: Normoalbuminuric, normotensive Type 1 diabetic patients (no.=85) had their ambulatory blood pressure monitoring (ABPM) performed over 24 h, together with measurement of HbA1c and lipid profile, polymorphisms of the ACE gene, non-midriatic retinography, and the "historical HbA1c" calculated (mean of all the determinations available on the patient).

RESULTS

Of the 85 patients, a mean of 18.8% had pathologic values of BP over the 24 h, 31.8% during active periods and 22.4% during rest periods; in 42% there was a non-dipper pattern in BP. The patients with alterations of BP had higher body mass index (BMI), higher levels of glycemia and of triglycerides, and decreased levels of HDL cholesterol. The "historical HbA1c" was significantly higher in the patients with the non-dipper pattern (8.6 ± 1.4% vs 7.9 ± 1.4%; p=0.046). Pulse pressure was directly associated with male gender (p=0.006) and with BMI (p=0.001). No differences were detected in the distribution of the polymorphisms of the ACE gene as a function of the BP alterations.

CONCLUSIONS

An elevated number normoalbuminuric, normotensive, Type 1 diabetic patients have alterations in BP detected with ABPM over 24 h, and these are associated with a greater BMI, poor long-term metabolic control and a more atherogenic lipid profile.

Uncontrolled home blood pressure in the morning is associated with nephropathy in Japanese type 2 diabetes

The purposes of this study were to investigate the state of blood pressure control level and to investigate the relationship between blood pressure control level and nephropathy in Japanese type 2 diabetes. We measured clinic and home blood pressure in 923 type 2 diabetic patients. According to the criteria for hypertension in the Japanese Society of Hypertension Guidelines 2009, patients were classified into four groups by clinic systolic blood pressure (130 mmHg) and morning systolic blood pressure (125 mmHg), as follows: controlled hypertension (CH), white-coat hypertension (WCH), masked hypertension (MH), and sustained hypertension (SH). Of all patients, 13.9, 12.6, 13.3, and 60.2% were identified as having CH, WCH, MH, and SH, respectively. The average number of drugs prescribed was 1.8. We assessed the association between blood pressure control level and nephropathy in diabetic patients. The degree of urinary albumin excretion and the prevalence of nephropathy in diabetic patients were higher in MH and SH groups than those in the CH group. The majority of patients had poor blood pressure control, regardless of ongoing conventional antihypertensive therapy, and diabetic patients with MH and SH were associated with nephropathy. It is suggested that more aggressive antihypertensive treatment is recommended to prevent nephropathy in diabetic patients.

Clinical inertia in management of T2DM

Diabetes is highly prevalent and serious chronic debilitating disease and reported to be the fourth main cause of death in Europe. Despite extensive evidence of benefits of tight glycemic control, large proportions of people with diabetes do not achieve target glycemic control. One major reason for this is clinical inertia which is "recognising the problem but failure to act" by health care professionals in primary care. The key issues in the management of people with T2DM include early detection of problems, realistic goal setting, improved patient adherence, better knowledge and understanding of pharmacotherapeutic treatment options and prompt intervention. Health care professionals must need to overcome clinical inertia and need to intensify therapy in an appropriate and timely manner.

Endothelial dysfunction as a potential contributor in diabetic nephropathy

The mechanisms that drive the development of diabetic nephropathy remain undetermined. Only 30-40% of patients with diabetes mellitus develop overt nephropathy, which suggests that other contributing factors besides the diabetic state are required for the progression of diabetic nephropathy. Endothelial dysfunction is associated with human diabetic nephropathy and retinopathy, and advanced diabetic glomerulopathy often exhibits thrombotic microangiopathy, including glomerular capillary microaneurysms and mesangiolysis, which are typical manifestations of endothelial dysfunction in the glomerulus. Likewise, diabetic mice with severe endothelial dysfunction owing to deficiency of endothelial nitric oxide synthase develop progressive nephropathy and retinopathy similar to the advanced lesions observed in humans with diabetes mellitus. Additionally, inhibitors of the renin-angiotensin system fail to be renoprotective in some individuals with diabetic nephropathy (due in part to aldosterone breakthrough) and in some mouse models of the disease. In this Review, we discuss the clinical and experimental evidence that supports a role for endothelial nitric oxide deficiency and subsequent endothelial dysfunction in the progression of diabetic nephropathy and retinopathy. If endothelial dysfunction is the key factor required for diabetic nephropathy, then agents that improve endothelial function or raise intraglomerular nitric oxide level could be beneficial in the treatment of diabetic nephropathy.

Study protocol: the Adherence and Intensification of Medications (AIM) study--a cluster randomized controlled effectiveness study

Background

Many patients with diabetes have poor blood pressure (BP) control. Pharmacological therapy is the cornerstone of effective BP treatment, yet there are high rates both of poor medication adherence and failure to intensify medications. Successful medication management requires an effective partnership between providers who initiate and increase doses of effective medications and patients who adhere to the regimen.

Methods

In this cluster-randomized controlled effectiveness study, primary care teams within sites were randomized to a program led by a clinical pharmacist trained in motivational interviewing-based behavioral counseling approaches and authorized to make BP medication changes or to usual care. This study involved the collection of data during a 14-month intervention period in three Department of Veterans Affairs facilities and two Kaiser Permanente Northern California facilities. The clinical pharmacist was supported by clinical information systems that enabled proactive identification of, and outreach to, eligible patients identified on the basis of poor BP control and either medication refill gaps or lack of recent medication intensification. The primary outcome is the relative change in systolic blood pressure (SBP) measurements over time. Secondary outcomes are changes in Hemoglobin A1c, low-density lipoprotein cholesterol (LDL), medication adherence determined from pharmacy refill data, and medication intensification rates.

Discussion

Integration of the three intervention elements - proactive identification, adherence counseling and medication intensification - is essential to achieve optimal levels of control for high-risk patients. Testing the effectiveness of this intervention at the team level allows us to study the program as it would typically be implemented within a clinic setting, including how it integrates with other elements of care.

Trial Registration

The ClinicalTrials.gov registration number is NCT00495794.

Encounter frequency and blood pressure in hypertensive patients with diabetes mellitus

The relationship between encounter frequency (average number of provider-patient encounters over a period of time) and blood pressure for hypertensive patients is unknown. We tested the hypothesis that shorter encounter intervals are associated with faster blood pressure normalization. We performed a retrospective cohort study of 5042 hypertensive patients with diabetes mellitus treated at primary care practices affiliated with 2 academic hospitals between 2000 and 2005. Distinct periods of continuously elevated blood pressure (>or=130/85 mm Hg) were studied. We evaluated the association of the average encounter interval with time to blood pressure normalization and rate of blood pressure decrease. Blood pressure of the patients with the average interval between encounters <or=1 month normalized after a median of 1.5 months at the rate of 28.7 mm Hg/month compared with 12.2 months at 2.6 mm Hg/month for the encounter interval >1 month (P<0.0001 for all). Median time to blood pressure normalization was 0.7 versus 1.9 months for the average encounter interval <or=2 weeks versus between 2 weeks and 1 month, respectively (P<0.0001). In proportional hazards analysis adjusted for patient demographics, initial blood pressure, and treatment intensification rate, a 1 month increase in the average encounter interval was associated with a hazard ratio of 0.764 for blood pressure normalization (P<0.0001). Shorter encounter intervals are associated with faster decrease in blood pressure and earlier blood pressure normalization. Greatest benefits were observed at encounter intervals (<or=2 weeks) shorter than what is currently recommended.

Patient-provider concordance in the prioritization of health conditions among hypertensive diabetes patients

BACKGROUND

Many patients with diabetes have multiple other chronic conditions, but little is known about whether these patients and their primary care providers agree on the relative importance that they assign these comorbidities.

OBJECTIVE

To understand patterns of patient-provider concordance in the prioritization of health conditions in patients with multimorbidity.

DESIGN

Prospective cohort study of 92 primary care providers and 1,169 of their diabetic patients with elevated clinic triage blood pressure (> or = 140/90) at nine Midwest VA facilities.

MEASUREMENTS

We constructed a patient-provider concordance score based on responses to surveys in which patients were asked to rank their most important health concerns and their providers were asked to rank the most important conditions likely to affect that patient's health outcomes. We then calculated the change in predicted probability of concordance when the patient reported having poor health status, pain or depression, or competing demands (issues that were more pressing than his health), controlling for both patient and provider characteristics.

RESULTS

For 714 pairs (72%), providers ranked the patient's most important concern in their list of three conditions. Both patients and providers ranked diabetes and hypertension most frequently; however, providers were more likely to rank hypertension as most important (38% vs. 18%). Patients were more likely than providers to prioritize symptomatic conditions such as pain, depression, and breathing problems. The predicted probability of patient-provider concordance decreased when a patient reported having poor health status (55% vs. 64%, p < 0.01) or non-health competing demands (46% vs. 62%, p < 0.01).

CONCLUSIONS

Patients and their primary care providers often agreed on the most important health conditions affecting patients with multimorbidity, but this concordance was lower for patients with poor health status or non-health competing demands. Interventions that increase provider awareness about symptomatic concerns and competing demands may improve chronic disease management in these vulnerable patients.

Competence of Polish primary-care doctors in the pharmacological treatment of hypertension

RATIONALE, AIMS AND OBJECTIVES

Compliance with treatment guidelines for hypertension is variable. This study assessed the competence of Polish general practitioners in compliance with hypertension treatment guidelines, and doctor and patient characteristics associated with compliance.

METHODS

The study was conducted on a random sample of Polish primary-care doctors working in clinics contracted by the national health insurance funds. Doctors completed a questionnaire consisting of eight case vignettes describing patients with elevated blood pressure. The cases differed on three variables relating to the level of blood pressure, the presence or absence of diabetes mellitus, and the presence or absence of other risk factors. Doctors were asked to give their treatment decision for each case. Demographic data and details of the doctor's practice were also collected. Treatment decisions were tabulated, and associations between doctor and patient characteristics and treatments were assessed.

RESULTS

One hundred twenty-five doctors (65% response rate) completed the questionnaire. Compliance with treatment guidelines was judged to be 51%. Poor compliance with guidelines was noted for patients with diabetes mellitus. The level of blood pressure was the strongest predictor of drug treatment. Angiotensin-converting enzyme inhibitors were the most frequently prescribed medications. Appropriate decisions were associated with practice in large cities.

CONCLUSIONS

Compliance with hypertension treatment guidelines was judged to be poor in this study of a sample of Polish primary-care doctors using case vignettes to test competence. Additional emphasis on hypertension guidelines in training doctors is needed, especially for diabetic patients and for doctors outside urban centres.

First Things First: Difficulty with Current Medications Is Associated With Patient Willingness to Add New Ones

BACKGROUND: Inadequate blood pressure (BP) control remains prevalent. One proposed explanation is "clinical inertia," often defined as the failure by providers to initiate or intensify medication therapy when otherwise appropriate. However, patients could contribute to clinical inertia by signaling an unwillingness to consider medication intensification. OBJECTIVE: To explore covariates of patient attitudes regarding medication intensification. STUDY DESIGN: Cross-sectional survey. SETTING: 9 Midwestern U. S. Veterans' Administration medical facilities. PARTICIPANTS: 1,062 diabetics identified as having BP>= 140/90 mm Hg as part of a prospective cohort study of clinical inertia in hypertension treatment. MEASUREMENTS: Primary outcome was participants' indicated willingness to intensify BP medications if their provider noted elevated BP levels. Potential covariates assessed included BP control (actual and perceived), perceived importance of BP control, BP management self-efficacy, competing demands, medication factors (adherence and management issues), trust in provider, and sociodemographic factors. RESULTS: While 64% of participants reported complete willingness to intensify BP medications, 36% of participants expressed at least some unwillingness. In ordered logistic regression analysis, willingness to intensify was negatively associated with medication concerns, particularly concern about side effects (OR=0.49, 95% CI: 0.42, 0.59) and adherence or management problems (OR=0.72, 95% CI: 0.57, 0.91), and positively associated with perceived dependence of health on BP medications (OR=1.50, 95% CI: 1.26, 1.79) and trust in provider (OR=1.30, 95% CI: 1.10, 1.54). Importance of BP control had a weaker, non-significant association with willingness to intensify as well (OR=1.17, 95% CI: 0.99, 1.40). Neither competing demands, current BP control, current number of medications prescribed, nor self-efficacy was associated with willingness to intensify medications. CONCLUSIONS: Patients' willingness to consider intensification of BP medications appears primarily determined by how well patients are managing their current medications, rather than patients' perceived importance of BP control, their self-efficacy, or their prioritization of BP control versus other health demands. Greater attention to patients' pre-existing medication issues may improve providers' ability to intensify BP medication therapy when medically appropriate while simultaneously improving patient satisfaction with care.

Proteinuria and clinical outcomes in hypertensive patients

This narrative review focuses on outcomes related to proteinuria in hypertension (HT), and also examines the role of current and future therapeutic strategies. Proteinuria is an independent marker of renal and cardiovascular (CV) disease in hypertensive populations, particularly in high-risk groups such as diabetic patients. Effective blood pressure (BP) control and proteinuria management are associated with significant improvements in the risk of key adverse outcomes, although a causative relationship needs careful assessment. Available antihypertensives have varying effects on proteinuria reduction. Drugs affecting the renin system offer antiproteinuric and renoprotective effects that are probably at least partially independent of their BP effects. Economic evaluations of these interventions confirm their cost-saving benefits relative to other antihypertensives, but outcomes-based research is needed in some settings.

Effects of efforts to intensify management on blood pressure control among patients with type 2 diabetes mellitus and hypertension: a pilot study

There continues to be a need for improved medical management of diabetes patients with hypertension in primary care. While several care models have shown effectiveness in achieving various outcomes among these patients, it remains unclear what care model is most effective in improving blood pressure control in primary care. In this prospective study, 54 patients with type 2 diabetes mellitus and blood pressure of >140/90 identified through the registry, were randomized into three groups. Group A attended a nurse educator-conducted class on diabetes and hypertension, group B attended the same class and was asked to monitor their home blood pressure using provided device, and group C served as control (usual care). Of the 24 subjects who completed the study, only 20% achieved the target blood pressure of <130/80 and there was no statistical difference in mean systolic and diastolic blood pressures among the three groups (p > 0.05). Efforts to intensify management of hypertension among type 2 diabetes patients did not result in better blood pressure control compared to usual care. Studies looking into factors which limit patients’ participation in group classes and determining patients’ preferences in disease management would be helpful in ensuring success of any chronic disease management program.

The decision to intensify therapy in patients with type 2 diabetes: results from an experiment using a clinical case vignette

PURPOSE

Lack of medication intensification is a widely recognized but poorly understood barrier to effective diabetes care. We used a video case vignette to assess whether patient or physician demographic variables influence the decision to intensify therapy.

METHODS

One hundred ninety-two US primary care physicians each viewed one case vignette of an actor portraying a patient who had type 2 diabetes and borderline indications for medication intensification. Case vignettes were clinically identical and differed only by patient age (35 or 65 years old); sex; race/ethnicity (white, Hispanic, or black); and socioeconomic status (occupation of lawyer or janitor). After viewing the vignette and indicating their management plans, physicians were also asked to discuss the challenges related to managing such a patient.

RESULTS

Just over half (53%) of physicians indicated that they would recommend a medication prescription for the vignette patient. Demographic characteristics (of the patient, physician, or practice) did not significantly influence this decision (P > .1 for all comparisons). Compared with physicians who did not recommend a diabetic-related prescription, physicians recommending therapy more often identified patient medication costs (74% vs 43% of physicians who would not increase therapy); medication adherence (63% vs 49%); and subsequent complications (34% vs 22%) as important clinical issues in managing diabetes. Physicians not intensifying therapy more often indicated that they needed more clinical information (16% vs 9%).

CONCLUSIONS

Using an experimental design we found that differences in the decision to intensify therapy were not significantly explained by patient, physician, or practice demographic variables. Physicians who intensified therapy were more likely to consider issues such as medication costs, patient adherence, and downstream complications.

Management of hypertension in patients with diabetes: the place of angiotensin-II receptor blockers

Hypertension is an important cardiovascular (CV) risk factor in patients with diabetes mellitus. In this setting, tight control of blood pressure (BP) significantly reduces CV morbidity and mortality. In the UK Prospective Diabetes Study, a 10 mmHg reduction in systolic blood pressure (SBP) was superior to a 0.7% decrease in glycosylated haemoglobin A1c (HbA1c) as far as reducing morbidity and mortality was concerned. In the Hypertension Optimal Treatment study, the risk of CV events decreased by 51% among patients with type 2 diabetes randomized to the lower BP level. Based on these findings, contemporary treatment guidelines recommend a target SBP/diastolic blood pressure of <130/80 mmHg for patients with diabetes.

Are blood pressure levels taken during a secondary care diabetic clinic likely to be higher than when measured in primary care?

Blood pressure management guidelines are widely available. Our aim was to examine differences in blood pressure on the same subjects in primary and secondary care. We identified 661 diabetic subjects with measurements with the aid of the SAIL databank. Blood pressure in primary care was significantly lower than secondary care.

Comparison of medicine resident diabetes care between Veterans Affairs and academic health care systems

BACKGROUND

Although others have reported national disparities in the quality of diabetes care between the Veterans Affairs (VA) and private health care delivery systems, it is not known whether these differences persist among internal medicine resident providers in academic settings.

OBJECTIVE

We compared the quality of diabetes primary care delivered by resident physicians in either a private academic health care system (AHS) or its affiliated VA health care system.

DESIGN

Cross-sectional observational study

PARTICIPANTS

We included patients who: had a diagnosis of diabetes, had >2 primary care visits with the same resident provider during 2005, and were not separately managed by an attending physician or endocrinologist. A total of 640 patients met our criteria and were included in the analysis.

MEASUREMENTS AND RESULTS

Compared to the VA, patients in the AHS were more likely to be younger, female, have fewer medications, and be treated with insulin, but had less comorbidity. Patients in the VA were more likely to be referred for an annual eye exam (94% vs. 78%), receive lipid screening (88% vs. 74%), receive proteinuria screening (63% vs. 34%), and receive a complete foot exam (85% vs. 32%) in analyses adjusted for patient demographics and comorbidities (p-value <0.001 for all comparisons). In adjusted analyses, there were no significant differences in HbA1(c), blood pressure, or LDL cholesterol control.

CONCLUSIONS

In spite of similar resident providers and practice models, there were substantial differences in the diabetes quality of care delivered in the VA and AHS. Understanding how these factors influence subsequent practice patterns is an important area for study.