RESUMEN
BACKGROUND: Current diabetes management guidelines offer blueprints for providers, yet type 2 diabetes control is often poor in disadvantaged populations. The group visit is a new treatment modality originating in managed care for efficient service delivery to patients with chronic health problems. Group visits offer promise for delivering care to diabetic patients, as visits are lengthier and can be more frequent, more organized, and more educational. OBJECTIVE: To evaluate the effect of group visits on clinical outcomes, concordance with 10 American Diabetes Association (ADA) guidelines [American Diabetes Association, Diabetes Care, 28:S4-36, 2004] and 3 United States Preventive Services Task Force (USPSTF) cancer screens [U.S. Preventive Services Task Force, http://www.ahrq.gov/clinic/uspstf/resource.htm, 2003]. RESEARCH DESIGN AND METHODS: A 12-month randomized controlled trial of 186 diabetic patients comparing care in group visits with care in the traditional patient-physician dyad. Clinical outcomes (HbA1c, blood pressure [BP], lipid profiles) were assessed at 6 and 12 months and quality of care measures (adherence to 10 ADA guidelines and 3 USPSTF cancer screens) at 12 months. RESULTS: At both measurement points, HbA1c, BP, and lipid levels did not differ significantly for patients attending group visits versus those in usual care. At 12 months, however, patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators (p < .0001) and higher screening rates for cancers of the breast (80 vs. 68%, p = .006) and cervix (80 vs 68%, p = .019). CONCLUSIONS: Group visits can improve the quality of care for diabetic patients, but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes.
Asunto(s)
Diabetes Mellitus Tipo 2/epidemiología , Hospitales de Práctica de Grupo , Cooperación del Paciente , Guías de Práctica Clínica como Asunto , Diabetes Mellitus Tipo 2/terapia , Femenino , Hospitales de Práctica de Grupo/tendencias , Humanos , Masculino , Persona de Mediana Edad , Atención Primaria de Salud/métodos , Atención Primaria de Salud/tendenciasRESUMEN
The prevalence of hypertension dictates that blood pressure must be managed effectively in primary care. The American Society of Hypertension (ASH) regional chapters and clinical hypertension specialists represent a positive response by ASH to the growing problems of hypertension and metabolic syndrome-related risks and disease. To have a significant public health effect, the impact of clinical hypertension specialists must be leveraged. Key activities in the community include educating other providers locally, delivering care for complex referral patients, and fostering growth of a practice network with a central database in collaboration with academic partners. The database supports practice audit and feedback reports to enhance quality improvement, identify continuing medical education topics, and facilitate clinical trials to test new therapeutic and best-practice approaches to risk factor management. The ASH regional chapters serve as a forum for community and academic hypertension specialists to collaborate with like-minded individuals and organizations. The collaboration among the ASH Carolinas-Georgia chapter, the Hypertension Initiative, and the Community Physicians' Network provides a model for other ASH chapters and health delivery groups to partner in delivering continuing medical education programs focused on cardiovascular risk factor management, recruiting practices into the network, and developing and maintaining a centralized patient database. Evidence suggests that this collaboration is facilitating application of evidence-based medicine and risk factor control.
Asunto(s)
Redes Comunitarias/organización & administración , Promoción de la Salud , Hipertensión/prevención & control , Sociedades Médicas/organización & administración , Anciano , Presión Sanguínea , Femenino , Georgia , Humanos , Hipertensión/fisiopatología , Relaciones Interprofesionales , Masculino , Persona de Mediana Edad , North Carolina , South CarolinaRESUMEN
Therapeutic inertia (TI), defined as the providers' failure to increase therapy when treatment goals are unmet, contributes to the high prevalence of uncontrolled hypertension (> or =140/90 mm Hg), but the quantitative impact is unknown. To address this gap, a retrospective cohort study was conducted on 7253 hypertensives that had > or =4 visits and > or =1 elevated blood pressure (BP) in 2003. A 1-year TI score was calculated for each patient as the difference between expected and observed medication change rates with higher scores reflecting greater TI. Antihypertensive therapy was increased on 13.1% of visits with uncontrolled BP. Systolic BP decreased in patients in the lowest quintile of the TI score but increased in those in the highest quintile (-6.8+/-0.5 versus +1.8+/-0.6 mm Hg; P<0.001). Individuals in the lowest TI quintile were &33 times more likely to have their BP controlled at the last visit than those in highest quintile (odds ratio, 32.7; 95% CI, 25.1 to 42.6; P<0.0001). By multivariable analysis, TI accounted for &19% of the variance in BP control. If TI scores were decreased &50%, that is, increasing medication dosages on &30% of visits, BP control would increase from the observed 45.1% to a projected 65.9% in 1 year. This study confirms the high rate of TI in uncontrolled hypertensive subjects. TI has a major impact on BP control in hypertensive subjects receiving regular care. Reducing TI is critical in attaining the Healthy People 2010 goal of controlling hypertension in 50% of all patients.
Asunto(s)
Antihipertensivos/uso terapéutico , Hipertensión/tratamiento farmacológico , Hipertensión/fisiopatología , Rol del Médico , Calidad de la Atención de Salud , Antihipertensivos/administración & dosificación , Presión Sanguínea/efectos de los fármacos , Estudios de Cohortes , Diástole , Relación Dosis-Respuesta a Droga , Femenino , Objetivos , Humanos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Análisis Multivariante , Estudios Retrospectivos , SístoleRESUMEN
Platelet and white blood cell counts are higher among some insulin-resistant patients and may contribute to atherothromboembolic complications. Metabolic syndrome patients are insulin resistant, often hypertensive, and at high cardiovascular disease risk, yet the relationship of platelets to the metabolic syndrome is unknown. Platelet and white blood cell counts were obtained from 135 volunteers who had measurements of blood pressure, fasting triglycerides, high-density lipoprotein cholesterol, and glucose. A body mass index >30 kg/m2 served as a surrogate for increased waist circumference. Subjects were subdivided into three groups by the number of metabolic syndrome criteria, i.e., no metabolic syndrome risk factor (MS-0; n = 40), one or two metabolic syndrome risk factors (MS1-2; n = 61), and three to five metabolic syndrome risk factors (MS3-5; n = 34). Platelet counts were increased significantly from 226+/-8 to 257+/-8 and 276+/-10 (x10(3)/mm3) in the MS-0, MS1-2, and MS3-5 groups, respectively (p < 0.01), after adjustment for age, gender, ethnicity, total cholesterol, and low-density lipoprotein cholesterol. White blood cell counts were also increased across the three groups (5.4+/-0.2, 6.2+/-0.2, and 6.6+/-0.3 [x10(3)/mm3]; p < 0.01) after multivariate adjustment. Compared with patients with zero to two metabolic syndrome risk factors, metabolic syndrome patients have higher platelet and white blood counts, which may serve as markers of a prothrombotic and proinflammatory state and contributors to atherothromboembolic risk.
Asunto(s)
Recuento de Leucocitos , Síndrome Metabólico/sangre , Recuento de Plaquetas , Adulto , Glucemia/análisis , Presión Sanguínea , Índice de Masa Corporal , HDL-Colesterol/sangre , Femenino , Humanos , Hipertensión/complicaciones , Resistencia a la Insulina/fisiología , Masculino , Síndrome Metabólico/epidemiología , Análisis Multivariante , Factores de Riesgo , Triglicéridos/sangreRESUMEN
BACKGROUND: Hypertension is often uncontrolled and contributes to health disparities, especially among individuals >or=50 years old. Ethnic differences in awareness, knowledge, and beliefs about hypertension may contribute to these disparities, but information is limited. METHODS: To address this gap, data from a national telephone survey on 1503 Americans 50 years and older were used to assess ethnic differences in awareness, knowledge, and beliefs about hypertension and the relationship of the responses to self-reported blood pressure (BP) control. RESULTS: Overall there were no ethnic differences in knowledge and beliefs about hypertension; however, there were differences in responses to specific questions. African Americans were more knowledgeable about the definition of hypertension and were more aware that hypertension can cause kidney failure than Hispanics and whites (64.2% v 54.8% and 46.3%, P<.0001). African American and Hispanics were more likely to perceive medications as the only way to control BP (50.5% and 55.5% v 23.3%, P<.0001), whereas whites reported lifestyle changes as more important than African Americans in BP control. Comparing self-reported BP control between ethnic groups, belief that medications are not the only way to treat BP (odds ratio [OR] 2.37, 95% confidence interval [CI] 1.43-3.95) and knowledge that moderation of alcohol use can lower BP (OR 2.34, 95% CI 1.20-4.57) were significantly associated with higher BP control rates. CONCLUSIONS: Ethnic differences in specific dimensions of knowledge and beliefs about hypertension exist and account for some of the disparities in BP control. Culturally appropriate educational programs that address these deficiencies may reduce disparities.
Asunto(s)
Anciano/psicología , Etnicidad , Hipertensión/epidemiología , Hipertensión/psicología , Negro o Afroamericano , Antihipertensivos/uso terapéutico , Recolección de Datos , Utilización de Medicamentos , Femenino , Hábitos , Hispánicos o Latinos , Humanos , Conocimiento , Estilo de Vida , Masculino , Persona de Mediana Edad , Fumar , Factores Socioeconómicos , Encuestas y Cuestionarios , Estados Unidos/epidemiología , Población BlancaRESUMEN
Among diabetic hypertensive patients, ethnic differences in blood pressure control and outcomes have been attributed in part to greater reluctance of providers to prescribe combination antihypertensive regimens to African Americans than to Caucasians. African Americans purportedly receive fewer angiotensin-converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs), which reduce target organ complications. To assess these issues, cross-sectional data were analyzed from 19,864 diabetic hypertensives from 62 primary care clinics. Among diabetic hypertensives, African Americans (N=6230) were less likely than Caucasians (N=8041) to have blood pressure (BP) <130/80 mm Hg at their last clinic visit (23.1% [23.0%-23.2%] vs. 30.7% [30.6%-30.9%]) despite a greater number of prescriptions for antihypertensive medications (2.67 [2.63-2.70] vs. 2.23 [2.20-2.26]). African Americans were more likely than Caucasians to have an ACEI and/or ARB prescribed and to receive prescriptions for at least two antihypertensive medications that included an ACEI or ARB (64.1% [63.8%-64.4%] vs. 53.1% [52.8%-53.4%]). Among diabetic hypertensives, African Americans are less likely than Caucasians to attain BP <130/80 mm Hg, despite receiving more antihypertensive medication prescriptions. African Americans receive more ACEIs and/or ARBs than Caucasians for target organ protection and/or BP control. The data suggest provider prescribing patterns are not a major contributor to ethnic differences in BP control and outcomes in diabetic hypertensives.
Asunto(s)
Negro o Afroamericano/estadística & datos numéricos , Diabetes Mellitus/etnología , Hipertensión/etnología , Hipertensión/terapia , Población Blanca/estadística & datos numéricos , Anciano , Estudios Transversales , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Differential access to health care may contribute to lower blood pressure (BP) control rates to under 140/90 mm Hg in African American compared with white hypertensive patients, especially men (26.5% vs 36.5% of all hypertensive patients in the National Health and Nutrition Examination Survey 1999-2000). The Department of Veterans Affairs (VA) system, which provides access to health care and medications across ethnic and economic boundaries, may reduce disparities in BP control. METHODS: To test this hypothesis, BP treatment and control groups were compared between African American (VA, n = 4379; non-VA, n = 2754) and white (VA, n = 7987; non-VA, n = 4980) hypertensive men. RESULTS: In both groups, whites were older than African Americans (P<.05), had lower BP (P<.001), and had BP controlled to below 140/90 mm Hg more often on their last visit (P<.01). Blood pressure control to below 140/90 mm Hg was comparable among white hypertensive men at VA (55.6%) and non-VA (54.2%) settings (P = .12). In contrast, BP control was higher among African American hypertensive men at VA (49.4%) compared with non-VA (44.0%) settings (P<.01), even after controlling for age, numerous comorbid conditions, and rural-urban classification. African American hypertensive men received a comparable number of prescriptions for BP medications at VA sites (P = .18) and more prescriptions at non-VA sites than did whites (P<.001). African Americans had more visits in the previous year at VA sites (P<.001) and fewer visits at non-VA sites (P<.001) compared with whites. CONCLUSIONS: The ethnic disparity in BP control between African Americans and whites was approximately 40% less at VA than at non-VA health care sites (6.2% vs 10.2%; P<.01). Ensuring access to health care could constitute one constructive component of a national initiative to reduce ethnic disparities in BP control and cardiovascular risk.
Asunto(s)
Negro o Afroamericano , Hipertensión/etnología , Hipertensión/prevención & control , Población Blanca , Centros Médicos Académicos , Anciano , Instituciones de Atención Ambulatoria , Accesibilidad a los Servicios de Salud , Humanos , Masculino , Persona de Mediana Edad , Estados Unidos , United States Department of Veterans AffairsRESUMEN
The aging kidney is at risk for both toxic and hemodynamic-induced acute damage, resulting in a high incidence of acute renal failure (ARF) in elderly patients. The effect of age and or gender in ARF mortality in African Americans (AA) was studied in a 3-year, computer assisted retrospective review. In an inner city medical center, 100 patients classified as ARF at discharge or expiration were included in the study. Patients were classified into 3 age categories: <40, 40-64, and >64 years. The incidence of ARF was 35%, 28% and 37%, respectively. Patients >64 years of age were less likely to be dialyzed. Both pre- and postrenal causes of ARF were more common in patients >64 years of age than in younger patients. Hospital length of stay increased progressively with age. Mortality was lower in patients >64 years of age than in younger patients. The incidence of ARF was higher in male than female patients and the incidence of sepsis was higher in female than male patients. Dialytic need was greater in male patients, but mortality was higher in female than male patients. Multivariate logistic regression showed that in the presence of sepsis, oliguria and mechanical ventilatory support, the relative risk of mortality associated with advanced age was 16.5, the relative risk of mortality associated with female gender was 0.2. In summary, hospitalized elderly African-American patients have a high incidence of ARF, and patients less than 40 years of age are equally at risk. Although mortality was higher in female patients, gender and advanced age did not independently contribute to high mortality. Neither age nor gender considerations should supplant sound clinical judgment in the management of and decision making in elderly African-American patients with ARF.