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BACKGROUND: Hypertension is a leading risk factor for cardiovascular disease among patients living with HIV (PLWH). Understanding the predictors and patterns of antihypertensive medication prescription and blood pressure (BP) control among PLWH with hypertension (HTN) is important to improve the primary prevention efforts for this high-risk population. We sought to identify important patient-level correlates for (e.g., race) and assess inter-facility variations in antihypertension medication prescriptions and BP control among Veterans living with HIV (VLWH) and HTN. METHODS: We studied VLWH with a diagnosis of HTN who received care in the Veterans Health Administration (VHA) from January 2018 to December 2019. We evaluated HTN treatment and blood pressure control across demographic variables, including race, and by medical comorbidities. Data were also compared among VHA facilities. Predictors of HTN treatment and control were assessed in two-level hierarchical multivariate logistic regression models to estimate odds ratios (ORs). The VHA facility random-effects parameters from the hierarchical models were used to calculate the median odds ratios to characterize the variation across the different VHA facilities. RESULTS: A total of 17,468 VLWH with HTN (mean age 61 years, 97% male, 54% Black, 40% White) who received care within the VHA facilities in 2018-2019 were included. 73% were prescribed antihypertension medications with higher prescription rates among Black versus White patients (75% vs. 71%) and higher prescription rates among patients with a history of cardiovascular disease, diabetes, and kidney disease (>80%), and those receiving antiretroviral therapy and with controlled HIV viral load (∼75%). Only 27% of VLWH with HTN had optimal BP control of systolic BP <130 mmHg and diastolic BP <80 mmHg, with a lower rate of control among Black versus White patients (24% v. 31%). In multivariate regression, Black patients had a higher likelihood of HTN medication prescription (OR 1.32, 95% CI: 1.22-1.42 used Table 3) but were less likely to have optimal BP control (OR 0.82; 0.76-0.88). Important correlates of antihypertensive prescription and optimal BP control included: number of outpatient visits, and histories of diabetes, coronary artery disease, and heart failure. There was about 10% variability in both antihypertensive prescription and BP control patterns between VHA facilities for patients with similar characteristics. There was increased inter-facility variation antihypertensive prescription among those with a history of heart failure and those not receiving antiretroviral therapy. CONCLUSION: In a retrospective analysis of large VHA data, we found that VLWH with HTN have suboptimal antihypertensive medication prescription and BP control. Black VLWH had higher HTN medication prescription rates but lower optimal BP control.

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BACKGROUND: Shared medical appointments (SMAs) in heart failure (HF) are medical visits where several patients with HF meet with multidisciplinary providers at the same time for efficient and comprehensive care. It is unknown whether HF-SMAs can improve overall and cardiac health status for high-risk patients with HF discharged from acute care. METHODS AND RESULTS: A 3-site, open-label, randomized-controlled-trial was conducted. Participants within 12 weeks of HF acute care (emergency-room/hospitalization) requiring intravenous diuretic therapy were randomized to receive either HF-SMA or usual HF clinical care (usual-care) on a 1:1 ratio. The HF-SMA team, which consisted of a nurse, nutritionist, psychologist, nurse practitioner and/or a clinical pharmacist, provided four 2-hour session HF-SMAs that met every other week for 8 weeks. Primary outcomes were the overall health status measured by European Quality of Life Visual Analog Scale and cardiac health status by Kansas City Cardiomyopathy Questionnaire, 180 days postrandomization. Of the 242 patients enrolled (HF-SMA n=117, usual-care n=125, mean age 69.3±9.4 years, 71.5% White patients, 94.6% male), 84% of participants completed the study (n=8 HF-SMA and n=9 usual-care patients died). After 180 days, both HF-SMA and usual-care participants had significant improvements from baseline in Kansas City Cardiomyopathy Questionnaire that were not statistically different. Only HF-SMA participants had significant improvements in European Quality of Life Visual Analog Scale (mean change = 7.2±15.8 in HF-SMA versus -0.4±19.0 points in usual-care, P < 0.001). CONCLUSIONS: Both HF-SMA and usual-care in participants with HF achieved significant improvements in cardiac health status, but only a team approach through HF-SMA achieved significant improvements in overall health status. Future larger studies are needed to evaluate hospitalization and death outcomes. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02481921.

Asunto(s)

Insuficiencia Cardíaca , Calidad de Vida , Citas Médicas Compartidas , Humanos , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/mortalidad , Masculino , Femenino , Anciano , Persona de Mediana Edad , Estado de Salud , Grupo de Atención al Paciente/organización & administración , Resultado del Tratamiento , Factores de Tiempo , Diuréticos/uso terapéutico , Alta del Paciente

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Importance: Clinical outcomes after acute coronary syndromes (ACS) or percutaneous coronary interventions (PCIs) in people living with HIV have not been characterized in sufficient detail, and extant data have not been synthesized adequately. Objective: To better characterize clinical outcomes and postdischarge treatment of patients living with HIV after ACS or PCIs compared with patients in an HIV-negative control group. Data Sources: Ovid MEDLINE, Embase, and Web of Science were searched for all available longitudinal studies of patients living with HIV after ACS or PCIs from inception until August 2023. Study Selection: Included studies met the following criteria: patients living with HIV and HIV-negative comparator group included, patients presenting with ACS or undergoing PCI included, and longitudinal follow-up data collected after the initial event. Data Extraction and Synthesis: Data extraction was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Clinical outcome data were pooled using a random-effects model meta-analysis. Main Outcome and Measures: The following clinical outcomes were studied: all-cause mortality, major adverse cardiovascular events, cardiovascular death, recurrent ACS, stroke, new heart failure, total lesion revascularization, and total vessel revascularization. The maximally adjusted relative risk (RR) of clinical outcomes on follow-up comparing patients living with HIV with patients in control groups was taken as the main outcome measure. Results: A total of 15 studies including 9499 patients living with HIV (pooled proportion [range], 76.4% [64.3%-100%] male; pooled mean [range] age, 56.2 [47.0-63.0] years) and 1 531 117 patients without HIV in a control group (pooled proportion [range], 61.7% [59.7%-100%] male; pooled mean [range] age, 67.7 [42.0-69.4] years) were included; both populations were predominantly male, but patients living with HIV were younger by approximately 11 years. Patients living with HIV were also significantly more likely to be current smokers (pooled proportion [range], 59.1% [24.0%-75.0%] smokers vs 42.8% [26.0%-64.1%] smokers) and engage in illicit drug use (pooled proportion [range], 31.2% [2.0%-33.7%] drug use vs 6.8% [0%-11.5%] drug use) and had higher triglyceride (pooled mean [range], 233 [167-268] vs 171 [148-220] mg/dL) and lower high-density lipoprotein-cholesterol (pooled mean [range], 40 [26-43] vs 46 [29-46] mg/dL) levels. Populations with and without HIV were followed up for a pooled mean (range) of 16.2 (3.0-60.8) months and 11.9 (3.0-60.8) months, respectively. On postdischarge follow-up, patients living with HIV had lower prevalence of statin (pooled proportion [range], 53.3% [45.8%-96.1%] vs 59.9% [58.4%-99.0%]) and ß-blocker (pooled proportion [range], 54.0% [51.3%-90.0%] vs 60.6% [59.6%-93.6%]) prescriptions compared with those in the control group, but these differences were not statistically significant. There was a significantly increased risk among patients living with HIV vs those without HIV for all-cause mortality (RR, 1.64; 95% CI, 1.32-2.04), major adverse cardiovascular events (RR, 1.11; 95% CI, 1.01-1.22), recurrent ACS (RR, 1.83; 95% CI, 1.12-2.97), and admissions for new heart failure (RR, 3.39; 95% CI, 1.73-6.62). Conclusions and Relevance: These findings suggest the need for attention toward secondary prevention strategies to address poor outcomes of cardiovascular disease among patients living with HIV.

Asunto(s)

Síndrome Coronario Agudo , Infecciones por VIH , Intervención Coronaria Percutánea , Humanos , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/epidemiología , Intervención Coronaria Percutánea/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Femenino , Resultado del Tratamiento , Revascularización Miocárdica/estadística & datos numéricos , Adulto

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BACKGROUND: The benefit-risk profile of direct oral anticoagulants (DOACs) compared with warfarin, and between DOACs in patients with atrial fibrillation (AF) and chronic liver disease is unclear. METHODS: We conducted a new-user, retrospective cohort study of patients with AF and chronic liver disease who were enrolled in a large, US-based administrative database between January 1, 2011, and December 31, 2017. We assessed the effectiveness and safety of DOACs (as a class and individually) compared with warfarin, and between DOACs in patients with AF and chronic liver disease. The primary outcomes were hospitalization for ischemic stroke/systemic embolism and hospitalization for major bleeding. Inverse probability treatment weights were used to balance the treatment groups on measured confounders. RESULTS: Overall, 10 209 participants were included, with 4421 (43.2%) on warfarin, 2721 (26.7%) apixaban, 2211 (21.7%) rivaroxaban, and 851 (8.3%) dabigatran. The incidence rates per 100 person-years for ischemic stroke/systemic embolism were 2.2, 1.4, 2.6, and 4.4 for DOACs as a class, apixaban, rivaroxaban, and warfarin, respectively. The incidence rates per 100 person-years for major bleeding were 7.9, 6.5, 9.1, and 15.0 for DOACs as a class, apixaban, rivaroxaban, and warfarin, respectively. After inverse probability treatment weights, the risk of hospitalization for ischemic stroke/systemic embolism was significantly lower between DOACs as a class (hazard ratio [HR], 0.64 [95% CI, 0.46-0.90]) or apixaban (HR, 0.40 [95% CI, 0.19-0.82]) compared with warfarin, but not significantly different between rivaroxaban versus warfarin (HR, 0.76 [95% CI, 0.47-1.21]) or rivaroxaban versus apixaban (HR, 1.73 [95% CI, 0.91-3.29]). Compared with warfarin, the risk of hospitalization for major bleeding was lower with DOACs as a class (HR, 0.69 [95% CI, 0.58-0.82]), apixaban (HR, 0.60 [95% CI, 0.46-0.78]), and rivaroxaban (HR, 0.79 [95% CI, 0.62-1.0]). However, the risk of hospitalization for major bleeding was higher for rivaroxaban versus apixaban (HR, 1.59 [95% CI, 1.18-2.14]). CONCLUSIONS: Among patients with AF and chronic liver disease, DOACs as a class were associated with lower risks of hospitalization for ischemic stroke/systemic embolism and major bleeding versus warfarin. However, the incidence of clinical outcomes among patients with AF and chronic liver disease varied between individual DOACs and warfarin, and in head-to-head DOAC comparisons.

Asunto(s)

Fibrilación Atrial , Embolia , Accidente Cerebrovascular Isquémico , Hepatopatías , Accidente Cerebrovascular , Humanos , Warfarina/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/epidemiología , Rivaroxabán/efectos adversos , Anticoagulantes/efectos adversos , Estudios de Cohortes , Estudios Retrospectivos , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/tratamiento farmacológico , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Hemorragia/tratamiento farmacológico , Dabigatrán/efectos adversos , Hepatopatías/diagnóstico , Hepatopatías/epidemiología , Embolia/epidemiología , Embolia/prevención & control , Embolia/complicaciones , Administración Oral

RESUMEN

BACKGROUND AND AIMS: The relationship between hostility and the prevalence of diabetes mellitus (DM) among black adults was investigated using the Jackson Heart Study (JHS) cohort. We hypothesized that Cook-Medley Hostility scores will be positively related with the prevalence of DM. METHODS AND RESULTS: A total of 3232 black adults who completed at least one question for each of the three subscales of the Cook-Medley Hostility Scale and had data available regarding DM status were included. Using multivariate logistic regression, we studied the cross-sectional relationship between the overall Total Cook-Medley Hostility scores and individual subscales, hostile affect (n = 3232), aggression (n = 3119) and cynical distrust (n = 3085), with prevalent DM, adjusting for known DM confounders. Our population was 36% male with a mean age of 53.5 ± 0.9 years. In risk-factor adjusted models, each point higher in the overall Total Cook-Medley Hostility scores was associated with increased odds of having DM [Adjusted OR 1.02, 95%CI 1.00-1.04, P = 0.03]. Higher scores of cynicism were independently associated with prevalent DM [Adjusted OR 1.04, 95%CI 1.01-1.07, p = 0.021]. CONCLUSIONS: There was a positive relationship between overall hostility levels and prevalent DM. Future studies should investigate the extent to which additional social determinants may impact the relationship between hostile affect and prevalent DM.

Asunto(s)

Negro o Afroamericano , Diabetes Mellitus , Hostilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiología , Diabetes Mellitus/etnología , Diabetes Mellitus/psicología , Estudios Longitudinales , Prevalencia , Negro o Afroamericano/psicología , Negro o Afroamericano/estadística & datos numéricos , Agresión , Confianza , Determinantes Sociales de la Salud/etnología , Determinantes Sociales de la Salud/estadística & datos numéricos

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OBJECTIVE: To study the relationship between county-level COVID-19 outcomes (incidence and mortality) and county-level median household income and status of Medicaid expansion of US counties. METHODS: Retrospective analysis of 3142 US counties was conducted to study the relationship between County-level median-household-income and COVID-19 incidence and mortality per 100,000 people in US counties, January-20th-2021 through December-6th-2021. County median-household-income was log-transformed and stratified by quartiles. Multilevel-mixed-effects-generalized-linear-modeling adjusted for county socio-demographic and comorbidities and tested for Medicaid-expansion-times-income-quartile interaction on COVID-19 outcomes. RESULTS: There was no significant difference in COVID-19 incidence-rate across counties by income quartiles or by Medicaid expansion status. Conversely, for non-Medicaid-expansion states, counties in the lowest income quartile had a 41% increase in COVID-19 mortality-rate compared to counties in the highest income quartile. Mortality-rate was not related to income in counties from Medicaid-expansion states. CONCLUSIONS: Median-household-income was not related to COVID-19 incidence-rate but negatively related to COVID-19 mortality-rate in US counties of states without Medicaid-expansion.

Asunto(s)

COVID-19 , COVID-19/epidemiología , Humanos , Renta , Medicaid , Pobreza , Estudios Retrospectivos , Estados Unidos/epidemiología

RESUMEN

Shared medical appointments (SMAs) offer a means for providing knowledge and skills needed for chronic disease management to patients. However, SMAs require a time and attention investment from health care providers, who must understand the goals and potential benefits of SMAs from the perspective of patients and providers. To better understand how to gain provider engagement and inform future SMA implementation, qualitative inquiry of provider experience based on a knowledge-attitude-practice model was explored. Semi-structured interviews were conducted with 24 health care providers leading SMAs for heart failure at three Veterans Administration Medical Centers. Rapid matrix analysis process techniques including team-based qualitative inquiry followed by stakeholder validation was employed. The interview guide followed a knowledge-attitude-practice model with a priori domains of knowledge of SMA structure and content (understanding of how SMAs were structured), SMA attitude/beliefs (general expectations about SMA use), attitudes regarding how leading SMAs affected patients, and providers. Data regarding the patient referral process (organizational processes for referring patients to SMAs) and suggested improvements were collected to further inform the development of SMA implementation best practices. Providers from all three sites reported similar knowledge, attitude and beliefs of SMAs. In general, providers reported that the multi-disciplinary structure of SMAs was an effective strategy towards improving clinical outcomes for patients. Emergent themes regarding experiences with SMAs included improved self-efficacy gained from real-time collaboration with providers from multiple disciplines, perceived decrease in patient re-hospitalizations, and promotion of self-management skills for patients with HF. Most providers reported that the SMA-setting facilitated patient learning by providing opportunities for the sharing of experiences and knowledge. This was associated with the perception of increased comradery and support among patients. Future research is needed to test suggested improvements and to develop best practices for training additional sites to implement HF SMA.

Asunto(s)

Personal de Salud , Insuficiencia Cardíaca/terapia , Citas Médicas Compartidas , Adulto , Citas y Horarios , Actitud del Personal de Salud , Femenino , Procesos de Grupo , Personal de Salud/organización & administración , Personal de Salud/psicología , Humanos , Entrevistas como Asunto , Satisfacción en el Trabajo , Masculino , Persona de Mediana Edad , Percepción , Atención Primaria de Salud/métodos , Atención Primaria de Salud/organización & administración , Investigación Cualitativa , Encuestas y Cuestionarios , Estados Unidos , Adulto Joven

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Warfarin has been widely used to treat thromboembolism. The effect of nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH), on warfarin dosing remains unknown. This study aims to examine the effects of NAFLD/NASH on the average daily dose (ADD) of warfarin and the time in therapeutic range (TTR). This is a retrospective study utilizing an administrative data. We included patients with at least 2 months of warfarin dispensing and two subsequent consecutive INR measures. The ADD of warfarin to achieve therapeutic range INR levels, and TTR were compared between patients with and without NAFLD/NASH in four subgroups of patients accounting for the presence of obesity and diabetes. Generalized linear models (GLM) with Propensity score (PS) fine stratification were applied to evaluate the relative differences (RD) of warfarin ADD and TTR (>60%) in four subgroups. A total of 430 NAFLD/NASH patients and 38,887 patients without NAFLD/NASH were included. The ADD and TTR, were not significant in the overall cohort between those with and without NAFLD/NASH. However, GLM results in patients without diabetes or obesity (N = 26,685) showed a significantly lower warfarin ADD (RD: -0.38; 95%CI: -0.74--0.02) and shorter TTR (OR: 0.71; 95%CI: 0.52-0.97) in patients diagnosed with NAFLD/NASH. The effects of NAFLD/NASH on warfarin dose or TTR were observed in patients without obesity and diabetes. Obesity and diabetes appear to be significant modifiers for the effects of NAFLD/NASH on warfarin dose and TTR.

Asunto(s)

Anticoagulantes/administración & dosificación , Enfermedad del Hígado Graso no Alcohólico/diagnóstico , Warfarina/administración & dosificación , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Cálculo de Dosificación de Drogas , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Estudios Retrospectivos , Factores de Tiempo , Warfarina/uso terapéutico

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BACKGROUND: Data on effectiveness of ambulatory intravenous (IV) diuretic clinics for volume management in patients with heart failure to prevent rehospitalization and mortality are limited. Therefore, the primary goal of this research is to evaluate the effectiveness of an out- patient multidisciplinary IV diuretic clinic versus standard observational hospitalizations of less than 48 hours for decompensated heart failure on the time to rehospitalization or death. METHODS: A retrospective cohort study of patients with heart failure (n=90) at the Providence Veterans Affairs Medical Center was conducted. Patients were included in the analyses if they received at least one ambulatory IV diuretic clinic visit or an observational hospitalization of less than 48 hours for decompensated heart failure between January 1, 2014 and June 30, 2016. Using Cox proportional hazards modeling, we compared the time to any hospitalization or death between the IV clinic and the observational hospitalization cohort over 180 days of follow-up. RESULTS: In the ambulatory IV diuretic clinic group, 27 patients (mean age 78.3 ± 8.3 years) received a median of 3 (interquartile range [IQR] 2-12), IV diuretic treatments. In the comparison group, 63 patients (mean age 80.3 ± 11.0 years) were hospitalized for observation for 48 hours or less during the same time period. Adjusting for age and imbalances in baseline characteristics, left ventricular ejection fraction and enrollment in hospice care, the hazards of any hospitalization or death (HR 0.39, 95% confidence interval 0.19 to 0.83) were reduced for patients in the ambulatory IV diuretic clinic versus those in the observational hospitalization cohort. CONCLUSIONS: In patients with decompensated heart failure, an ambulatory IV diuretic clinic was associated with risk reduction of any rehospitalization or death over 180 days of follow up when compared to a strategy of observational hospitalization for less than 48 hours. Future research should prospectively analyze outpatient IV therapy in a larger and more diverse population.

Asunto(s)

Diuréticos , Insuficiencia Cardíaca , Anciano , Anciano de 80 o más Años , Diuréticos/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Hospitalización , Humanos , Alta del Paciente , Estudios Retrospectivos , Conducta de Reducción del Riesgo , Volumen Sistólico , Función Ventricular Izquierda

RESUMEN

Background Women represent a large proportion of the growing heart failure (HF) epidemic, yet data are lacking regarding optimal dietary and lifestyle prevention strategies for them. Specifically, the association between magnesium intake and HF in a multiracial cohort of women is uncertain. Methods and Results We included 97 725 postmenopausal women from the WHI (Women's Health Initiative) observational studies and placebo arms of the hormone trial. Magnesium intake was measured at baseline by a 122-item validated food-frequency questionnaire and stratified into quartiles based on diet only, total intake (diet with supplements), and residual intake (calibration by total energy). Incident hospitalized HF (2153 events, median follow-up 8.1 years) was adjudicated by medical record abstraction. In Cox proportional hazards models, we evaluated the association between magnesium intake and HF adjusting for potential confounders. Analyses were repeated on a subcohort (n=18 745; median-follow-up, 13.2 years) for whom HF cases were subclassified into preserved ejection fraction (526 events), reduced ejection fraction (291 events) or unknown (168 events). Most women were white (85%) with a mean age of 63. Compared with the highest quartile of magnesium intake, women in the lowest quartile had an increased risk of incident HF, with adjusted hazard ratios of 1.32 (95% CI, 1.02-1.71) for diet only (P trend=0.03), 1.26 (95% CI, 1.03-1.56) for total intake, and 1.31 (95% CI, 1.02-1.67) for residual intake. Results did not significantly vary by race. Subcohort analyses showed low residual magnesium intake was associated with HF with reduced ejection fraction (hazard ratio, 1.81, lowest versus highest quartile; 95% CI, 1.08-3.05) but not HF with preserved ejection fraction. Conclusions Low magnesium intake in a multiracial cohort of postmenopausal women was associated with a higher risk of incident HF, especially HF with reduced ejection fraction.

Asunto(s)

Dieta , Suplementos Dietéticos , Insuficiencia Cardíaca/epidemiología , Deficiencia de Magnesio/epidemiología , Magnesio/administración & dosificación , Ingesta Diaria Recomendada , Factores de Edad , Anciano , Dieta/efectos adversos , Femenino , Factores de Riesgo de Enfermedad Cardiaca , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Humanos , Incidencia , Deficiencia de Magnesio/diagnóstico , Persona de Mediana Edad , Posmenopausia , Estudios Prospectivos , Medición de Riesgo , Factores Sexuales , Factores de Tiempo , Estados Unidos/epidemiología , Función Ventricular Izquierda

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INTRODUCTION: The aim of this study was to determine whether a pharmacist-led telehealth disease management program is superior to usual care of nurse-led telehealth in improving diabetes medication adherence, haemoglobin A1C (A1C), and depression scores in patients with concomitant diabetes and depression. METHODS: Patients with diabetes and depression were randomized to pharmacist-led or nurse-led telehealth. Veterans with type 1 or type 2 diabetes, an A1C ≥ 7.5%, diagnosis of depression, and access to a landline phone were invited to participate. Patients were randomized to usual care of nurse-led telehealth or pharmacist-led telehealth. Patients were shown how to use the telehealth equipment by the nurse or pharmacist. In the pharmacist-led group, the patients received an in-depth medication review in addition to the instruction on the telehealth equipment. RESULTS: After six months, the pharmacist-led telehealth arm showed significant improvements for cardiovascular medication adherence (14.0; 95% confidence interval (CI) 0.4 to 27.6), antidepressant medication adherence (26.0; 95% CI 0.9 to 51.2), and overall medication adherence combined (13.9; 95% CI 6.6 to 21.2) from baseline to six-month follow-up. There was a significant difference in A1C between each group at the six-month follow-up in the nurse-led telehealth group (6.9 ± 0.9) as compared to the pharmacist-led telehealth group (8.8 ± 2.0). There was no significance in the change in patient health questionnaire-9 (PHQ-9) and Center for Epidemiologic Studies Depression Scale (CES-D) from baseline to follow-up in both groups. DISCUSSION: Pharmacist-led telehealth was efficacious in improving medication adherence for cardiovascular, antidepressants, and overall medications over a six-month period as compared to nurse-led telehealth. There was no significant improvement in overall depression scores.

Asunto(s)

Depresión/terapia , Diabetes Mellitus Tipo 1/terapia , Diabetes Mellitus Tipo 2/terapia , Cumplimiento de la Medicación/estadística & datos numéricos , Telemedicina/organización & administración , Veteranos/estadística & datos numéricos , Depresión/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Manejo de la Enfermedad , Femenino , Hemoglobina Glucada/análisis , Humanos , Masculino , Persona de Mediana Edad , Farmacéuticos/organización & administración

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Background Center-based cardiac rehabilitation (CBCR) has been shown to improve outcomes in patients with heart failure (HF). Home-based cardiac rehabilitation (HBCR) can be an alternative to increase access for patients who cannot participate in CBCR. Hybrid cardiac rehabilitation (CR) combines short-term CBCR with HBCR, potentially allowing both flexibility and rigor. However, recent data comparing these initiatives have not been synthesized. Methods and Results We performed a meta-analysis to compare functional capacity and health-related quality of life (hr-QOL) outcomes in HF for (1) HBCR and usual care, (2) hybrid CR and usual care, and (3) HBCR and CBCR. A systematic search in 5 standard databases for randomized controlled trials was performed through January 31, 2019. Summary estimates were pooled using fixed- or random-effects (when I2>50%) meta-analyses. Standardized mean differences (95% CI) were used for distinct hr-QOL tools. We identified 31 randomized controlled trials with a total of 1791 HF participants. Among 18 studies that compared HBCR and usual care, participants in HBCR had improvement of peak oxygen uptake (2.39 mL/kg per minute; 95% CI, 0.28-4.49) and hr-QOL (16 studies; standardized mean difference: 0.38; 95% CI, 0.19-0.57). Nine RCTs that compared hybrid CR with usual care showed that hybrid CR had greater improvements in peak oxygen uptake (9.72 mL/kg per minute; 95% CI, 5.12-14.33) but not in hr-QOL (2 studies; standardized mean difference: 0.67; 95% CI, -0.20 to 1.54). Five studies comparing HBCR with CBCR showed similar improvements in functional capacity (0.0 mL/kg per minute; 95% CI, -1.93 to 1.92) and hr-QOL (4 studies; standardized mean difference: 0.11; 95% CI, -0.12 to 0.34). Conclusions HBCR and hybrid CR significantly improved functional capacity, but only HBCR improved hr-QOL over usual care. However, both are potential alternatives for patients who are not suitable for CBCR.

Asunto(s)

Rehabilitación Cardiaca/métodos , Insuficiencia Cardíaca/rehabilitación , Terapia por Ejercicio/métodos , Insuficiencia Cardíaca/fisiopatología , Humanos , Centros de Rehabilitación , Autocuidado , Resultado del Tratamiento

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BACKGROUND/OBJECTIVE: Normal weight obesity (NWO) is associated with increased risk of metabolic syndrome, cardiovascular- and all-cause mortality. However, no data have been reported on the relationship between adiposity and cognitive performance in NWO. We therefore studied the association between cognitive function and body fat percentage (BF%) in NWO, using a representative sample of the United States population. METHODS: A cross-sectional study was performed using the nationwide 1988 to 1994 data set from the Third National Health and Nutrition Examination Survey. Cognitive function was measured by three validated cognitive tests: simple reaction time test (SRTT), symbol digit substitution test (SDST), and serial digit learning test (SDLT). The association between BF% and cognitive performance was evaluated in 2,039 adults aged 20-59 years and with a body mass index ranging from 18.5 to 24.9 kg/m2. Linear regression modeling was used to adjust for potential confounders. RESULTS: Increased BF% was significantly associated with poorer performance on SDLT in the entire study sample (coefficient [95% CI]: 0.15 [0.01, 0.29]) and with poorer performance on SDST in the age group 20-29 years (coefficient [95% CI]: 0.30 [0.10, 0.49]). Increased BF% did not significantly predict poorer performance on SRTT. CONCLUSION: Higher BF% is significantly associated with poorer cognitive function in a nationally representative sample of US adults with NWO. The identification of possible complications associated with increased adipose tissue underlines the need to measure body fat content in NWO individuals, whose metabolic and cognitive dysfunction could go undetected for years due to their young age and normal body weight.

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Trastornos del Conocimiento/etiología , Encuestas Nutricionales , Obesidad/complicaciones , Adulto , Distribución por Edad , Índice de Masa Corporal , Trastornos del Conocimiento/epidemiología , Estudios Transversales , Impedancia Eléctrica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Obesidad/epidemiología , Solución de Problemas/fisiología , Tiempo de Reacción/fisiología , Estados Unidos , Adulto Joven

RESUMEN

A primary goal of this research project is to better understand how shared medical appointments (SMAs) can improve the health status and decrease hospitalization and death for patients recently discharged with heart failure (HF) by providing education, disease state monitoring, medication titration, and social support to patients and their caregivers. We propose a 3-site randomized-controlled efficacy trial with mixed methods to test a SMA intervention, versus usual care. Patients within 12 weeks of a HF hospitalization will be randomized to receive either HF-SMA (intervention arm) with optional co-participation with their caregivers, versus usual care (control arm). The HF-SMA will be provided by a non-physician team composed of a nurse, a nutritionist, a health psychologist, a nurse practitioner and/or a clinical pharmacist and will consist of four sessions of 2-h duration that occur every other week for 8 weeks. Each session will start with an assessment of patient needs followed by theme-based disease self-management education, followed by patient-initiated disease management discussion, and conclude with break-out sessions of individualized disease monitoring and medication case management. The study duration will be 180 days for all patients from the day of randomization. The primary study hypothesis is that, compared with usual care, patients randomized to HF-SMA will experience better cardiac health status at 90 and 180 days follow-up. The secondary hypotheses are that, compared to usual care, patients randomized to HF-SMA will experience better overall health status, a combined endpoint of hospitalization and death, better HF self-care behavior, and lower B-type natriuretic peptide levels.

Asunto(s)

Citas y Horarios , Estructura de Grupo , Insuficiencia Cardíaca , Alta del Paciente , Educación del Paciente como Asunto , Autocuidado , Apoyo Social , Femenino , Disparidades en el Estado de Salud , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/psicología , Insuficiencia Cardíaca/terapia , Hospitalización , Humanos , Masculino , Administración del Tratamiento Farmacológico , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Gravedad del Paciente , Participación del Paciente , Autocuidado/métodos , Autocuidado/psicología , Análisis de Supervivencia

RESUMEN

OBJECTIVES: The effectiveness and costs associated with addition of pharmacist-led group medical visits to standard care for patients with Type-2 Diabetes Mellitus (T2DM) is unknown. METHODS: Randomized-controlled-trial in three US Veteran Health Administration (VHA) Hospitals, where 250 patients with T2DM, HbA1c >7% and either hypertension, active smoking or hyperlipidemia were randomized to either (1) addition of pharmacist-led group-medical-visits or (2) standard care alone for 13 months. Group (4-6 patients) visits consisted of 2-hour, education and comprehensive medication management sessions once weekly for 4 weeks, followed by quarterly visits. Change from baseline in cardiovascular risk estimated by the UKPDS-risk-score, health-related quality-of-life (SF36v) and institutional healthcare costs were compared between study arms. RESULTS: After 13 months, both groups had similar and significant improvements from baseline in UKPDS-risk-score (-0.02 ±0.09 and -0.04 ±0.09, group visit and standard care respectively, adjusted p<0.05 for both); however, there was no significant difference between the study arms (adjusted p = 0.45). There were no significant differences on improvement from baseline in A1c, systolic-blood-pressure, and LDL as well as health-related quality-of-life measures between the study arms. Compared to 13 months prior, the increase in per-person outpatient expenditure from baseline was significantly lower in the group visit versus the standard care arm, both during the study intervention period and at 13-months after study interventions. The overall VHA healthcare costs/person were comparable between the study arms during the study period (p = 0.15); then decreased by 6% for the group visit but increased by 13% for the standard care arm 13 months post-study (p<0.01). CONCLUSIONS: Addition of pharmacist-led group medical visits in T2DM achieved similar improvements from baseline in cardiovascular risk factors than usual care, but with reduction in the healthcare costs in the group visit arm 13 months after completion compared to the steady rise in cost for the usual care arm. TRIAL REGISTRATION: NCT00554671 ClinicalTrials.gov.

Asunto(s)

Atención Ambulatoria/economía , Análisis Costo-Beneficio , Diabetes Mellitus Tipo 2/epidemiología , Servicios Farmacéuticos/economía , Farmacéuticos , Anciano , Comorbilidad , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Femenino , Hospitales de Veteranos , Humanos , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud , Atención Primaria de Salud/economía , Estados Unidos/epidemiología

RESUMEN

BACKGROUND: Shared medical appointments (SMAs) are clinical visits in which several patients meet with 1 or more providers at the same time. OBJECTIVE: To describe the outcomes of an interdisciplinary SMA for veterans recently discharged for heart failure (HF). METHODS: A retrospective chart review for patients' readmission rates, survival, medication adherence, and medication-related problems. For qualitative outcomes, we performed semistructured interviews on 12 patients who had undergone HF SMAs and their respective caregivers focusing on care satisfaction, HF knowledge, disease self-care, medication reconciliation, and peer support. RESULTS: The cohort comprised 70 patients-49% had left ventricular function <40% and 50% were prescribed >10 medications. Medication-related problems occurred in 60% of patients. Interviews revealed overall satisfaction with HF-SMA, but patients felt overwhelmed with HF instructions, perceived lack of peer support and self-efficacy, and feelings of hopelessness related to HF. CONCLUSION: Shared medical appointments are well-perceived. Medication problems and need for medication management are prevalent along with patient's lack of self-efficacy in HF care. Multiple HF-SMA visits may be needed to reinforce concepts, reduce confusion, and garner peer support.

RESUMEN

AIM: To explore whether Video-Shared Medical Appointments (video-SMA), where group education and medication titration were provided remotely through video-conferencing technology would improve diabetes outcomes in remote rural settings. METHODS: We conducted a pilot where a team of a clinical pharmacist and a nurse practitioner from Honolulu VA hospital remotely delivered video-SMA in diabetes to Guam. Patients with diabetes and HbA1c ≥7% were enrolled into the study during 2013-2014. Six groups of 4-6 subjects attended 4 weekly sessions, followed by 2 bi-monthly booster video-SMA sessions for 5 months. Patients with HbA1c ≥7% that had primary care visits during the study period but not referred/recruited for video-SMA were selected as usual-care comparators. We compared changes from baseline in HbA1c, blood-pressure, and lipid levels using mixed-effect modeling between video-SMA and usual care groups. We also analyzed emergency department (ED) visits and hospitalizations. Focus groups were conducted to understand patient's perceptions. RESULTS: Thirty-one patients received video-SMA and charts of 69 subjects were abstracted as usual-care. After 5 months, there was a significant decline in HbA1c in video-SMA vs. usual-care (9.1±1.9 to 8.3±1.8 vs. 8.6±1.4 to 8.7±1.6, P=0.03). No significant change in blood-pressure or lipid levels was found between the groups. Patients in the video-SMA group had significantly lower rates of ED visits (3.2% vs. 17.4%, P=0.01) than usual-care but similar hospitalization rates. Focus groups suggested patient satisfaction with video-SMA and increase in self-efficacy in diabetes self-care. CONCLUSION: Video-SMA is feasible, well-perceived and has the potential to improve diabetes outcomes in a rural setting.

Asunto(s)

Diabetes Mellitus/prevención & control , Hospitalización/estadística & datos numéricos , Cumplimiento de la Medicación , Farmacéuticos , Atención Primaria de Salud , Autocuidado , Comunicación por Videoconferencia/estadística & datos numéricos , Citas y Horarios , Presión Sanguínea , Servicio de Urgencia en Hospital , Femenino , Hemoglobina Glucada/análisis , Humanos , Hipoglucemiantes/uso terapéutico , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Proyectos Piloto , Estudios Prospectivos , Población Rural

RESUMEN

BACKGROUND: Little is known about magnesium intake and risk of heart failure (HF) hospitalizations, particularly in blacks. We hypothesize that magnesium intake relates to HF hospitalization in blacks. METHODS AND RESULTS: From the Jackson Heart Study cohort (n=5301), we studied 4916 blacks recruited during 2000 to 2004 in Jackson (Mississippi), who completed an 158-item Food-Frequency Questionnaire that included dietary supplements. Daily magnesium intake derived from the questionnaire was divided by the body weight to account for body storage and stratified by quartiles (0.522-2.308, 2.309-3.147, 3.148-4.226, and ≥4.227 mg magnesium intake/kg). Cox proportional hazards modeling assessed the association between quartiles of magnesium intake/kg and hospitalizations for HF adjusting for HF risk, energy intake, and dietary factors. The cohort had a mean age=55.3 (SD=12.7 years) and composed of 63.4% women, 21.6% diabetes mellitus, 62.7% hypertension, 7.1% coronary disease, and 2.8% with known HF. When compared with participants in the first quartile of magnesium intake/kg, those with higher magnesium intake (>2.308 mg/kg) had decreased risk of HF admission, with adjusted hazard ratios of 0. 66(95% confidence interval, 0.47-0.94) in the second quartile to 0.47 (95% confidence interval, 0.27-0.82) in the highest quartile. Results were similar when individuals with previously diagnosed HF (2.8%) were excluded or when the analysis was repeated using quartiles of magnesium intake without accounting for body weight. CONCLUSIONS: Magnesium intake <2.3 mg/kg was related to increased risk of subsequent HF hospitalizations. Future studies are needed to test whether serum magnesium levels predict risk of HF.

Asunto(s)

Negro o Afroamericano , Dieta , Suplementos Dietéticos , Insuficiencia Cardíaca/etnología , Hospitalización , Magnesio/administración & dosificación , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Comorbilidad , Diástole , Ecocardiografía Doppler , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/terapia , Humanos , Estimación de Kaplan-Meier , Modelos Lineales , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Mississippi/epidemiología , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Ingesta Diaria Recomendada , Medición de Riesgo , Factores de Riesgo , Encuestas y Cuestionarios , Sístole , Factores de Tiempo , Función Ventricular Izquierda , Adulto Joven

RESUMEN

Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.

Asunto(s)

Diabetes Mellitus/tratamiento farmacológico , Diabetes Mellitus/enfermería , Cuidados a Largo Plazo , Instituciones de Cuidados Especializados de Enfermería , Adulto , Anciano , Anciano de 80 o más Años , Glucemia , Comorbilidad , Complicaciones de la Diabetes , Manejo de la Enfermedad , Humanos , Hipoglucemia/etiología , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Persona de Mediana Edad , Prevalencia , Calidad de Vida , Estados Unidos

RESUMEN

AIMS: To evaluate the efficacy of two maintenance strategies compared to usual care after discharge from a pharmacist-led cardiovascular risk reduction clinic (CRRC). METHODS: Open-label, randomized-controlled trial of 200 consecutive CRRC patients that met clinic discharge criteria (HbA1c ≤7% (53 mmol/mol); blood pressure ≤140/80 mmHg for those with diabetes and ≤140/90 mmHg for those without diabetes; and an LDL-cholesterol ≤2.59 mmol/l). Participants were randomized to either quarterly group medical visits or quarterly CRRC individual clinic visits, or a usual care control arm with the standard primary care alone first in a 1:1:1 ratio, followed by a 2:2:1 ratio after first 100 patients. Primary outcome measures were time to failure for guideline recommended goals of HbA1c and blood pressure over 12-months. RESULTS: Of the 200 participants randomized, 89% had diabetes and were similar in other cardiovascular risk factors. After 1-year, the HbA1c failure rate was 0.36 [95% CI, 0.28-0.47] per quarter for the group medical visit arm, 0.24 [95% CI, 0.18-0.33] per quarter for the quarterly CRRC individual arm and, 0.82 [95% CI, 0.69-0.96] per quarter for the usual care control arm, p<0.001. The rate of failure for blood pressure was 0.31 [95% CI, 0.23-0.41] per quarter for the group medical visit arm, 0.22 [95% CI, 0.16-0.30] per quarter for the CRRC individual arm and, 0.53 [95% CI, 0.40-0.71] per quarter the control arm, p<0.001. CONCLUSION: After discharge from a CRRC program, both individual and group interventions are more effective in maintaining glycemia and blood pressure control for patients with diabetes than usual care after 1-year of follow-up.

Asunto(s)

Enfermedades Cardiovasculares/prevención & control , Cardiomiopatías Diabéticas/prevención & control , Educación del Paciente como Asunto/métodos , Cuidados Posteriores , Anciano , Atención Ambulatoria , Biomarcadores/sangre , Presión Sanguínea , Enfermedades Cardiovasculares/sangre , LDL-Colesterol/sangre , Cardiomiopatías Diabéticas/sangre , Femenino , Hemoglobina Glucada/análisis , Humanos , Masculino , Persona de Mediana Edad , Alta del Paciente , Conducta de Reducción del Riesgo