Implementing a Quality Intervention to Improve Confidence in Outpatient Venous Thromboembolism Management.

INTRODUCTION: Guidelines recommend that patients with acute venous thromboembolism (VTE) represented by low-risk deep vein thrombosis (DVT) and pulmonary embolism (PE) receive initial treatment at home versus at the hospital, but a large percentage of these patients are not managed at home. This study assessed the effectiveness of a quality intervention on provider knowledge and confidence in evaluating outpatient treatment for patients with VTE in the emergency department (ED). METHODS: A pilot program to overcome obstacles to outpatient VTE treatment in appropriate patients was initiated at Baylor Scott & White Health Temple ED. Subsequently, a formalized quality intervention with a targeted educational program was developed and delivered to ED providers. Provider surveys were administered pre- and post-quality intervention in order to assess clinical knowledge, confidence levels, and perceived barriers. Patient discharge information was extracted from electronic health records. RESULTS: Twenty-five ED providers completed the pre- and post-surveys; 690 and 356 patients with VTE were included in the pre- and post-pilot and pre- and post-quality intervention periods, respectively. Many ED providers reported that a major barrier to discharging patients to outpatient care was the lack of available and adequate patient follow-up appointments. Notably, after the quality intervention, an increase in provider clinical knowledge and confidence scores was observed. Discharge rates for patients with VTE increased from 25.6% to 27.5% after the pilot intervention and increased from 28.5% to 29.9% after the quality intervention, but these differences were not statistically significant. Despite instantaneous uptick in discharge rates after the interventions, there was not a long-lasting effect. CONCLUSION: Although the quality intervention led to improvements in provider clinical knowledge and confidence and identified barriers to discharging patients with VTE, discharge rates remained stable, underscoring the need for additional endeavors.

When patients develop blood clots in their veins or have blood clots travel to their lungs, they may seek treatment at the hospital emergency department. As a best practice, most people can treat blood clots with medicines at home; however, many patients are treated at the hospital. This study looked at how an education program for doctors in the hospital could help more patients be treated at home. The education program improved doctors' knowledge and confidence when evaluating patients with blood clots who could be treated at home. However, this study found that the number of patients treated at home was the same before and after the doctors participated in the education program. Two major problems that prevented patients from being treated at home were not having follow-up appointments readily available and patients taking their medicine as needed. More and different types of programs may help doctors understand the best ways to treat patients with blood clots in the emergency department.

Digital dashboards for direct oral anticoagulant surveillance, intervention and operational efficiency: uptake, obstacles, and opportunities.

Direct oral anticoagulants (DOAC) are the most widely prescribed oral anticoagulants in the United States. Despite advantages over warfarin, system-level improvements are needed to optimize outcomes. While Veterans Health Administration and others have described successful DOAC management dashboard implementation, the extent of use nationally is unknown. A survey of Anticoagulation Forum's members was conducted to assess access to digital tools available within a dashboard and to describe implementation models. An Expert Forum was subsequently convened to identify barriers to dashboard development and adoption. Responses were received from 340 targeted recipients (8.5% of invitees). Only a minority of inpatient (25/52, 48.1%) and outpatient (47/133, 35.3%) respondents outside of Veterans Health Administration were able to generate rosters of DOAC users on-demand, and fewer had the ability to digitally display key clinical data elements, identify drug-related problems, document interventions, or generate reports. The lack of regulatory requirements regarding Anticoagulation Stewardship was identified by the Expert Forum as the major barrier to widespread development of digital tools for improved anticoagulation management. While some health systems have demonstrated the feasibility of DOAC dashboards and described their impact on quality and efficiency, these tools do not appear to be widely available in the United States apart from Veterans Health Administration. The lack of regulatory requirements for Anticoagulation Stewardship may be the primary barrier to the development of digital resources to better manage anticoagulants. Efforts to secure regulatory requirements for Anticoagulation Stewardship are needed, and evidence of improvements in clinical and financial outcomes through DOAC dashboard use will likely bolster such efforts.

Digital dashboards for oral anticoagulation management: a literature scoping review.

This scoping review summarizes the extent and characteristics of the published literature describing digital population management dashboards implemented to improve the quality of anticoagulant management. A standardized search protocol was executed to identify relevant manuscripts published between January 1, 2015 and May 31, 2022. The resulting records were systematically evaluated by multiple blinded reviewers and the findings from selected papers were evaluated and summarized. Twelve manuscripts were identified, originating from 5 organizations within the US and 2 from other countries. The majority (75%) described implementation in the outpatient setting. The identified papers described a variety of positive results of dashboard use, including a 24.5% reduction of questionable direct oral anticoagulant dosing in one organization, a 33.3% relative improvement in no-show appointments in an ambulatory care clinic, and a 75% improvement in intervention efficiency. One medical center achieved a 98.4% risk-appropriate venous thromboembolism risk prophylaxis prescribing rate and 40.6% reduction in anticoagulation-related adverse event rates. The manuscripts primarily described retrospective findings from single-center dashboard implementation experiences. Digital dashboards have been successfully implemented to support the anticoagulation of acute and ambulatory patients and available manuscripts suggest a positive impact on care-related processes and relevant patient outcomes. Prospective studies are needed to better characterize the implementation and impact of dashboards for anticoagulation management. Published reports suggest that digital dashboards may improve the quality, safety, and efficiency of anticoagulation management. Additional research is needed to validate these findings and to understand how best to implement these tools.

Building Resilience in the Face of Crisis: Lessons Learned from a Community Behavioral Healthcare Organization.

The novel coronavirus (SARS-CoV-2 or COVID19) has defied the healthcare system at every turn. The impact of this pandemic on ensuring the health and safety of individuals with serious and persistent mental illness-particularly those living in community-based residential settings-has been challenging. As one of the largest community behavioral health organizations in Oregon, the authors present a descriptive study of an organizational response to the COVID-19 pandemic. This paper presents barriers, strategies, and lessons learned, through firsthand experience and interviews with key residential staff. This paper is not formal research, but the integration and assessment of staff perspective, and organizational experience and knowledge. By sharing these insights and experience, this paper contributes to a collective roadmap for the future, to guide responses to public health crises or other unprecedented events that threaten organizations caring for some of the most vulnerable members of the community.

Understanding End-of-Life Preferences: Predicting Life-Prolonging Treatment Preferences Among Community-Dwelling Older Americans.

OBJECTIVES: To determine how demographic, socioeconomic, health, and psychosocial factors predict preferences to accept life-prolonging treatments (LPTs) at the end of life (EOL). METHODS: This is a retrospective cohort study of a nationally representative sample of community-dwelling older Americans (N = 1648). Acceptance of LPT was defined as wanting to receive all LPTs in the hypothetical event of severe disability or severe chronic pain at the EOL. Participants with a durable power of attorney, living will, or who discussed EOL with family were determined to have expressed their EOL preferences. The primary analysis used survey-weighted logistic regression to measure the association between older adult characteristics and acceptance of LPT. Secondarily, the associations between LPT preferences and health outcomes were measured using regression models. RESULTS: Approximately 31% of older adults would accept LPT. Nonwhite race/ethnicity (odds ratio [OR] 0.54; 95% CI 0.41, 0.70; white vs. nonwhite), self-realization (OR 1.34; 95% CI 1.01, 1.79), attendance of religious services (OR 1.44; 95% CI 1.07, 1.94), and expression of preferences (OR 0.54; 95% CI 0.40, 0.72) were associated with acceptance of LPT. LPT preferences were not independently associated with mortality or disability. CONCLUSIONS: Approximately one-third of older Americans would accept LPT in the setting of severe disability or severe chronic pain at the EOL. Adults who discussed their EOL preferences were more likely to reject LPT. Conversely, minorities were more likely to accept LPT. Sociodemographics, physical capacity, and health status were poor predictors of acceptance of LPT. A better understanding of the complexities of LPT preferences is important to ensuring patient-centered care.

Preventing Harm From Fluoroscopically Guided Interventional Procedures With a Risk-Based Analysis Approach.

PURPOSE: Fluoroscopically guided interventional (FGI) procedures often have lower complication rates compared with alternative surgical procedures, providing an option for patients with a high risk of perioperative mortality. Although severe radiation injuries are rare, patients receiving peak skin doses exceeding 3 Gy can suffer from radiation-induced tissue injuries, ranging from transient erythema to nonhealing wounds. As these iatrogenic injuries may manifest weeks to months postprocedure, proper diagnosis and timely medical intervention are less likely. Clinically, the lack of situational awareness for monitoring air kerma continues to be a challenge despite the recommendations of numerous organizations on ways to achieve fluoroscopy safety. For patient safety efforts, this study aimed to identify and mitigate systematic gaps associated with potentially high-radiation dose fluoroscopic procedures in US Department of Veterans Affairs (VA) and non-VA medical institutions. METHODS: In this study, a multi-institutional team utilized Healthcare Failure Mode and Effect Analysis (HFMEA) on an example implantable cardioverter defibrillator lead extraction procedure. RESULTS: With this approach, 29 interventions were devised and prioritized by feasibility, cost-effectiveness, and expected clinical impact. Five of the 29 interventions were recommended for immediate implementation or piloting. CONCLUSIONS: This work demonstrates the application of formal risk-based analysis techniques in FGI procedures. These high priority interventions may be valuable for other facilities to consider when performing potentially high-radiation dose procedures and conducting risk-benefit analyses. Formal risk analysis techniques such as the HFMEA process are recommended for other facilities to use to improve safety for their high-risk procedures.

Difficulty and independence in shopping among older Americans: more than just leaving the house.

BACKGROUND: The built, social and economic environments are associated with disability, but knowledge of how these environmental characteristics simultaneously influence older adults' ability to shop independently is limited. OBJECTIVE: We investigated cross-sectional associations between the outdoor home, local neighborhood and macrosocioeconomic levels of the environment and shopping difficulty and interactions between environmental factors and shopping difficulty. METHODS: Using nationally representative data from a study of Medicare-eligible adults, we conducted a cross-sectional secondary data analysis to examine associations between the environment and difficulty shopping (N = 5504). RESULTS: Sidewalk conditions, broken steps, neighborhood social cohesion and neighborhood socioeconomic disadvantage were associated with more difficulty shopping, although health factors partially accounted for associations between broken steps and disadvantage and shopping difficulty. The association between social cohesion and shopping difficulty also depended on the degree of socioeconomic disadvantage in the neighborhood. CONCLUSIONS: Overall, results suggest that factors in the outdoor and local neighborhood environment influence the ability to shop independently for older adults, but that it also may depend on the socioeconomic context of the neighborhood. Interventions aimed at improving the built environment directly outside of older adults' homes and helping increase social cohesion among neighbors, has the potential to reduce difficulty in carrying out this important activity. Implications for rehabilitation Built features of the outdoor home environment including sidewalks and broken steps influence whether older adults are able to safely leave their home to conduct daily activities such as shopping, so it is important that clinicians and rehabilitation professionals are aware of these challenges when helping their patients resume daily activities such as shopping. The physical condition and safety of the immediate outdoor home and neighborhood environment is critical for maintaining independence and well-being for older adults, which is critical for physical rehabilitation as well as maintenance of essential activities such as shopping. Living in more socially cohesive neighborhoods may aid in physical rehabilitation efforts by helping older adults feel more comfortable and able to shop independently in neighborhoods with social and economic disadvantages.

Understanding Socioenvironmental Contributors to Racial and Ethnic Disparities in Disability Among Older Americans.

Our understanding of the mechanisms through which racial/ethnic disparities in disability in older adults develop and are maintained is limited. We examined the role of physical impairment, socioeconomic factors and health for racial/ethnic disparities in activities of daily living (ADL), and the modifying role of the indoor home environment. Data come from the National Health and Aging Trends Study ( N = 5,640), and negative binomial regression models were specified separately for men and women. Blacks and Hispanics reported more ADL difficulty than Whites. Living in homes with clutter was associated with higher rates of ADL difficulty, but it was not related to racial/ethnic disparities. Racial/ethnic differences were explained by physical impairment for men, but not for women. Socioeconomic factors and health accounted for remaining disparities for Black, but not for Hispanic women. Attention to individual and environmental factors is necessary to fully understand and address race/ethnic disparities in disability in older Americans.

The Epidemiology of Coping in African American Adults in the Jackson Heart Study (JHS).

Differences in coping within the African American population are not well understood, yet these differences may be critical to reducing stress, improving health, and reducing racial health disparities. Using a descriptive, exploratory analysis of the Jackson Heart Study (N = 5301), we examine correlations between coping responses and associations between coping and demographic, socioeconomic, psychosocial, and neighborhood factors. Overall, coping responses were not strongly correlated and patterns of associations between covariates and coping responses were largely inconsistent. The results suggest that coping varies substantially within this African American population and is driven mainly by psychosocial factors such as spirituality and interpersonal support. Understanding these complex relationships may inform strategies by which to intervene in the stress process to mitigate the effects of stress on health and to identify vulnerable subgroups of African Americans that might need targeted interventions to reduce exposure to stressors and improve coping capacities.

Child and Adult Socioeconomic Status and the Cortisol Response to Acute Stress: Evidence From the Multi-Ethnic Study of Atherosclerosis.

OBJECTIVE: A long-hypothesized pathway through which low socioeconomic status (SES) harms health is through dysregulation of the physiologic stress response systems. No previous studies have tested this hypothesis by investigating cortisol reactivity and recovery to acute stress in relation to SES at different times in the life course in adults. Alteration of the cortisol response to an acute stressor could signal dysregulation of the hypothalamic-pituitary-adrenal axis and has been associated with chronic illness. METHODS: We used data on 997 adults 54 years or older from a multiethnic, multisite United States study to examine associations between life course SES and cortisol response to a laboratory stress challenge. Informed by life course theory, we hypothesized that lower child and adult SES would be associated with lower reactivity (i.e., smaller increase in cortisol) and a slower recovery rate (i.e., slower rate of decline in cortisol after the challenge). RESULTS: In demographics-adjusted multilevel piecewise linear regression models, low child and adult SES were associated with a 19% (95% CI = 4%-50%) and 27% (7%-55%) slower recovery rate compared with high child and adult SES, respectively. Compared with participants with stable high SES, those with stable low SES had a 48% (16%-70%) slower recovery rate. Differences in reactivity by SES were small. CONCLUSIONS: Our results support the hypothesis that low SES throughout life affects the hypothalamic-pituitary-adrenal axis and in turn the ability to recover from exposure to acute stressors. This mechanism can help explain how socioeconomic disparities contribute to disparities in chronic disease.

Moving Toward an Understanding of Disability in Older U.S. Stroke Survivors.

OBJECTIVES: We test a comprehensive model of disability in older stroke survivors and determine the relative contribution of neighborhood, economic, psychological, and medical factors to disability. METHOD: The sample consisted of 728 stroke survivors from the National Health and Aging Trends Study (NHATS), who were 65 years and older living in community settings or residential care. Confirmatory factor analysis and structural equation modeling were used to test relationships between neighborhood, socioeconomic, psychological, and medical factors, and disability. RESULTS: Economic and medical context were associated with disability directly and indirectly through physical impairment. Neighborhood context was associated with disability, but was only marginally statistically significant ( p = .05). The effect of economic and neighborhood factors was small compared with that of medical factors. DISCUSSION: Neighborhood and economic factors account for a portion of the variance in disability among older stroke survivors beyond that of medical factors.

Perceived discrimination is associated with health behaviours among African-Americans in the Jackson Heart Study.

BACKGROUND: Using Jackson Heart Study data, we examined associations of multiple measures of perceived discrimination with health behaviours among African-Americans (AA). METHODS: The cross-sectional associations of everyday, lifetime and burden of discrimination with odds of smoking and mean differences in physical activity, dietary fat and sleep were examined among 4925 participants aged 35-84 years after adjustment for age and socioeconomic status (SES). RESULTS: Men reported slightly higher levels of everyday and lifetime discrimination than women and similar levels of burden of discrimination as women. After adjustment for age and SES, everyday discrimination was associated with more smoking and a greater percentage of dietary fat in men and women (OR for smoking: 1.13, 95% CI 1.00 to 1.28 and 1.19, 95% CI 1.05 to 1.34; mean difference in dietary fat: 0.37, p<0.05 and 0.43, p<0.01, in men and women, respectively). Everyday and lifetime discrimination were associated with fewer hours of sleep in men and women (mean difference for everyday discrimination: -0.08, p<0.05 and -0.18, p<0.001, respectively; and mean difference for lifetime discrimination: -0.08, p<0.05 and -0.24, p<0.001, respectively). Burden of discrimination was associated with more smoking and fewer hours of sleep in women only. CONCLUSIONS: Higher levels of perceived discrimination were associated with select health behaviours among men and women. Health behaviours offer a potential mechanism through which perceived discrimination affects health in AA.

Childhood family wealth and mental health in a national cohort of young adults.

PURPOSE: Mental health is critical to young adult health, as the onset of 75% of psychiatric disorders occurs by age 24 and psychiatric disorders early in life predict later behavioral health problems. Wealth may serve as a buffer against economic stressors. Family wealth may be particularly relevant for young adults by providing them with economic resources as they make educational decisions and move towards financial and social independence. METHODS: We used prospectively collected data from 2060 young adults aged 18-27 in 2005-2011 from the Panel Study of Income Dynamics, a national cohort of US families. We examined associations between nonspecific psychological distress (measured with the K-6 scale) and childhood average household wealth during ages 0-18 years (net worth in 2010 dollars). RESULTS: In demographics-adjusted generalized estimating equation models, higher childhood wealth percentile was related to a lower prevalence of serious psychological distress: compared to below-median wealth, prevalence ratio (PR) = 0.56 (0.36-0.87) for 3rd quartile and PR = 0.46 (0.29-0.73) for 4th quartile. The associations were attenuated slightly by adjustment for parent education and more so by adjustment for childhood household income percentile. CONCLUSIONS: Understanding the lifelong processes through which distinct aspects of socioeconomic status affect mental health can help us identify high-risk populations and take steps to minimize future disparities in mental illness.

Associations of Alcohol Availability and Neighborhood Socioeconomic Characteristics With Drinking: Cross-Sectional Results From the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: Living in neighborhoods with a high density of alcohol outlets and socioeconomic disadvantage may increase residents' alcohol use. Few researchers have studied these exposures in relation to multiple types of alcohol use, including beverage-specific consumption, and how individual demographic factors influence these relationships. OBJECTIVE: To examine the relationships of alcohol outlet density and neighborhood disadvantage with alcohol consumption, and to investigate differences in these associations by race/ethnicity and income. METHODS: Using cross-sectional data (N = 5,873) from the Multi-ethnic Study of Atherosclerosis in 2002, we examine associations of residential alcohol outlet density and neighborhood socioeconomic disadvantage with current, total weekly and heaviest daily alcohol use in gender-specific regression models, as well as moderation by race/ethnicity and income. RESULTS: Drinking men living near high densities of alcohol outlets had 23%-29% more weekly alcohol use than men in low density areas. Among women who drank, those living near a moderate density of alcohol outlets consumed approximately 40% less liquor each week than those in low density areas, but higher outlet densities were associated with more wine consumption (35%-49%). Living in highly or moderately disadvantaged neighborhoods was associated with a lower probability of being a current drinker, but with higher rates of weekly beer consumption. Income moderated the relationship between neighborhood context and weekly alcohol use. CONCLUSIONS/IMPORTANCE: Neighborhood disadvantage and alcohol outlet density may influence alcohol use with effects varying by gender and income. Results from this research may help target interventions and policy to groups most at risk for greater weekly consumption.

Longitudinal associations of neighborhood socioeconomic characteristics and alcohol availability on drinking: Results from the Multi-Ethnic Study of Atherosclerosis (MESA).

Neighborhood socioeconomic characteristics and alcohol availability may affect alcohol consumption, but adequate longitudinal research to support these hypotheses does not exist. We used data from the Multi-Ethnic Study of Atherosclerosis (MESA) (N = 6163) to examine associations of changes in neighborhood socioeconomic status (SES) and alcohol outlet density, with current, weekly, and heavy daily alcohol consumption in hybrid effects models. We also examined whether these associations were moderated by gender, race/ethnicity, and income. Increases in neighborhood SES were associated with decreases in the probability of current alcohol use after adjustment for age, gender, race/ethnicity, individual SES, marital status and time since baseline [probability ratio (PR) per SD increase in neighborhood SES = 0.96, 95% confidence interval (CI) (0.96.0.99)]. Increases in liquor store densities were associated with increases in weekly alcohol consumption [ratio of weekly drinks per SD increase in outlet density = 1.07, 95% CI (1.01.1.05) for men, PR = 1.11, 95% CI (1.01.1.21) for women]. Relationships between current alcohol use and neighborhood SES and between weekly beer consumption and neighborhood SES were generally stronger among those with higher incomes. Neighborhood socioeconomic context and the availability of alcohol may be important for understanding patterns of alcohol use over time, and for targeting interventions and policies to reduce harmful alcohol use.

A Spatial Analysis of Heterogeneity in the Link Between Alcohol Outlets and Assault Victimization: Differences Across Victim Subpopulations.

The positive association between alcohol outlet density and assault rates is well established, but little is known about how this association differs across victim subpopulations. We use spatial point process models on police data from Flint, Michigan, to test how the link between alcohol outlet density and assault rates changes as a function of three victim characteristics: age, gender, and race. We found that, although both on-premises and package outlet densities consistently emerge as risk factors for victimization, their relative effects are markedly larger in Whites than in African Americans. No analogous age- or gender-based differences were found. These results suggest the racial effects arise more from relative differences in the atmosphere in and around alcohol outlets than differences in drinking behavior alone.

The impact of lifecourse socioeconomic position on cardiovascular disease events in African Americans: the Jackson Heart Study.

BACKGROUND: Few studies have examined the impact of lifecourse socioeconomic position (SEP) on cardiovascular disease (CVD) risk among African Americans. METHODS AND RESULTS: We used data from the Jackson Heart Study (JHS) to examine the associations of multiple measures of lifecourse SEP with CVD events in a large cohort of African Americans. During a median of 7.2-year follow-up, 362 new or recurrent CVD events occurred in a sample of 5301 participants aged 21 to 94. Childhood SEP was assessed by using mother's education, parental home ownership, and childhood amenities. Adult SEP was assessed by using education, income, wealth, and public assistance. Adult SEP was more consistently associated with CVD risk in women than in men: age-adjusted hazard ratios for low versus high income (95% CIs), 2.46 (1.19 to 5.09) in women and 1.50 (0.87 to 2.58) in men, P for interaction=0.1244, and hazard ratio for low versus high wealth, 2.14 (1.39 to 3.29) in women and 1.06 (0.62 to 1.81) in men, P for interaction=0.0224. After simultaneous adjustment for all adult SEP measures, wealth remained a significant predictor of CVD events in women (HR=1.73 [1.04, 2.85] for low versus high). Education and public assistance were less consistently associated with CVD. Adult SEP was a stronger predictor of CVD events in younger than in older participants (HR for high versus low summary adult SEP score 3.28 [1.43, 7.53] for participants ≤50 years, and 1.90 (1.36 to 2.66) for participants >50 years, P for interaction 0.0846). Childhood SEP was not associated with CVD risk in women or men. CONCLUSIONS: Adult SEP is an important predictor of CVD events in African American women and in younger African Americans. Childhood SEP was not associated with CVD events in this population.

Quantitative identification of metastable magnesium carbonate minerals by solid-state 13C NMR spectroscopy.

In the conversion of CO2 to mineral carbonates for the permanent geosequestration of CO2, there are multiple magnesium carbonate phases that are potential reaction products. Solid-state (13)C NMR is demonstrated as an effective tool for distinguishing magnesium carbonate phases and quantitatively characterizing magnesium carbonate mixtures. Several of these mineral phases include magnesite, hydromagnesite, dypingite, and nesquehonite, which differ in composition by the number of waters of hydration or the number of crystallographic hydroxyl groups. These carbonates often form in mixtures with nearly overlapping (13)C NMR resonances which makes their identification and analysis difficult. In this study, these phases have been investigated with solid-state (13)C NMR spectroscopy, including both static and magic-angle spinning (MAS) experiments. Static spectra yield chemical shift anisotropy (CSA) lineshapes that are indicative of the site-symmetry variations of the carbon environments. MAS spectra yield isotropic chemical shifts for each crystallographically inequivalent carbon and spin-lattice relaxation times, T1, yield characteristic information that assist in species discrimination. These detailed parameters, and the combination of static and MAS analyses, can aid investigations of mixed carbonates by (13)C NMR.

Evaluation of the efficacy and safety of a hydrochlorothiazide to chlorthalidone medication change in veterans with hypertension.

BACKGROUND: There are few data available examining the clinical impact of switching patients from hydrochlorothiazide (HCTZ) to chlorthalidone for blood pressure management. OBJECTIVES: The goal of this study was to compare within-patient clinic blood pressure readings, serum electrolyte levels, and renal function markers before and after a medication change from HCTZ to chlorthalidone in a veteran population. METHODS: This was a retrospective, pre- and postmeasure, self-controlled study. Veterans Affairs Ann Arbor Healthcare System patients switched from HCTZ to chlorthalidone between January 1, 2001, and January 31, 2012, who had at least 1 follow-up clinic blood pressure reading recorded between 2 and 8 weeks from the date of the medication change were included in the study. Mean pre- and postmeasure values for systolic and diastolic clinic blood pressures, serum potassium, serum sodium, serum calcium, serum creatinine, and blood urea nitrogen were compared by using a 2-tailed, paired t test with a significance level (α) of 0.05. RESULTS: Of the 40 patients included in the study 95% were male, 65% were white, and the mean age was 64.9 (10.8) years. Both mean systolic (-15.8 mm Hg [95% CI, 8.9 to 22.6], P < 0.0001) and mean diastolic (-4.2 mm Hg [95% CI, 1.5 to 6.9], P = 0.0035) blood pressures showed statistically and clinically significant reductions after the medication change. A statistically significant decrease in mean sodium (-1.1 mmol/L [95% CI, 0.4 to 1.9], P = 0.003) and an increase in mean serum creatinine (0.06 mg/dL [95% CI, -0.09 to -0.02], P = 0.002) was observed; however, these changes may not be viewed as clinically significant by many practitioners. No statistically significant changes were observed in any of the other outcomes examined. Most patients (38 of 40) were taking at least 1 additional antihypertensive agent; 73% of patients were using ≥ 3 antihypertensive agents at the time of the medication change. CONCLUSIONS: In patients with hypertension already taking HCTZ, switching to chlorthalidone seems to further reduce systolic and diastolic blood pressures without any clinically significant changes in renal function or electrolyte levels.