A Project to Promote Adherence to Blood Pressure Medication Among People Who Use Community Pharmacies in Rural Montana, 2014-2016.

INTRODUCTION: Pharmacists can assist patients in managing their blood pressure levels. We assessed whether adherence to blood pressure medication improved among people who used community pharmacies in rural Montana after pharmacists initiated consultations and distributed educational materials developed for the Million Hearts Initiative's "Team Up. Pressure Down." (TUPD) program. METHODS: From 2014 to 2016, the Cardiovascular Health Program at the Montana Department of Public Health and Human Services conducted a statewide project to evaluate an intervention for adherence to blood pressure medication administered through community pharmacies. After the year 1 pilot, we redesigned the program for year 2 and year 3 and measured the percentage of participating patients who adhered to blood pressure medication. We also conducted a statewide survey to assess pharmacy characteristics, computer-system capabilities, and types of consulting services provided by pharmacists. RESULTS: Twenty-five community pharmacies completed Montana's TUPD program: 8 pharmacies in the pilot year, 11 pharmacies in year 2, and 6 pharmacies in year 3. For year 2 and year 3 combined, the percentage of participating patients who achieved blood pressure medication adherence improved preintervention to postintervention from 73% to 89%, and adherence improved in 15 of the 17 pharmacies. The pilot pharmacies identified 3 major barriers to project success: patient buy-in, staff burden in implementing the project, and funding. In the statewide assessment, TUPD-funded pharmacies were significantly more likely than non-TUPD-funded pharmacies to provide prescription synchronization and medication management with feedback to the patient's physician. CONCLUSION: Community pharmacies in rural areas can effectively use brief consultations and standard educational materials to improve adherence to blood pressure medication.

Implementation of Strategies to Recognize and Control Hypertension in a Multispecialty Clinic, Montana, 2012-2013.

Benefis Medical Group, in Great Falls, Montana, improved identification and treatment of hypertension through multifaceted interventions. The interventions included adopting policies for collection of vital signs, enhancing system-level reporting capability, tracking patients for the registry, and conducting patient outreach activities. From baseline to follow-up (December 2012 through September 2013), the percentage of patients with a documented blood pressure increased from 67% to 80%, the percentage diagnosed with hypertension increased from 16% to 36%, and the percentage with blood pressure control increased from 41% to 64%. Benefis Medical Group plans to sustain the successful evidence-based strategies that were adopted.

Cooperative strategies to develop effective stroke and heart attack awareness messages in rural american Indian communities, 2009-2010.

INTRODUCTION: National initiatives to improve the recognition of heart attack and stroke warning signs have encouraged symptomatic people to seek early treatment, but few have shown significant effects in rural American Indian (AI) communities. METHODS: During 2009 and 2010, the Montana Cardiovascular Health Program, in collaboration with 2 tribal health departments, developed and conducted culturally specific public awareness campaigns for signs and symptoms of heart attack and stroke via local media. Telephone surveys were conducted before and after each campaign to evaluate the effectiveness of the campaigns. RESULTS: Knowledge of 3 or more heart attack warning signs and symptoms increased significantly on 1 reservation from 35% at baseline to 47% postcampaign. On the second reservation, recognition of 2 or more stroke signs and symptoms increased from 62% at baseline to 75% postcampaign, and the level of awareness remained at 73% approximately 4 months after the high-intensity campaign advertisements ended. Intent to call 9-1-1 did not increase in the heart attack campaign but did improve in the stroke campaign for specific symptoms. Recall of media campaigns on both reservations increased significantly from baseline to postcampaign for both media outlets (ie, radio and newspaper). CONCLUSION: Carefully designed, culturally specific campaigns may help eliminate disparities in the recognition of heart attack and stroke warning signs in AI communities.

Statewide efforts to narrow the rural-urban gap in acute stroke care.

BACKGROUND: Rural-urban gaps in stroke care remain challenging in part because of the lack of resources, personnel, and necessary infrastructure. PURPOSE: The purpose of this study was to assess changes in the acute stroke diagnosis and treatment capacity among rural hospitals before and after implementation of a regionwide stroke initiative. METHODS: In 2004, the Montana Cardiovascular Health Program partnered with stroke stakeholders throughout the state and surveyed hospitals in Montana and northern Wyoming to assess the availability of technology, services, and personnel for acute stroke care. The Montana Stroke Initiative (MSI) developed protocols, educational material, and stroke awareness campaigns to address the geographic disparities identified in the survey. From 2004 to 2006, protocols and educational material were made available on a website and distributed to rural and critical-access hospitals throughout the region. Stroke awareness campaigns were completed, and MSI members conducted acute stroke care training of prehospital, nursing, and primary providers throughout the region. A follow-up survey in 2008 assessed changes in the stroke systems of care between 2004 and 2008. Data were analyzed in 2009. RESULTS: There were significant increases in availability of prehospital stroke screens, written emergency department protocols, computed tomographic scanning capability, acute stroke teams, and community stroke awareness programs. CONCLUSIONS: A systematic statewide effort to improve stroke care led to improved acute stroke care capabilities in necessary infrastructure in rural facilities and a narrowing of the gap between these facilities and the urban facilities.

Stroke awareness: surveillance, educational campaigns, and public health practice.

Stroke is a leading cause of death and disability in the United States. However, there is limited public knowledge about stroke signs and symptoms and the importance of seeking immediate medical care. Educational efforts such as stroke awareness campaigns are one way of informing the public about stroke symptoms and the need for early medical treatment following their onset. In this article, we present recent surveillance data concerning public awareness of stroke symptoms; summarize findings from 12 studies of the effectiveness of stroke awareness campaigns; and describe the efforts by three states to develop, implement, and evaluate heart disease and stroke programs, and the lessons to be learned from their experiences.

Impact of media on community awareness of stroke warning signs: a comparison study.

Prompt identification of the warning signs of ischemic stroke is critical to ensure appropriate and timely treatment. We implemented a 20-week public education campaign in one media market to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older in the intervention county and a comparison county before and after the campaign to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up in the intervention county (73%-82%) but not in the comparison county (68%-69%). Respondent awareness of stroke warning signs increased significantly in the intervention county among men (68%-79%) and women (76%-84%) and among respondents aged 45 to 64 years (77%-85%) and respondents aged 65 years and older (67%-78%). There was no significant change in the proportion of respondents indicating they would call 911 if they witnessed someone having a stroke in the intervention county (81%-84%). However, after the campaign, an increased proportion of respondents in the intervention county indicated they would call 911 if they experienced sudden numbness or loss of sensation (50%-56%). Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911 for specific symptoms.

Educational outreach to improve emergency medical services systems of care for stroke in Montana.

OBJECTIVE: To improve stroke knowledge, identification, and acute care among first responders (FRs) and emergency medical technicians (EMTs) through educational outreach and support. METHODS: Beginning in 2006, the Montana Stroke Initiative implemented outreach to FRs and EMTs and emergency medical services (EMS) statewide. Cross-sectional telephone surveys of FRs and EMTs were used to evaluate changes in stroke knowledge and practice in 2006 (n = 988) and 2009 (n = 944), overall and in rural and urban counties. RESULTS: The respondents to the 2009 survey were more likely to report the availability of a stroke protocol in their service (69% vs. 61%, p = 0.001), training in the use of a stroke screening tool (62% vs. 42%, p < 0.001), use of a stroke screening tool (62% vs. 40%, p < 0.001), and an adequate level of knowledge about stroke (81% vs. 66%, p < 0.001) compared with the respondents to the 2006 survey. Significant improvements in each of these areas were achieved for both rural and urban FRs and EMTs. CONCLUSIONS: Educational outreach to FRs and EMTs was associated with marked improvement in selected components of the EMS system of stroke care.

The Montana cardiac rehabilitation regional outcomes project.

PURPOSE: Outcomes evaluation is a critical component in early outpatient cardiac rehabilitation (CR). The goal of this project was to develop a regional CR outcomes program to help facilitate quality improvement. METHODS: The Montana Outcomes Project initiated data collection on a uniform set of outcomes indicators. Each participating program submitted de-identified data for analysis on a quarterly basis. Results were sent back to each program with its individual program data plotted against the regional mean. RESULTS: Year 1 data collection included outcomes information from 22 facilities and 850 patients. Mean age was 68 years, 96% were white, 68% were men, and the mean number of CR visits was 24. The mean resting blood pressure at program completion was 118/68 mm Hg, with 90% of patients meeting criteria for blood pressure control (<140/90 or <130/80 mm Hg for patients at high risk). Mean low-density lipoprotein was 87 mg/dL; 94% were on lipid-lowering medications; and 73% achieved low-density lipoprotein values of less than 100 mg/dL. Upon program completion, significant improvements (P < .001) were noted in prescore versus postscore for functional capacity measured by the Duke Activity Status Index (5.5 metabolic equivalents vs 7.3 metabolic equivalents), Medical Outcomes Study SF-36 Health Status Questionnaire physical (36.9 vs 45.8) and mental (47.2 vs 52.2) composite scores, Dartmouth Primary Care Cooperative questionnaire (22 vs 15.9), and fat intake measured by the Block Dietary Fat Screener (19.6 vs 14.7). CONCLUSION: Our findings suggest that the development of a regional CR outcomes project is feasible and could aid in the development of quality improvement projects.

How are we diagnosing cardiometabolic risk in primary care settings?

AIMS: To assess attitudes, barriers and practices of clinicians in assessing and treating cardiometabolic risk in overweight adults. METHODS: In 2006, primary care physicians and mid-level practitioners in Montana were surveyed (N=430). RESULTS: Most primary care clinicians (95%) recognized the clinical benefit of weight loss, but many cited patient motivation (87%), lack of support services (61%), and lack of time (58%) as barriers. Over 80% identified obesity, hypertension, abnormal lipids, history of gestational diabetes, and family history as indications for diabetes screening. Most clinicians used fasting glucose (89%), random glucose (58%), and A1c (42%) as initial screens for diabetes. To confirm the diagnosis, the majority of respondents used A1c testing (80%) or fasting glucose (64%). Approximately one-quarter used the diagnosis pre-diabetes (26%), but just over half (52%) used alternative diagnoses of glucose intolerance. Sixty-five percent used the diagnosis of metabolic syndrome. Of those using metabolic syndrome, mid-level practitioners were more likely than physicians to assess waist circumference (49% vs. 63%). CONCLUSIONS: Despite citing significant barriers, clinicians routinely assessed cardiometabolic risk with diabetes screening, but relatively few reported using the diagnosis pre-diabetes. Metabolic syndrome was used commonly to diagnose overweight adults at risk for diabetes and cardiovascular disease.

Public education strategies to increase awareness of stroke warning signs and the need to call 911.

Rapid identification and treatment of ischemic stroke can lead to improved patient outcomes. We implemented a 20-week public education campaign to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older before and after the intervention to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up (67% to 83%). Awareness increased significantly among both men and women and younger and older respondents. There was no significant change in the proportion of respondents indicating that they would call 911 if they witnessed someone having a stroke (74% to 76%). However, after the campaign, an increased proportion of respondents indicated that they would call 911 if they experienced sudden speech problems (51% to 58%), numbness or loss of sensation (41% to 51%), or paralysis (46% to 59%) that would not go away. Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911.

Improving access to quality diabetes education in a rural state: the Montana Quality Diabetes Education Initiative.

PURPOSE: Diabetes self-management education (DSME) is an integral component of diabetes care; however, skilled educators and recognized programs are not uniformly available in rural communities. METHODS: To increase access to quality DSME, the Montana Diabetes Control Program and the Montana chapter of the American Association of Diabetes Educators developed a mentoring program with 3 levels: basic, intermediate, and advanced. All participants were assisted by a volunteer certified diabetes educator (CDE) mentor. In addition, the program provided technical support for recognition through the American Diabetes Association and the Indian Health Service. RESULTS: From 2000 to 2005, 90 individuals participated; 76% were nurses and 21% dietitians. Twenty-seven of the 90 enrollees (30%) completed their structured option, and 13 achieved CDE certification. Most provided services in frontier counties (66%). Statewide, the number of CDEs in Montana increased 46% from 52 in 2000 to 76 in 2005. Twenty-five of the 30 facilities that received technical assistance achieved recognition. Statewide, the number of recognized education programs increased from 2 in 2000 to 22 in 2005. Twelve (55%) of these programs were located in frontier counties. CONCLUSIONS: Mentoring and technical support is an effective method to increase personnel skills for DSME and to increase access to quality education programs in rural areas.

Availability of diagnostic and treatment services for acute stroke in frontier counties in Montana and Northern Wyoming.

CONTEXT: Rapid diagnosis and treatment of ischemic stroke can lead to improved patient outcomes. Hospitals in rural and frontier counties, however, face unique challenges in providing diagnostic and treatment services for acute stroke. PURPOSE: The aim of this study was to assess the availability of key diagnostic technology and programs for acute stroke evaluation and treatment in Montana and northern Wyoming. METHODS: In 2004, hospital medical directors or their designees were mailed a survey about the availability of diagnostic technology, programs, and personnel for acute stroke care. FINDINGS: Fifty-eight of 67 (87%) hospitals responded to the survey. Seventy-nine percent (46/58) of responding hospitals were located in frontier counties, with an average bed size of 18 (11 SD). Of the hospitals in frontier counties, 44% reported emergency medical services prehospital stroke identification programs, 39% had 24-hour computed tomography capability, 44% had an emergency department stroke protocol, and 61% had a recombinant tissue plasminogen activator protocol. Thirty percent of hospitals in frontier counties reported that they met 6-10 of the criteria established by the Brain Attack Coalition to improve acute stroke care compared to 67% of hospitals in the nonfrontier counties. CONCLUSION: A stroke network model could enhance care and improve outcomes for stroke victims in frontier counties.

Awareness of cardiovascular disease risk in American Indians.

OBJECTIVES: The objective of this study was to identify factors associated with perceived risk for cardiovascular disease (CVD) among older American Indians. DESIGN: In 2003, a telephone survey was conducted in American Indians aged > or = 45 years who lived on or near the seven reservations in Montana. Respondents were asked about their history of CVD and selected risk factors and their perceived risk for CVD. The prevalence of CVD and risk factors among men and women aged > or = 45 years (N = 516) was high: CVD (26% and 15%), diabetes (24% and 26%), high blood pressure (48% and 46%), high cholesterol (34% and 40%), smoking (28% and 33%), and obesity (37% vs 46%). Men with a history of CVD (87% vs 46%), high blood pressure (70% vs 44%), high cholesterol (71% vs 53%), and obesity (67% vs 52%) were more likely to report being at risk for heart disease compared to men without these conditions. Women with a history of CVD (98% vs 58%), diabetes (74% vs 60%), high blood pressure (73% vs 56%), high cholesterol (72% vs 60%), and obesity (74% vs 55%) were more likely to report being at risk for heart disease compared to women without these conditions. Neither men nor women associated smoking with their own risk for heart disease. CONCLUSIONS: The prevalence of CVD risk factors was high in this population, and most people recognized the risks associated with the modifiable CVD risk factors. However, neither men nor women who smoked reported being at risk for heart disease more frequently than nonsmokers.

Extending the public health impact of screening for diabetes in high-risk populations: opportunities in American Indian communities.

OBJECTIVE: To assess trends in diabetes screening among American Indian adults and identify opportunities to extend blood glucose screening to those at risk for undiagnosed diabetes and prediabetes. METHODS: In 1999, 2001, and 2003, approximately 1,000 American Indian adults aged 18 years and older living on or near the seven reservations in Montana were interviewed through telephone surveys. RESULTS: Of respondents without diagnosed diabetes, the proportion who recalled blood glucose screening for diabetes within the past 3 years increased from 68 percent in 1999 to 78 percent in 2003. Between 1999 and 2003, screening increased among men (64%-75%), women (71%-80%), those aged 18-44 years (64%-72%), and those aged 45 years and older (76%-84%). Factors independently associated with screening included age more than 45 years, family history of diabetes, and a history of high cholesterol. Current smokers were less likely to report screening compared to nonsmokers. Gender, obesity, and a history of high blood pressure were not associated with screening. CONCLUSIONS: Although self-reported diabetes screening increased over a 5-year period among Indians in Montana, additional groups who could benefit from screening include younger and obese individuals, and those with hypertension.

Defining disparities in cardiovascular disease for American Indians: trends in heart disease and stroke mortality among American Indians and whites in Montana, 1991 to 2000.

BACKGROUND: Disparities in stroke and heart disease have been well defined in many populations in the United States. Relatively few studies, however, have assessed current disparities in cardiovascular disease in American Indian populations and compared trends with other regions of the United States. METHODS AND RESULTS: Using mortality data, age-adjusted all-cause, heart disease, and stroke mortality rates (per 100,000) were calculated for American Indians and whites from 1991 to 1995 and 1996 to 2000. The all-cause mortality rate was strikingly higher for American Indians than for whites. For example, during 1996 to 2000, the all-cause mortality rate for American Indians (1317, +/-61) was more than half again greater than that for whites (831, +/-8). Heart disease mortality declined significantly in whites (237 to 216 per 100,000) in Montana over the past decade and declined, although not significantly, in American Indians (326 to 283 per 100,000). Stroke mortality also declined significantly in whites (64 to 60 per 100,000) but not in American Indians (80 to 81 per 100,000) during this time period. The proportion of deaths before age 65 years for heart disease and stroke was considerably higher in Indian men (45% and 36%) and Indian women (29% and 28%) compared with white men (21% and 11%) and white women (8% and 7%). CONCLUSIONS: The disparity in heart disease and stroke mortality exists between American Indians and whites in Montana. Regional or state-level surveillance data will be needed to describe the changing patterns of heart disease and stroke mortality and cardiovascular risk factors in many native communities in the United States and Canada.

A field-based approach to support improved diabetes care in rural states.

INTRODUCTION: Diabetes care is a challenge in rural areas where primary care practices are faced with limited resources, few clinical information systems, and relative isolation from education programs and diabetes centers with multispecialty teams. This report describes an effective field-based approach to support improved care for patients with diabetes in primary care practices in rural states. METHODS: A collaborative effort between diabetes prevention and control programs in Montana and Wyoming and the University of North Dakota was established to provide support to rural primary care practices for improvement in diabetes care. Field teams from each state diabetes program approached primary care practices. After assessment and orientation of office staff, a computer-based registry was established in each practice. Baseline data were collected in 1997 in Montana and in 1998 in Wyoming; follow-up occurred on July 31, 2004. Health department staff provided ongoing technical support for implementing and evaluating quality-improvement interventions. RESULTS: Forty primary care practices, providing care to more than 7000 patients with diabetes, participated in this quality-improvement effort at follow-up. Of the 37 primary care practices participating in the quality-improvement program for 6 or more months at follow-up, there were significant improvements in Montana in rates of hemoglobin A1c testing, blood glucose control, low-density lipoprotein cholesterol testing, foot and dilated retinal examinations, and pneumococcal vaccinations, and there were significant improvements in pneumococcal vaccinations in Wyoming. CONCLUSION: A field-based approach in which individual practices maintain and use their own registries for both clinical care and quality improvement with ongoing support is a sustainable and an effective strategy for improving diabetes care for rural populations.

Perceived risk for developing stroke among older adults.

BACKGROUND: Persons who perceive their risk for stroke accurately may be more likely to engage in prevention practices to reduce their risk. METHODS: In 2004, 800 adults aged 45 years and older in two counties participated in a telephone survey to assess their perceived risk for stroke and their history of stroke risk factors. RESULTS: Overall, 39% of respondents perceived themselves to be at risk for having a stroke. In the multivariate analyses, younger age, current smoking, and a history of diabetes, high blood pressure, high cholesterol, heart disease, and stroke/TIA were independently associated with perceived risk for stroke. Respondents with atrial fibrillation were no more likely to report being at risk for stroke compared to respondents without atrial fibrillation. Perceived risk for stroke increased as the number of risk factors increased. However, 46% of respondents with three or more risk factors did not perceive themselves to be at risk. CONCLUSIONS: Many adults with multiple risk factors do not perceive themselves to be at risk for stroke. Clinical and public health efforts are needed to increase awareness of the risk for stroke.

Rural community knowledge of stroke warning signs and risk factors.

INTRODUCTION: Rapid identification and treatment of ischemic stroke can lead to improved patient outcomes. Public education campaigns in selected communities have helped to increase knowledge about stroke, but most data represent large metropolitan centers working with academic institutions. Much less is known about knowledge of stroke among residents in rural communities. METHODS: In 2004, 800 adults aged 45 years and older from two Montana counties participated in a telephone survey using unaided questions to assess awareness of stroke warning signs and risk factors. The survey also asked respondents if they had a history of atrial fibrillation, diabetes, high blood pressure, high cholesterol, smoking, heart disease, or stroke. RESULTS: More than 70% of survey participants were able to correctly report two or more warning signs for stroke: numbness on any side of the face/body (45%) and speech difficulties (38%) were reported most frequently. More than 45% were able to correctly report two or more stroke risk factors: smoking (50%) and high blood pressure (44%) were reported most frequently. Respondents aged 45 to 64 years (odds ratio [OR] 2.44; 95% confidence interval [CI], 1.78-3.46), women (OR 2.02; 95% CI, 1.46-2.80), those with 12 or more years of education (OR 1.96; 95% CI, 1.08-3.56), and those with high cholesterol (OR 1.68; 95% CI, 1.17-2.42) were more likely to correctly identify two or more warning signs compared with respondents without these characteristics. Women (OR 1.48; 95% CI, 1.07-2.05) and respondents aged 45 to 64 years (OR 1.35; 95% CI, 1.01-1.81) were also more likely to correctly identify two or more stroke risk factors compared with men and older respondents. CONCLUSION: Residents of two rural counties were generally aware of stroke warning signs, but their knowledge of stroke risk factors was limited.

Increasing prevalence of cardiovascular risk factors among American Indians in Montana.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death among American Indians. The objective of this study was to assess trends in CVD and CVD risk factors among American Indians in Montana. METHODS: In 1999 and 2003, 1000 American Indian adults aged > or =18 years living on or near the seven reservations in Montana were interviewed each year using an adapted Behavior Risk Factor Surveillance System survey. RESULTS: During the 5-year period from 1999 to 2003, the prevalence of CVD risk factors increased significantly: diabetes (12% to 16%), high blood pressure (26% to 34%), high cholesterol (23% to 30%), and obesity (34% to 39%). The percentage reporting current smoking was stable and remained high (38% to 36%). After adjusting for age and gender, the increases in high blood pressure, high cholesterol, and obesity remained significant. The percentage reporting two or more CVD risk factors increased significantly overall, among men and women, and among older and younger respondents during the 5-year time period. CONCLUSIONS: The prevalence of CVD risk factors among American Indian adults in Montana is high, and for many of the risk factors, has increased significantly over a 5-year period.

Increasing rate of diabetes in pregnancy among American Indian and white mothers in Montana and North Dakota, 1989-2000.

OBJECTIVES: The purpose of this study was to assess trends in diabetes in pregnancy in American Indian and whites mothers in Montana and North Dakota. METHODS: Montana and North Dakota birth records were utilized to assess trends in any diabetes in pregnancy in American Indians and whites from 1989 to 2000. RESULTS: From 1989 through 2000, there were 133,991 and 102,232 births in Montana and North Dakota, respectively. The majority of mothers were American Indian (11%) or white (87%). The rate of any diabetes in pregnancy increased significantly in Montana Indian (3.1-4.1%, p = 0.04) and white mothers (1.8-2.6%, p < 0.001) from 1989-1991 to 1998-2000. The rate also increased significantly in white North Dakota mothers (1.6-3.2%, p < 0.001), but the increase in rate for Indian mothers in North Dakota did not reach statistical significance (3.8-4.8%, p = 0.06) during this time period. In each time period, Montana and North Dakota Indian mothers were more likely than white mothers to have any diabetes in pregnancy. CONCLUSIONS: The rate of diabetes in pregnancy has increased in American Indian and white mothers. Thus public health programs are now facing an increasing number of women with a history of GDM at future risk of type 2 diabetes and an increasing number of offspring of diabetic pregnancies at risk for becoming overweight and developing type 2 diabetes at a young age.