Reach and effectiveness of a non-university cardio-obstetrics program.

BACKGROUND: Current guidelines recommend multidisciplinary cardiovascular obstetric programs (CVOB) to manage complex pregnant patients with cardiovascular disease. Minimal evaluation of these programs exists, with most of these programs offered at university-based centers. METHODS: A cohort of 113 patients managed by a CVOB team at a non-university health system (2018-2019) were compared to 338 patients seen by cardiology prior to the program (2016-2017). CVOB patients were matched with comparison patients (controls) on modified World Health Organization (mWHO) category classification, yielding a cohort of 102 CVOB and 102 controls. RESULTS: CVOB patients were more ethnically diverse and cardiovascular risk was higher compared to controls based on mWHO ≥ II-III (57% vs 17%) and. After matching, CVOB patients had more cardiology tests during pregnancy (median of 8 tests vs 5, p < .001) and were more likely to receive telemetry care (32% vs 19%, p = .025). The median number of perinatology visits was significantly higher in the CVOB group (8 vs 2, p < .001). Length of stay was a half day longer for vaginal delivery patients in the CVOB group (median 2.66 vs 2.13, p = .006). CONCLUSION: Implementation of a CVOB program resulted in a more diverse patient population than previously referred to cardiology. The CVOB program participants also experienced a higher level of care in terms of increased cardiovascular testing, monitoring, care from specialists, and appropriate use of medications during pregnancy.

Patient Experience and Decision-Making Process for Laser Photocoagulation for Monochorionic Twin Pregnancy: A Qualitative Exploration.

INTRODUCTION: The aim of the study was to explore patients' perspectives on diagnosis and treatment options for complicated monochorionic multiple gestations, and experiences with fetoscopic laser photocoagulation. METHODS: This is a prospective cohort study of patients undergoing laser photocoagulation. Participants were interviewed during pregnancy and the postpartum period. Qualitative analysis was performed. RESULT: Twenty-seven patients who were candidates for laser photocoagulation were included. All elected to have laser photocoagulation. Patients chose surgery with goals of improving survival, decreasing the risk of preterm delivery, and improving the long-term health of their fetuses. They demonstrated accurate knowledge of the risks and benefits of treatment. Most (74%) felt that laser photocoagulation represented their only viable clinical option. Few seriously considered pregnancy termination or selective reduction (7% and 11% respectively). Postpartum, patients expressed no regrets about their decisions for surgery, but many felt unprepared for the challenges of preterm delivery. CONCLUSION: Participants weighed treatment options similarly to fetal specialists. They acknowledged but did not seriously consider treatments other than fetoscopic laser photocoagulation and were highly motivated to do whatever they could to improve outcomes for their fetuses.

Prenatal and postpartum depression diagnosis in a large health system: prevalence and disparities.

BACKGROUND/OBJECTIVES/INTRODUCTION: Depression during pregnancy or postpartum carries the same risks as general depression as well as additional risks specific to pregnancy, infant health and maternal well-being. The purpose of this study is to document the prevalence of depression symptoms and diagnosis during pregnancy and in the first 3 months postpartum among a cohort of women receiving prenatal care in a large health system. Secondarily, we examine variability in screening results and diagnosis by race, ethnicity, language, economic status and other maternal characteristics during pregnancy and postpartum. PATIENTS/MATERIALS AND METHODS: A retrospective study with two cohorts of patients screened for depression during pregnancy and postpartum. Out of 7807 patients with at least three prenatal care visits and a delivery in 2016, 6725 were screened for depression (87%) at least once during pregnancy or postpartum. Another 259 were excluded because of missing race data. The final sample consisted of 6523 prenatal care patients who were screened for depression; 4914 were screened for depression in pregnancy, 4619 were screened postpartum (0-3 months). There were 3010 screened during both periods who are present in both the pregnancy and postpartum cohorts. Depression screening results are from the Patient Health Questionnaire (PHQ-9) and diagnosis of depression was measured using ICD codes. For patients screened more than once during either time period, the highest score is used for analysis. RESULTS: Approximately, 11% of women had a positive depression screen as indicated by an elevated PHQ-9 score (>10) during pregnancy (11.3%) or postpartum (10.7%). Prevalence of depression diagnosis was similar in the two periods: 12.6% during pregnancy and 13.0% postpartum. A diagnosis of depression during pregnancy was most prevalent among women who were age 24 and younger (19.7%), single (20.5%), publicly insured (17.8%), multiracial (24.1%) or Native American (23.8%), and among women with a history of depression in the past year (58.9%). Among women with a positive depression screen, Black women were less than half as likely as White women to receive a diagnosis in adjusted models (AOR 0.40, CI: 0.23-0.71, p = .002). This difference was not present postpartum. CONCLUSIONS: Depression symptoms and diagnoses differ by maternal characteristics during pregnancy with some groups at substantially higher risk. Efforts to examine disparities in screening and diagnosis are needed to identify reasons for variability in prenatal depression diagnosis between Black and White women.Key messagesWomen who were young, single, have public insurance, and women who identify as multiracial or non-Hispanic (NH) Native American were most likely to have a positive depression screen or a diagnosis for depression.After adjustment for confounders, NH Black women with a positive depression screen were about half as likely to have a diagnosis of depression during pregnancy as NH White women.Awareness of the differing prevalence of depression risk screening results, diagnoses and potential for variation in diagnosis may identify opportunities to improve equity in the delivery of essential mental health care to all patients.

The Use of Saliva Samples to Test for Congenital Cytomegalovirus Infection in Newborns: Examination of False-Positive Samples Associated with Donor Milk Use.

A universal screening research study was conducted in six hospitals to identify the clinical sensitivity of polymerase chain reaction (PCR) testing on newborn dried blood spots (DBSs) versus saliva specimens for the diagnosis of congenital cytomegalovirus (cCMV). CMV DNA positive results from DBSs or saliva were confirmed with urine testing. Findings of several false-positive (FP) saliva PCR results prompted an examination of a possible association with donor milk. Documentation of the frequency of positive saliva results, including both true-positive (TP) and FP status from clinical confirmation, occurred. The frequency of donor milk use was compared for TP and FP cases. Of 22,079 participants tested between 2016 and 2022, 96 had positive saliva results, 15 were determined to be FP, 79 TP, and 2 were excluded for incomplete clinical evaluation. Newborn donor milk use was identified for 18 (19.14%) of all the positive saliva screens. Among the 15 FPs, 11 (73.33%) consumed donor milk compared to 7 of the 79 TPs (8.8%) (OR 28.29, 95% CI 7.10-112.73, p < 0.001). While milk bank Holder pasteurization inactivates CMV infectivity, CMV DNA may still be detectable. Due to this possible association, screening programs that undertake testing saliva for CMV DNA may benefit from documenting donor milk use as a potential increased risk for FP results.

Implementation and Outcomes of a Model of Care for Placenta Accreta Spectrum in a Community-Based Private Practice.

OBJECTIVE: The aim of the study is to describe a model of care and outcomes for placenta accreta spectrum (PAS) implemented in the context of a community based non-academic health system. STUDY DESIGN: The program for management of PAS includes a multidisciplinary team approach with protocols for ultrasound assessment, diagnosis, and surgery. The program was implemented in the two largest private hospitals in the Twin Cities, Minnesota, United States. Maternal and fetal outcomes as well as cost were compared for histopathologic confirmed PAS cases before (2007-2014, n = 41) and after (2015-2017, n = 26) implementation of the PAS program. RESULTS: Implementation of the PAS program was associated with ICU admission reductions from 53.7 to 19.2%, p = 0.005; a decrease of 1,682 mL in mean estimated blood loss (EBL) (p = 0.061); a decrease in transfusion from 85.4 to 53.9% (p = 0.005). The PAS program also resulted in a (non-significant) decrease in both surgical complications from 48.8 to 38.5% (p = 0.408) and postoperative complications from 61.0 to 42.3% (p = 0.135). The total cost of care for PAS cases in the 3 years after implementation of the program decreased by 33%. CONCLUSION: The implementation of a model of care for PAS led by a perinatology practice at a large regional non-academic referral center resulted in reductions of ICU admissions, operating time, transfusion, selected surgical complications, overall postoperative complications, and cost. KEY POINTS: · Implementation of a PAS care model resulted in reduced ICU admissions from 53.7% to 19.2%.. · Patient safety increased by reducing blood loss, transfusions and postoperative complications.. · This model decreased operating time, as well as total cost of care by 33%..

The impact of a population-based prevention program on cardiovascular events: Findings from the heart of new Ulm project.

BACKGROUND: Cardiovascular disease (CVD) and its associated risk factors are the principal drivers of mortality and healthcare costs in the United States with rural residents experiencing higher CVD death rates than their urban counterparts. METHODS: The purpose of this study was to examine incidence of major CVD events over 9 years of implementation of the Heart of New Ulm (HONU) Project, a rural population-based CVD prevention initiative. HONU interventions were delivered at individual, organizational, and community levels addressing clinical risk factors, lifestyle behaviors and environmental changes. The sample included 4,056 residents of New Ulm matched with 4,056 residents from a different community served by the same health system. The primary outcome was a composite of major CVD events (myocardial infarction, ischemic stroke, percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and CVD-related death). Secondary outcomes were the individual CVD events and procedures. RESULTS: The proportion of residents in New Ulm with a major CVD event (7.79%) was not significantly different than the comparison community (8.43%, P = .290). However, the total number of events did differ by community with fewer events in New Ulm than the comparison community (447 vs 530, P = .005), with 48 fewer strokes (84 vs 132, P = .001) and 42 fewer PCI procedures (147 vs 189, P = 0.019) in New Ulm. Incidence of ischemic stroke was lower in the New Ulm community (1.85 vs 2.61, P = .020) than in the comparison community. Other specific CVD events did not have significantly different incidence or frequencies between the 2 communities. CONCLUSION: In HONU, the proportion of residents experiencing a CVD event was not significantly lower than a match comparison community. However, there was a significant reduction in the total number of CVD events in New Ulm, driven primarily by lower stroke, PCI, and CABG events in the intervention community.

Population-Level Reach of Cardiovascular Disease Prevention Interventions in a Rural Community: Findings from the Heart of New Ulm Project.

This study examines participation by residents of a rural community in programs implemented as part of The Heart of New Ulm (HONU) Project, a population-based cardiovascular disease (CVD) prevention initiative. The study compares participation rates for the various interventions to assess which were the most engaging in the priority community and identifies factors that differentiate participants vs. nonparticipants. Participation data were merged with electronic health record (EHR) data representing the larger community population to enable an analysis of participation in the context of the entire community. HONU individual-level interventions engaged 44% of adult residents in the community. Participation ranked as follows: (1) heart health screenings (37% of adult residents), (2) a year-long community weight loss intervention (12% of adult residents), (3) community health challenges (10% of adult residents), and (4) a phone coaching program for invited high CVD-risk residents (enrolled 6% of adult residents). Interventions that yielded the highest engagement were those that had significant staffing and recruited participants over several months, often with many opportunities to participate or register. Compared to nonparticipants, HONU participants were significantly older and a higher proportion were female, married, overweight or obese, and had high cholesterol. Participants also had a lower prevalence of smoking and diabetes than nonparticipants. Findings indicate community-based CVD prevention initiatives can be successful in engaging a high proportion of adult community members. Partnering with local health care systems can allow for use of EHR data to identify eligible participants and evaluate reach and engagement of the priority population.

Universal childhood obesity prevention in a rural community: Study design, methods and baseline participant characteristics of the NU-HOME randomized controlled trial.

Childhood obesity is a major health concern in the United States (US) and those living in rural communities are at higher risk than their urban counterparts. Few prevention trials have engaged whole families of school-age children in community settings, and none to date have promoted family meals, family activity and healthful home environments in rural settings through a rigorous, randomized controlled trial (RCT). The New Ulm at HOME (NU-HOME) study recruited 114 parent/child dyads in a two-arm (intervention versus wait-list control) RCT to test the efficacy of a family meals-focused program aimed to prevent excess weight gain among 7-10 year-old children in rural Minnesota. The NU-HOME program was adapted from a previously tested program for urban families through a unique community collaboration. The program included 7 monthly in-person sessions for all family members. Parents also participated in 4 motivational goal-setting phone calls. The primary outcome measures were age- and sex-adjusted child body mass index (BMI) z-score, percent body fat, and incidence of overweight and obesity post-intervention. Secondary outcomes included quality of food and beverage availability in the home; family meals and snacks; children's dietary intake quality (e.g., Healthy Eating Index (HEI)-2015, fruits and vegetables, sugar-sweetened beverages, snacks); and children's screen time and weekly minutes of moderate-to-vigorous physical activity, total physical activity, and sedentary behavior. The NU-HOME RCT was a collaborative effort of academic and health system researchers, interventionists and community leaders that aimed to prevent childhood obesity in rural communities through engagement of the whole family in an interactive intervention.

Maternal and Neonatal Outcomes in Hospital-Based Deliveries With Water Immersion.

OBJECTIVE: To compare neonatal intensive care unit (NICU) or special care nursery admission for deliveries with water immersion compared with deliveries in the matched control group without water immersion. Secondary outcomes included adverse neonatal diagnoses, maternal infections, and perineal lacerations. METHODS: We conducted a retrospective study using electronic health record data (2014-2018) from two health systems (eight hospitals), with similar clinical eligibility, associated with low risks of intrapartum complications, and implementation policies for waterbirth. The water immersion group included women intending waterbirth. Water immersion was recorded prospectively during delivery. The comparison population were women who met the clinical eligibility criteria for waterbirth but did not experience water immersion during labor. Comparison cases were matched (1:1) using propensity scores. Outcomes were compared using Fischer's exact tests and logistic regression with stratification by stage of water immersion. RESULTS: Of the 583 women with water immersion, 34.1% (199) experienced first-stage water immersion only, 65.9% (384) experienced second-stage immersion, of whom 12.0% (70) exited during second stage, and 53.9% (314) completed delivery in the water. Neonatal intensive care unit or special care nursery admissions were lower for second-stage water immersion deliveries than deliveries in the control group (odds ratio [OR] 0.3, 95% CI 0.2-0.7). Lacerations were lower in the second-stage immersion group (OR 0.5, 95% CI 0.4-0.7). Neonatal intensive care unit or special care nursery admissions and lacerations were not different between the first-stage immersion group and their matched comparisons. Cord avulsions occurred for 0.8% of second-stage water immersion deliveries compared with none in the control groups. Five-minute Apgar score (less than 7), maternal infections, and other adverse outcomes were not significantly different between either the first- or second-stage water immersion groups and their control group. CONCLUSION: Hospital-based deliveries with second-stage water immersion had lower risk of NICU or special care nursery admission and perineal lacerations than matched deliveries in the control group without water immersion.

Trends in prevalence of guideline-based use of lipid-lowering therapy in a large health system.

BACKGROUND: The 2013 ACC/AHA (American College of Cardiology/American Heart Association) cholesterol guidelines provided an evidence-based rationale for the allocation of lipid-lowering therapy based on risk for atherosclerotic cardiovascular disease (ASCVD). Adoption of these guidelines was initially suboptimal but whether this has improved over time remains unclear. HYPOTHESIS: Prevalence of guideline-based statin therapy will increase over time. METHODS: Electronic health record data were used to create two cross-sectional data sets of patients (age 40-75) served in 2013 and 2017 by a large health system. Data sets included demographics, clinical risk factors, lipid values, diagnostic codes, and active medication orders during each period. Prevalence of indications for statin therapy according to the ACC/AHA guidelines and statin prescriptions were compared between each time period. RESULTS: In 2013, of the 219 376 adults, 57.7% of patients met statin eligibility criteria, of which 61.3% were prescribed any statin and 19.0% a high intensity statin. Among those eligible, statin use was highest in those with established ASCVD (83.9%) and lowest in those with elevated ASCVD risk >7.5% (39.3%). In 2017, of the 256 074 adults, 62.3% were statin eligible, of which 62.3% were prescribed a statin and 24.3% a high intensity statin. In 2017, 66.4% of statin eligible men were prescribed a statin compared to 57.4% of statin eligible women (P < 0.001). The use of ezetimibe (3.6% in 2013, 2.4% in 2017) and protein convertase subtilisin/kexin type 9 inhibitors (<0.1% and 0.1%) was infrequent. CONCLUSION: In a large health system, guideline-based statin use has remained suboptimal. Improved strategies are needed to increase statin utilization in appropriate patients.

Who Gives Birth in the Water? A Retrospective Cohort Study of Intended versus Completed Waterbirths.

INTRODUCTION: Most waterbirth studies have been conducted outside the United States with a primary focus on birth outcomes. Studies to date provide limited information about how often women choosing waterbirth end water immersion before the birth and about the reasons for tub exit. This study examines a cohort of women intending a hospital-based waterbirth and documents the timing and reasons for tub exit. Demographic, clinical, and intrapartum care provider characteristics among women completing waterbirth were compared with those who exited the water prior to birth. METHODS: This is a collaborative, multisite study from 2 health systems (8 hospitals) using retrospective electronic health records from August 2014 through December 2017. RESULTS: Of 576 women who entered the waterbirth tub, 48% exited prior to the birth. The primary reasons for exit were maternal choice (50%), medical indication (32%), and provider decision (13%). Women exiting in the first stage did so primarily by choice (57%), whereas medical indication (42%) was the most common reason among women exiting in the second stage. Women who completed waterbirth did not differ from those who exited prior to birth with regard to age, race, ethnicity, country of origin, language, marital status, or intrapartum care provider specialty. Women completing waterbirth were more likely to have previously given birth (72% vs 47%) and to have a provider with more water immersion births during the study period (65% vs 55%). DISCUSSION: Giving birth in the tub was associated with parity and intrapartum care provider experience. Half of the women intending waterbirth in this study exited the tub, with variation in exit reason by stage and provider type. It is important for women to understand that they or their provider may change the birth plan based on labor progress and maternal experience.

Population-level changes in lifestyle risk factors for cardiovascular disease in the Heart of New Ulm Project.

Lifestyle significantly influences development of cardiovascular disease (CVD), but limited data exists demonstrating lifestyle improvements in community-based interventions. This study aims to document how lifestyle risk factors changed at the population level in the context of Heart of New Ulm (HONU), a community-based CVD prevention initiative in Minnesota. HONU intervened across worksites, healthcare and the community/environment to reduce CVD risk factors. HONU collected behavioral measures including smoking, physical activity, fruit/vegetable consumption, alcohol use and stress at heart health screenings from 2009 to 2014. All screenings were documented in the electronic health record (EHR). Changes at the community level for the target population (age 40-79) were estimated using weights created from EHR data and modeled using generalized estimating equation models. Screening participants were similar to the larger patient population with regard to age, race, and marital status, but were slightly healthier in regards to BMI, LDL cholesterol, blood pressure, and less likely to smoke. Community-level improvements were significant for physical activity (62.8% to 70.5%, p < 0.001) and 5+ daily fruit/vegetable servings (16.9% to 28.1%, p < 0.001), with no significant change in smoking, stress, alcohol or BMI. By leveraging local EHR data and integrating it with patient-reported outcomes, improvements in nutrition and physical activity were identified in the HONU population, but limited changes were noted for smoking, alcohol consumption and stress. Systematically documenting behaviors in the EHR will help healthcare systems impact the health of the communities they serve, both at the individual and population level.

Assessing the impact of the heart of New Ulm Project on cardiovascular disease risk factors: A population-based program to reduce cardiovascular disease.

The Heart of New Ulm Project (HONU), is a population-based project designed to reduce modifiable cardiovascular disease (CVD) risk factors in the rural community of New Ulm, MN. HONU interventions address multiple levels of the social-ecological model. The community is served by one health system, enabling the use of electronic health record (EHR) data for surveillance. The purpose of this study was to assess if trends in CVD risk factors and healthcare utilization differed between a cohort of New Ulm residents age 40-79 and matched controls selected from a similar community, using EHR data from baseline (2008-2009) through three follow up time periods (2010-2011, 2012-2013, 2014-2015). Matching, using covariate balance sparse technique, yielded a sample of 4077 New Ulm residents and 4077 controls. We used mixed effects longitudinal models to examine trends over time between the two groups. Blood pressure, total cholesterol, low-density lipoprotein-cholesterol, and triglycerides showed better management in New Ulm over time compared to the controls. The proportion of residents in New Ulm with controlled blood pressure increased by 6.2 percentage points compared to an increase of 2 points in controls (p < 0.0001). As the cohort aged, 10-year ASCVD risk scores increased less in New Ulm (5.1) than the comparison community (5.9). The intervention and control community did not differ with regard to inpatient stays, smoking, or glucose. Findings suggest efficacy for the HONU project interventions for some outcomes.

Changing the restaurant food environment to improve cardiovascular health in a rural community: implementation and evaluation of the Heart of New Ulm restaurant programme.

OBJECTIVE: The goals of the present study were to: (i) describe the implementation of a programme to improve the restaurant food environment in a rural community; and (ii) describe how practices changed in community restaurants. DESIGN: The intervention included a baseline assessment of all community restaurants (n 32) and a report on how they could increase the availability and promotion of healthful options. The assessment focused on sixteen healthy practices (HP) derived from the Nutrition Environment Measures Survey for Restaurants. Restaurants were invited to participate at gold, silver or bronze levels based on the number of HP attained. Participating restaurants received dietitian consultation, staff training and promotion of the restaurant. All community restaurants were reassessed 1·5 years after baseline. SETTING: The restaurant programme was part of the Heart of New Ulm Project, a community-based CVD prevention programme in a rural community. SUBJECTS: All community restaurants (n 32) were included in the study. RESULTS: Over one-third (38 %) of community restaurants participated in the programme. At baseline, 22 % achieved at least a bronze level. This increased to 38 % at follow-up with most of the improvement among participating restaurants that were independently owned. Across all restaurants in the community, the HP showing the most improvement included availability of non-fried vegetables (63-84 %), fruits (41-53 %), smaller portions and whole grains. CONCLUSIONS: Findings demonstrate successes and challenges of improving healthful food availability and promotion in a community-wide restaurant programme.

Examination of Routine Use of Prenatal Weight Gain Charts as a Communication Tool for Providers.

Objectives In 2009 the IOM revised prenatal weight gain guidelines. The primary purpose of this pilot study was to assess if provider education and use of prenatal weight gain charts to track weight gain and counsel patients was associated with better patient and provider knowledge and communication about the guidelines. Methods A prospective non-randomized study conducted in four OB practices (two control, two intervention). Data sources included provider surveys (n = 16 intervention, 21 control), patient surveys (n = 332), and medical records. Intervention clinics received provider education on the IOM guidelines and used patient education materials and prenatal weight gain charts to track weight gain and as a counseling tool. Comparison clinics received no education and did not use the charts or patient education information. Results More patients at intervention clinics (92.3%) reported that a provider gave them advice about weight gain, compared to patients from comparison clinics (66.4%) (p < 0.001). Intervention patients were also more likely to report satisfaction discussions with their provider about weight gain (83.1 vs. 64.3%, p = 0.007). Intervention clinic patients were more likely to have knowledge of the guidelines indicated by 72.3% reporting a target weight gain amount within the guidelines versus 50.4% of comparison patients (p < 0.001). Conclusion Provider education and use of weight gain charts resulted in higher patient reported communication about weight gain from their provider, higher patient satisfaction with those discussions, and better knowledge of the appropriate target weight gain goals.

Prenatal care: associations with prenatal depressive symptoms and social support in low-income urban women.

We examined associations of depressive symptoms and social support with late and inadequate prenatal care in a low-income urban population. The sample was prenatal care patients at five community health centers. Measures of depressive symptoms, social support, and covariates were collected at prenatal care entry. Prenatal care entry and adequacy came from birth certificates. We examined outcomes of late prenatal care and less than adequate care in multivariable models. Among 2341 study participants, 16% had elevated depressive symptoms, 70% had moderate/poor social support, 21% had no/low partner support, 37% had late prenatal care, and 29% had less than adequate prenatal care. Women with both no/low partner support and elevated depressive symptoms were at highest risk of late care (AOR 1.85, CI 1.31, 2.60, p < 0.001) compared to women with both good partner support and low depressive symptoms. Those with good partner support and elevated depressive symptoms were less likely to have late care (AOR 0.74, CI 0.54, 1.10, p = 0.051). Women with moderate/high depressive symptoms were less likely to experience less than adequate care compared to women with low symptoms (AOR 0.73, CI 0.56, 0.96, p = 0.022). Social support and partner support were negatively associated with indices of prenatal care use. Partner support was identified as protective for women with depressive symptoms with regard to late care. Study findings support public health initiatives focused on promoting models of care that address preconception and reproductive life planning. Practice-based implications include possible screening for social support and depression in preconception contexts.

Lifestyle changes and prevention of metabolic syndrome in the Heart of New Ulm Project.

Prior research has shown that unhealthy lifestyles increase the risk for developing a number of chronic diseases, but there are few studies examining how lifestyle changes impact metabolic syndrome. This study analyzed the association between two-year changes in key lifestyle risk metrics and incident metabolic syndrome in adults. A retrospective cohort study was conducted using data from metabolic syndrome free adults in the Heart of New Ulm Project (New Ulm, MN). The outcome was incident metabolic syndrome observed two years after baseline in 2009. The primary predictor was change in optimal lifestyle score based on four behavioral risk factors, including smoking, alcohol use, fruit/vegetable consumption, and physical activity. In the analytical sample of 1059 adults, 12% developed metabolic syndrome by 2011. Multivariable regression models (adjusted for baseline lifestyle score, age, sex, education, cardiovascular disease, and diabetes) revealed that a two-year decrease in optimal lifestyle score was associated with significantly greater odds of incident metabolic syndrome (OR = 2.92; 95% CI: 1.69, 5.04; p < 0.001). This association was primarily driven by changes in obesity, fruit/vegetable consumption, and alcohol intake. As compared to improving poor lifestyle habits, maintaining a healthy lifestyle seemed to be most helpful in avoiding metabolic syndrome over the two-year study timeframe.

Clinical implications of the American College of Cardiology/American Heart Association guidelines for the treatment of blood cholesterol for a rural community: Data from the Heart of New Ulm Project.

BACKGROUND: The 2013 American College of Cardiology (ACC)/AHA cholesterol guidelines represented a significant paradigm shift in the approach to the treatment of cholesterol in the United States. OBJECTIVE: To assess prevalence of indications for statin therapy according to the ACC/AHA cholesterol guidelines in a rural community. METHODS: A cross-sectional analysis was performed using data from the Heart of New Ulm Project, a population-based intervention aimed at reducing modifiable Adult Treatment Panel (ATP) III guidelines for the treatment of cholesterol for cardiovascular disease (ASCVD) risk factors in New Ulm, MN. Indications for statin therapy according to the ACC/AHA guidelines were determined using electronic health record data for area residents aged 40 to 79 years with visits in 2012 to 2013. There were 7855 adults aged 40 to 79 years in the target population, of which 4350 (55.4%) had a clinic visit with a fasting lipid panel. RESULTS: In our study sample (mean age 59.6 [10.4] years, 53.0% female), 2606 (59.9%) met one of the 4 major indications for statin therapy (19.2% clinical ASCVD, 15.5% diabetes, 1.1% low-density lipoprotein cholesterol ≥ 190 mg/dL, and 24.0% ≥ 7.5% 10-year ASCVD risk). Of those with an indication, 63.3% were on a statin (10.9% on a high-intensity statin). Of the 1375 patients (31.6%) who were not statin eligible (10-year ASCVD risk <5%), 29.5% were on a statin. CONCLUSIONS: In a community sample of individuals using health care, 60% were statin eligible according to ACC/AHA guidelines and two-thirds of these patients were prescribed a statin. In addition, almost 30% of those ineligible were taking a statin, suggesting the guidelines may provide an opportunity to decrease statin use in those at low ASCVD risk.

Changes in cardiovascular risk factors after 5 years of implementation of a population-based program to reduce cardiovascular disease: The Heart of New Ulm Project.

BACKGROUND: Population-based interventions aimed at reducing cardiovascular disease (CVD) hold significant potential and will be increasingly relied upon as the model for health care changes in the United States. METHODS: The Heart of New Ulm Project is a population-based project with health care, community, and workplace interventions addressing multiple levels of the social-ecological model designed to reduce modifiable CVD risk factors in rural New Ulm, MN. The community is served by one health system, enabling the use of electronic health record data for surveillance. Electronic health record data were extracted at baseline (2008-2009) and 2 follow-up periods (2010-2011, 2012-2013) for residents aged 40 to 79 years. Generalized estimating equations were used to fit longitudinal models of the risk factors. RESULTS: Of 7,855 residents in the target population, 80% had electronic health record data for each period. The prevalence of at goal (blood pressure [BP] <140/90 mm Hg) and (low-density lipoprotein cholesterol [LDL-C] <130 mg/dL) increased from 79.3% to 86.4% and 68.9% to 71.1%, respectively, from baseline to 5 years, with the largest reductions in BP and LDL-C seen in individuals not at goal at baseline. Blood pressure and lipid-lowering medication use increased from 41.8% to 44.0% and 25.3% to 29.1%, respectively. The proportion at goal for glucose increased from 46.9% to 48.2%. The prevalence body mass index <30 kg/m(2) (55%) did not change, whereas the proportion at-goal for high-density lipoprotein decreased from 63.8% to 58%, and smoking showed an increase from 11.3% to 13.6%. CONCLUSION: In a community participating in a multifaceted, population-based project aimed at reducing modifiable CVD risk factors, significant improvements in BP, LDL-C, and glucose were observed for 5 years, and body mass index remained stable in a state where obesity was increasing.

A Description of Inpatient Palliative Care Actions for Patients With Acute Heart Failure.

In a recent randomized trial, inpatient palliative care (PC) visits were associated with improved quality of life and symptom burden for patients with heart failure. To better understand what actions by PC providers may have led to those outcomes, we conducted chart reviews of 101 patients in the intervention group (who received PC). Palliative care actions are described for all patients and for those with higher symptoms. Orders were written for 24% of patients, most frequently for pain. Recommendations to change current care were made for 40% of patients. At least 1 element of future care planning was documented for 99% of patients. Palliative care for inpatients with HF led to additive actions beyond standard care, especially for pain, and promoted HF-specific goals of care discussions.