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.

Capacity of diabetes education programs to provide both diabetes self-management education and to implement diabetes prevention services.

OBJECTIVE: The purpose of this study was to assess the capacity of diabetes self-management education (DSME) programs in urban and rural counties to provide services to patients with diagnosed diabetes, lifestyle services to persons at high risk for developing diabetes, and to assess the potential barriers to providing diabetes prevention services. METHODS: In 2009, the Montana Department of Public Health and Human Services conducted an Internet-based survey of all DSME programs in Montana. RESULTS: Thirty of the 39 (77%) DSME programs completed the survey. Seventy-seven percent of the urban programs and 50% of the rural programs reported a capacity to provide DSME to additional patients with diagnosed diabetes. More than 70% of the urban and the rural programs currently provide lifestyle services to patients with abnormal glucose tolerance but without diabetes. Eighty-four percent of the urban programs and 60% of the rural programs reported a capacity to provide lifestyle services to additional persons at high risk for diabetes. Eighty-five percent of the urban programs and 58% of the rural programs have already implemented or intend to implement a lifestyle intervention service consistent with the Diabetes Prevention Program. Overall, the most frequently reported barriers to implementing a diabetes prevention services were lack of reimbursement (80%) and the lack of staff to provide the service (60%). CONCLUSION: Urban and rural DSME programs in Montana have the capacity to implement both DSME for patients with diagnosed diabetes and diabetes prevention lifestyle services to additional people at high risk for diabetes. Reimbursement for diabetes prevention services is critical to ensure program development and implementation.

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.

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.

Translating the diabetes prevention program into practice in the general community: findings from the Montana Cardiovascular Disease and Diabetes Prevention Program.

PURPOSE: The purpose of this study was to evaluate the feasibility of translating the Diabetes Prevention Program (DPP) lifestyle intervention into practice in the general community. METHODS: In 2008, the Montana Diabetes Control Program, working collaboratively with 4 health care facilities, implemented an adapted group-based DPP lifestyle intervention. Adults at high risk for diabetes and cardiovascular disease were recruited and enrolled (n = 355). Eighty-three percent (n = 295) of participants completed the 16-session program. Participants set targets to reduce fat intake and increase physical activity (>or=150 minutes per week) to achieve a weight loss goal of 7%. RESULTS: Seventy percent of participants achieved the physical activity goal of >or=150 minutes per week. There was a significant decrease among participants' weight from baseline (mean +/- SD, 99.3 +/- 19.7 kg) to week 16 (92.6 +/- 18.8 kg; mean difference, 6.7 +/- 4.0 kg, P < .001). Forty-five percent of the participants achieved the 7% weight loss goal, and 67% achieved at least 5% weight loss. Participants who were 60 years of age and older, had a diagnosis of hypertension, met their physical activity goal of >or=150 minutes per week, and those more frequently monitoring their fat intake were more likely to meet the 7% weight loss goal compared with participants without these characteristics. CONCLUSION: The findings suggest that it is feasible to recruit and retain high-risk participants and achieve weight loss and physical goals in a group setting that are comparable with those achieved in the DPP.

Monitoring prehospital stroke care in Utah to assess the feasibility of using EMS data for surveillance.

Many states are developing data systems that use the data elements from the National Emergency Medical Services Information System (NEMSIS) to monitor prehospital stroke care. To explore the feasibility of using emergency medical services data to monitor prehospital stroke care in Utah, the Heart Disease and Stroke Prevention Program and the state emergency medical services agency identified variables that could potentially be used to describe prehospital stroke care and explored the actual data from the first 16 months since inception of a system compatible with NEMSIS. We were able to develop a case definition for possible stroke and to describe modes of response, response times, destination hospitals, and stroke screening practices. Although not all emergency medical services agencies in Utah used the system and the data were not always complete for each stroke case, it was feasible to design a basic surveillance system for prehospital stroke care by using the data.

Stroke knowledge among urban and frontier first responders and emergency medical technicians in Montana.

PURPOSE: To assess stroke knowledge and practice among frontier and urban emergency medical services (EMS) providers and to evaluate the need for additional prehospital stroke training opportunities in Montana. METHODS: In 2006, a telephone survey of a representative sample of EMS providers was conducted in Montana. Respondents were stratified into 2 groups: those working in urban and frontier counties. FINDINGS: Compared to EMS providers from urban counties, those from frontier counties were significantly more likely to be older (mean age 44.7 vs 40.1 years), have fewer personnel working in their service (mean 17.7 vs 28.6), to be located farther away from a computed tomography scan (CT scan) (mean 41.3 vs 17.6 miles), and to be volunteers (84% vs 49%). They were also less likely to have a stroke protocol (58% vs 66%) and use a stroke screening tool (36% vs 47%) than their urban counterparts. There were no significant differences between frontier and urban EMS respondents' ability to correctly identify 4 or more stroke warning signs (58% vs 61%), 4 or more stroke risk factors (46% vs 43%), or the 3-hour recombinant tissue plasminogen activator (rt-PA) treatment window (56% vs 57%). Approximately two thirds of respondents from urban and frontier counties believed they had adequate stroke knowledge, but 90% indicated they were interested in additional stroke-related training. CONCLUSIONS: Although stroke knowledge did not differ between urban and frontier groups, stroke screens and stroke protocols were less likely to be used in the frontier areas. Training opportunities and the implementation of stroke protocols and screening tools are needed for EMS providers, particularly in frontier counties.

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.

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.

Cancer incidence in Montana: rates for American Indians exceed those for whites.

OBJECTIVES: Previous studies suggested that the cancer incidence rates in American Indians and Alaska Natives were lower than in other groups. The objective of this study was to compare the cancer incidence rates in American Indians and whites in Montana. METHODS: Age-adjusted 6-year cancer incidence rates were calculated for American-Indian and white men and women in Montana to allow comparison of rates in 1991-1996 to those in 1997-2002. RESULTS: The age-adjusted rates for American-Indian men were significantly higher than those for white men for all cancer sites (755+/-74 [95% confidence interval] per 100,000 vs 544+/-9 per 100,000), lung cancer (167+/-35 per 100,000 vs 83+/-4 per 100,000), and colorectal cancer (115+/-29 per 100,000 vs 61+/-4 per 100,000) from 1997 to 2002. The adjusted rates for American-Indian women were significantly higher than those for white women for all cancer sites (526+/-47 per 100,000 vs 412+/-8 per 100,000) and lung cancer (120+/-24 per 100,000 vs 56+/-3 per 100,000) during this same time period. There was a significant increase in the age-adjusted rates for all cancer sites among white men and women but not for American-Indian men or women between 1991-1996 and 1997-2002. CONCLUSIONS: There is a significant disparity in the cancer incidence rates between American Indians and whites in Montana. Regional or state-level surveillance data will be needed to describe the changing patterns of cancer incidence in many native communities in the United States.

Training effective interpreters for diabetes care and education: a new challenge.

PURPOSE: This article describes a pilot project to improve knowledge, attitudes, and skills of ad hoc interpreters working with Native American diabetes patients with limited English proficiency. METHODS: Case-based studies reflecting clinical situations were developed. Key concepts and terms from the cases were translated into the Navajo language and carefully back translated using the newly standardized Navajo diabetes terminology. Twenty-two health care workers from 2 Indian Health Service facilities were recruited for a pilot study to compare the performance of interpreters trained in a formal workshop using the case studies with that of interpreters who independently reviewed a video made from the training. RESULTS: Workshop participants noted significant improvements in their knowledge and comfort level in interpretation of diabetes concepts but not about unrelated topics; the independent study group perceived less improvement. CONCLUSION: Formal training for interpreters working with diabetes patients should be considered by diabetes educators working in settings where medical interpreters are needed. Diabetes educators should encourage back translation of key diabetes concepts to understand exactly what is being said to patients. Those working with multiple interpreters should make sure there are opportunities for interpreters to discuss translations of key concepts with each other and the educators so that translations are accurate and consistent among interpreters. Independent study did not appear to be an effective way to improve the ability of interpreters to translate current diabetes concepts accurately.

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.

Racial and ethnic differences in premature heart disease deaths in New Mexico: what is the role of diabetes?

Multiple-cause mortality files from 1999-2001 were obtained to describe premature heart disease (PHD) deaths and the role of diabetes as a contributing cause in heart disease (HD) mortality in American Indians, Hispanics, and non-Hispanic Whites in New Mexico. The proportion and rate of PHD and diabetes-related HD death were calculated and reported by race/ethnicity and gender. Results indicate that from 1999 to 2001, 24% of all deaths in New Mexico reported HD as the leading cause of death. Of these, 16.6% occurred in persons <65 years of age and were therefore classified as premature. The proportion of premature HD deaths was substantially higher in the American-Indian (29.2%) and Hispanic (20.8%) populations compared to Whites (13.7%). Furthermore, diabetes contributed to almost 18% of premature HD deaths in American Indians and Hispanics and to 10% of premature HD among Whites. These findings suggest that American Indians and Hispanics are disproportionately affected by premature HD death and that diabetes as a contributing cause is greater among these populations compared to non-Hispanic Whites.

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.

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.

Improvements in care and reduced self-management barriers among rural patients with diabetes.

CONTEXT: Improved preventive care and clinical outcomes among patients with diabetes can reduce complications and costs; however, diabetes care continues to be suboptimal. Few studies have described effective strategies for improving care among rural populations with diabetes. PURPOSE: In 2000, the Park County Diabetes Project and the Montana Diabetes Control Program collaboratively implemented a countywide effort, which included health systems interventions and coordinated diabetes education, to improve the quality of diabetes care. METHODS: Clinical data from the diabetes registries in 2 primary care practices, in addition to baseline and follow-up telephone surveys, were used to evaluate improvements in care, outcomes, education, and barriers to self-management. FINDINGS: In the cohort of patients, the proportion receiving the following services increased significantly from 2000 to 2003: annual foot examination (43% to 58%), influenza (30% to 53%), and pneumoccocal immunizations (39% to 70%). The median hemoglobin A1c values decreased significantly from baseline to follow-up (7.2% to 6.8%). Mean systolic and diastolic blood pressure decreased significantly over the 2 time periods (139 mmHg to 135 mmHg, and 78 mmHg to 75 mmHg, respectively). Significant decreases were also observed in barriers to self-management, including lack of knowledge (decrease from 12% to 5%), difficulties making lifestyle changes (36% to 27%), cost of monitors and test strips (25% to 16%), cost of medications (37% to 24%), and diabetes education (22% to 4%). CONCLUSIONS: Findings suggest that system changes in primary care practices and the implementation of accessible diabetes education can improve care and reduce barriers for rural patients with diabetes.

The informed consent process in a cross-cultural setting: is the process achieving the intended result?

This report is based on the experiences of Navajo interpreters working in a diabetes clinical trial and describes the problems encountered in translating the standard research consent across cultural and linguistic barriers. The interpreters and a Navajo language consultant developed a translation of the standard consent form, maintaining the sequence of information and exactly translating English words and phrases. After four months of using the translated consent, the interpreters met with the language expert and a diabetes expert to review their experiences in presenting the translation in the initial phases of recruitment. Their experiences suggest that the consent process often leads to embarrassment, confusion, and misperceptions that promoted mistrust. The formal processes that have been mandated to protect human subjects may create barriers to research in cross-cultural settings and may discourage participation unless sufficient attention is given to ensuring that both translations and cross-cultural communications are effective.

Age-related eye diseases: an emerging challenge for public health professionals.

In April 2004, The Eye Disease Prevalence Research Group published a series of articles that included age-specific estimates for the prevalence of low vision and blindness in whites, African Americans, and Hispanics living in the United States. Also included were age-, sex-, and ethnic-specific incidences of the following age-related eye diseases: diabetic retinopathy, macular degeneration, cataracts, and glaucoma. We reviewed the group's series of articles and highlighted key findings on the overall prevalence of and risk factors for age-related eye diseases, as well as opportunities to preserve and restore vision. We examined publications that show the public health impact of age-related eye diseases and the importance of projected increases in prevalence of low vision and blindness. Approximately 1 in 28 Americans aged older than 40 years is affected by low vision or blindness. Among community-dwelling adults, the prevalence of low vision and blindness increases dramatically with age in all racial and ethnic groups. Whites have higher rates of macular degeneration than African Americans, but glaucoma is more common among older African Americans. Between 2000 and 2020, the prevalence of blindness is expected to double. Age-related eye diseases are costly to treat, threaten the ability of older adults to live independently, and increase the risk for accidents and falls. To prevent vision loss and support rehabilitative services for people with low vision, it is imperative for the public health community to address the issue through surveillance, public education, and coordination of screening, examination, and treatment.