Cost-utility analysis of community-based interventions for hypertension control in Vietnam.

Between 2010 and 2011, stakeholders implemented a multi-faceted community-based intervention in response to the escalating issue of uncontrolled hypertension in Hung Yen province, Vietnam. This initiative integrated expanded community health worker services, home blood pressure self-monitoring, and a unique "storytelling intervention" into routine clinical care. From the limited societal perspective, our study evaluates the cost-effectiveness of this intervention using a Markov model with a one-year cycle over a lifetime horizon. The analysis, based on a cohort of 671 patients, reveals a lifetime incremental cost of approximately VND 90.37 million (USD 3,930) per quality-adjusted life year (QALY) gained. With a willingness to pay at three times GDP (VND 259.2 million per QALY), the intervention proves cost-effective 80% of the time. This research underscores the potential of the community-based approach to effectively control hypertension, offering valuable insights into its broader implications for public health.

Anxiety and Depression Among US Nursing Home Residents with Chronic Obstructive Pulmonary Disease.

Background: Chronic obstructive pulmonary disease (COPD) is highly prevalent among nursing home residents; however, few studies have focused on the psychological impact of this clinically significant condition on nursing home residents. Objective: We examine the prevalence of, and factors associated with, anxiety and depression in nursing home residents with COPD. Methods: Using the US 2018 Minimum Dataset (MDS), we conducted a cross-sectional study among 239,615 residents aged ≥50 years old in US Medicare/Medicaid certified nursing homes with COPD. Anxiety and depression were diagnosed based on clinical diagnoses, physical examination findings, and treatment orders. Multivariable adjusted Poisson models with a generalized estimating equations approach account for the clustering among residents within nursing homes. Results: The average age of the study population was 79 years (SD: 10.6), 62.0% were women, and 43.7% had five or more comorbid conditions. In this population, 37.2% had anxiety, 57.6% had depression, and 27.5% had both mental health conditions. Women, current tobacco users, persons 50-64 years old, those who reported having moderate or severe pain, and nursing home residents with multimorbidity were more likely to have anxiety or depression than respective comparison groups. Conclusion: Anxiety and depression are common among US nursing home residents with COPD. Women, medically complex patients, and those who report having moderate-to-severe pain appear to be more likely to have anxiety and depression. Clinical teams should be aware of these findings when managing nursing home residents with COPD and use various nonpharmacological and medical interventions for the effective management of anxiety and depression. Longitudinal studies evaluating how anxiety and depression affect the management of COPD and related outcomes, and how best to improve the quality of life of nursing home residents with COPD, are warranted.

Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment.

BACKGROUND: Oral anticoagulants (OACs) are effective in reducing the risk of cardioembolic stroke due to atrial fibrillation. While most nursing home residents with atrial fibrillation qualify for anticoagulation based on clinical guidelines, the net clinical benefits of OACs may diminish as residents approach the end of life. METHODS: We conducted a cross-sectional study of 30,503 US nursing home residents with atrial fibrillation (based on Minimum Data Set 3.0 and Medicare Part A records) who used OACs in the year before enrolling in hospice care during 2012-2016. Whether residents discontinued OACs before hospice enrollment was determined using Part D claims and date of hospice enrollment. Modified Poisson models estimated adjusted prevalence ratios (aPR). RESULTS: Almost half (45.7%) of residents who had recent OAC use discontinued prior to hospice enrollment. Residents who were underweight (aPR: 1.02; 95% confidence interval [CI]: 1.01-1.03), those with high bleeding risk (aPR: 1.04, 95% CI: 1.03-1.05), and those with moderate or severe cognitive impairment (aPR: 1.02, 95% CI: 1.02-1.03) had a higher prevalence of OAC discontinuation before entering hospice. Residents with venous thromboembolism (aPR: 0.94, 95% CI: 0.93-0.96), statin users (aPR: 0.88, 95% CI: 0.87-0.89), and those on polypharmacy (≥10 medications, aPR: 0.72; 95% CI: 0.71-0.73) were less likely to discontinue OACs before enrollment in hospice. CONCLUSION: Anticoagulants are often discontinued among older nursing home residents with atrial fibrillation before hospice enrollment; it is not clear that these decisions are driven solely by net clinical benefit considerations. Further research is needed on comparative outcomes to inform resident-centered decisions regarding OAC use in older adults entering hospice.

Medication cost-reducing behaviors in older adults with atrial fibrillation: The SAGE-AF study.

BACKGROUND: As patient prices for many medications have risen steeply in the United States, patients may engage in cost-reducing behaviors (CRBs) such as asking for generic medications or purchasing medication from the Internet. OBJECTIVE: The objective of this study is to describe patterns of CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications among older adults with atrial fibrillation (AF) and examine participant characteristics associated with CRB. METHODS: Data were from a prospective cohort study of older adults at least 65 years with AF and a high stroke risk (CHA2DS2VASc ≥ 2). CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications were evaluated using validated measures. Chi-square and t tests were used to evaluate differences in characteristics across CRB, and statistically significant characteristics (P < 0.05) were entered into a multivariable logistic regression to examine factors associated with CRB. RESULTS: Among participants (N = 1224; mean age 76 years; 49% female), 69% reported engaging in CRB, 4% reported cost-related medication nonadherence, and 6% reported spending less on basic needs. Participants who were cognitively impaired (adjusted odds ratio 0.69 [95% CI 0.52-0.91]) and those who did not identify as non-Hispanic white (0.66 [0.46-0.95]) were less likely to engage in CRB. Participants who were married (1.88 [1.30-2.72]), had a household income of $20,000-$49,999 (1.52 [1.02-2.27]), had Medicare insurance (1.38 [1.04-1.83]), and had 4-6 comorbidities (1.43 [1.01-2.01]) had significantly higher odds of engaging in CRB. CONCLUSION: Although CRBs were common among older adults with AF, few reported cost-related medication nonadherence and spending less on basic needs. Patients with cognitive impairment may benefit from pharmacist intervention to provide support in CRB and patient assistance programs.

Conquering hypertension in Vietnam-solutions at grassroots level: study protocol of a cluster randomized controlled trial.

BACKGROUND: Vietnam has been experiencing an epidemiologic transition to that of a lower-middle income country with an increasing prevalence of non-communicable diseases. The key risk factors for cardiovascular disease (CVD) are either on the rise or at alarming levels in Vietnam, particularly hypertension (HTN). Inasmuch, the burden of CVD will continue to increase in the Vietnamese population unless effective prevention and control measures are put in place. The objectives of the proposed project are to evaluate the implementation and effectiveness of two multi-faceted community and clinic-based strategies on the control of elevated blood pressure (BP) among adults in Vietnam via a cluster randomized trial design. METHODS: Sixteen communities will be randomized to either an intervention (8 communities) or a comparison group (8 communities). Eligible and consenting adult study participants with HTN (n = 680) will be assigned to intervention/comparison status based on the community in which they reside. Both comparison and intervention groups will receive a multi-level intervention modeled after the Vietnam National Hypertension Program including education and practice change modules for health care providers, accessible reading materials for patients, and a multi-media community awareness program. In addition, the intervention group only will receive three carefully selected enhancements integrated into routine clinical care: (1) expanded community health worker services, (2) home BP self-monitoring, and (3) a "storytelling intervention," which consists of interactive, literacy-appropriate, and culturally sensitive multi-media storytelling modules for motivating behavior change through the power of patients speaking in their own voices. The storytelling intervention will be delivered by DVDs with serial installments at baseline and at 3, 6, and 9 months after trial enrollment. Changes in BP will be assessed in both groups at several follow-up time points. Implementation outcomes will be assessed as well. DISCUSSION: Results from this full-scale trial will provide health policymakers with practical evidence on how to combat a key risk factor for CVD using a feasible, sustainable, and cost-effective intervention that could be used as a national program for controlling HTN in Vietnam. TRIAL REGISTRATION: ClinicalTrials.gov NCT03590691 . Registered on July 17, 2018. Protocol version: 6. Date: August 15, 2019.

PRACTITIONER UPDATE.

OBJECTIVE: To review the development and implementation of prescription formularies by managed care organizations, identify their current applications, and recognize future trends in the managed care pharmacy environment. DATA SOURCES: Current journal articles and texts regarding the use of formularies and the managed care environment. DATA SYNTHESIS: Not applicable. CONCLUSION: Formulary systems have proven to be a valuable means to control the pharmacy benefit and can be expected to expand in both scope and sophistication.

Ensuring the Availability of Clinical Clerkships at U.S. Hospitals: A Tale of 2 States.

U.S. medical schools are facing growing competition for limited clinical training resources, notably slots for the core clerkships that students most often complete in the third year of their undergraduate medical education. In particular, medical schools in the Caribbean (often referred to as offshore medical schools) are buying clerkship slots at U.S. hospitals for their students, most of whom will be U.S. citizen international medical graduates. For hospitals, especially those that are financially stressed, these payments are an attractive source of revenue. Yet, this practice has put pressure on U.S. medical schools to provide similar remuneration for clerkship slots for their students or to find new clinical training sites.In this Perspective, the authors outline the scope of the challenge facing U.S. medical schools and the U.S. medical education system. They outline legislative strategies implemented in 2 states (New York and Texas) to address this issue and propose the passage of similar legislation in other states to ensure that students at U.S. medical schools can access the clerkships they need to obtain the requisite clinical experience before entering residency. Such legislation would preserve the availability of clerkships for U.S. medical students and the educational quality of these clinical training experiences and, therefore, preserve the quantity and quality of the future physician workforce in the United States.

Dabigatran Versus Rivaroxaban for Secondary Stroke Prevention in Patients with Atrial Fibrillation Rehabilitated in Skilled Nursing Facilities.

BACKGROUND: Thromboembolic and bleeding risk are elevated in older patients with atrial fibrillation and prior stroke. We compared dabigatran with rivaroxaban for secondary prevention in a national population after skilled nursing facility (SNF) discharge. METHODS: Medicare fee-for-service beneficiaries aged ≥ 65 years with atrial fibrillation hospitalized for ischemic stroke (November 2011-October 2013) and subsequently admitted to an SNF were studied. Dabigatran (n = 332) and rivaroxaban users (n = 378) were compared in a retrospective, active comparator, new-user cohort. The index medication claim occurred within 120 days after hospital discharge and exposure continued until a 14-day treatment gap ('as treated'). The primary net clinical benefit outcome was the time to recurrent stroke, transient ischemic attack, intracranial hemorrhage, extracranial bleed, myocardial infarction, venous thromboembolism, or death. All-cause mortality was evaluated separately as a secondary outcome. Multivariable adjusted Cox models stratified by dosage estimated hazard ratios (aHR). RESULTS: Among those receiving low dosages, the crude composite event rate was 40.4/100 person-years among dabigatran users and 33.7/100 person-years among rivaroxaban users. The composite outcome [aHR 1.48; 95% confidence interval (CI) 0.87-2.51] and all-cause mortality (aHR 1.67; 95% CI 0.84-3.31) rates were higher among low-dose dabigatran users. For those receiving standard doses, the crude composite event rates were 19.5/100 person-years for dabigatran users and 37.1/100 person-years for rivaroxaban users. Although no difference in mortality was observed, the composite outcome rate was lower among standard-dose dabigatran users (aHR 0.65; 95% CI 0.36-1.15). CONCLUSIONS: In older adults treated with direct-acting oral anticoagulants after ischemic stroke, outcome rates varied considerably by drug and dosage.

Barriers to Healthcare Access and to Improvements in Health-Related Quality of Life After an Acute Coronary Syndrome (From TRACE-CORE).

Little is known about how barriers to healthcare access affect health-related quality of life (HRQOL) after an acute coronary syndrome (ACS). In a large cohort of ACS survivors from 6 medical centers in Massachusetts and Georgia enrolled from 2011 to 2013, patients were classified as having any financial barriers, no usual source of care (USOC), or transportation barriers to healthcare based on their questionnaire survey responses. The principal study outcomes included clinically meaningful declines in generic physical and mental HRQOL and in disease-specific HRQOL from 1 to 6 months posthospital discharge. Adjusted relative risks (aRRs) for declines in HRQOL were calculated using Poisson regression models, controlling for several sociodemographic and clinical factors of prognostic importance. In 1,053 ACS survivors, 29.0% had a financial barrier, 14.2% had no USOC, and 8.7% had a transportation barrier. Patients with a financial barrier had greater risks of experiencing a decline in generic physical (aRR 1.48, 95% confidence interval [CI] 1.17, 1.86) and mental (aRR 1.36, 95% CI 1.07, 1.75) HRQOL at 6 months. Patients with 2 or more access barriers had greater risks of decline in generic physical (aRR 1.53, 95% CI 1.20, 1.93) and mental (aRR 1.50, 95% CI 1.17, 1.93) HRQOL compared with those without any healthcare barriers. There was a modest association between lacking a USOC and experiencing a decline in disease-specific HRQOL (aRR 1.46, 95% CI 0.96, 2.22). Financial and other barriers to healthcare access may be associated with clinically meaningful declines in HRQOL after hospital discharge for an ACS.

Barriers to Healthcare Access and Long-Term Survival After an Acute Coronary Syndrome.

BACKGROUND: Barriers to healthcare are common in the USA and may result in worse outcomes among hospital survivors of an acute coronary syndrome (ACS). OBJECTIVE: To examine the relationship between barriers to healthcare and 2-year mortality after hospital discharge for an ACS. DESIGN: Longitudinal study. SETTING: Survivors of an ACS hospitalization were recruited from 6 medical centers in central Massachusetts and Georgia in 2011-2013. PATIENTS: Study participants with a confirmed ACS reported whether they had a financial-related healthcare barrier, no usual source of care, or a transportation-related healthcare barrier around the time of hospital admission. INTERVENTIONS: None. MEASUREMENTS: Cox regression analyses calculated adjusted hazard ratios (aHRs) for 2-year all-cause mortality for the three healthcare barriers while controlling for several demographic, clinical, and psychosocial characteristics. RESULTS: The mean age of study participants (n = 2008) was 62 years, 33% were women, and 77% were non-Hispanic white. One third of patients reported a financial barrier, 17% lacked a usual source of care, and 12% had a transportation barrier. Five percent (n = 100) died within 2 years after hospital discharge. Compared to patients without these barriers, those lacking a usual source of care and with barriers to transportation experienced significantly higher mortality (aHRs 1.40, 95% CI 1.30 to 1.51 and 1.46, 95% CI 1.13 to 1.89, respectively). Financial barriers were not associated with all-cause mortality (aHR 0.79, 95% CI 0.60 to 1.06). LIMITATIONS: Observational study with other unmeasured potentially confounding prognostic factors. CONCLUSIONS: Absence of an established usual source of care and inconsistent transportation availability were associated with a higher risk for dying after an ACS. Patients with these barriers to follow-up care may benefit from more intensive follow-up and support.

Who are they? Patients with heart failure in American skilled nursing facilities.

BACKGROUND: Heart failure (HF) is common among skilled nursing facility (SNF) residents, yet patients with HF in the SNF setting have not been well described. METHODS: Using Minimum Data Set 3.0 cross-linked to Medicare data (2011-2012), we studied 150,959 HF patients admitted to 13,858 SNFs throughout the USA. ICD-9 codes were used to differentiate patients with HF with preserved ejection fraction (HFpEF), reduced ejection fraction (HFrEF), or unspecified HF. RESULTS: The median age of the study population was 82 years, 68% were women, 34% had HFpEF, and 27% had HFrEF. HFpEF patients were older than those with HFrEF. Moderate/severe physical limitations (82%) and cognitive impairment (37%) were common, regardless of HF type. The burden and pattern of common comorbidities, with the exception of coronary heart disease, were similar among all groups, with a median of five comorbidities. One half of patients with HF had been prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 39% evidence-based ß-blockers. CONCLUSIONS: SNF residents with HF are old and suffer from significant physical limitations and cognitive impairment and a high degree of comorbidity. These patients differ substantially from HF patients enrolled in randomized clinical trials and that might explain divergence from treatment guidelines.

School nurse asthma program reduces healthcare utilization in children with persistent asthma.

OBJECTIVE: We examined the impact of a novel, school nurse-supervised asthma therapy program on healthcare utilization. METHODS: We retrospectively reviewed charts of 84 children enrolled in this program in central Massachusetts between 2012 and 2015. Physicians identified children with persistent asthma and poor medication adherence. These children were enrolled in the program to receive daily-inhaled corticosteroid at school, supervised by their school nurse, with ongoing communication between physician's office and school nurse through the school year. This program relied on established family, provider and school resources rather than research staff. The primary outcome was change in the number of emergency department (ED) visits in the year before and after enrollment. Secondary outcomes were hospital admissions, school absences, and rescue medication use. RESULTS: The study population was on average 10.5 years old, 63% male, 67% Hispanic, 19% black, 14% white with 95% using Medicaid insurance. Asthma-related ED visits over a 1-year period decreased 37.5%, from a pre-intervention mean of 0.8 visits to a post-intervention mean of 0.3 visits (p < 0.001). Asthma-related hospital admissions decreased from a pre-intervention mean of 0.3 admissions to post-intervention mean of 0 admissions (p < 0.001). Asthma rescue medication refills decreased by 46.3% from the pre- to post-intervention period (p = <.001). There were also non-significant declines in school absences and oral steroid use for children enrolled. CONCLUSIONS: We demonstrate a significant reduction in healthcare utilization for children enrolled in this unique school nurse-supervised asthma program, which utilizes a clinical-school partnership to deliver preventative asthma medication to school-aged children under sustainable conditions.

Pharmacotherapy Use in Older Patients With Heart Failure and Reduced Ejection Fraction After a Skilled Nursing Facility Stay.

BACKGROUND: Little is known about guideline-directed pharmacotherapy use in patients with heart failure and reduced ejection fraction (HFrEF) discharged to skilled nursing facilities (SNFs). This study aimed to describe the use of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blocker (ARBs) and evidence-based ß-blockers (EBBBs) among older patients with HFrEF within 90 days after the SNF admission and to identify factors associated with receipt of these medications. METHODS AND RESULTS: With the use of Minimum Data Set 3.0 cross-linked with Medicare data (2011-2012), we studied 35,792 Americans aged ≥65 years with HFrEF admitted to 10,333 SNFs. The median age was 82 years, 59% were women, 81% had at least moderate physical limitations, and 39% had moderate/severe cognitive impairment. Fifty-six percent received an ACEI/ARB and 53% an EBBB; one-fourth received neither. In a multivariable log-binomial model, advanced age, severe physical limitations, and greater number of comorbid conditions not associated with heart failure were inversely associated with ACEI/ARB and EBBB receipt. CONCLUSIONS: Use of standard pharmacotherapy among patients with HFrEF after an SNF stay is higher than previously reported. In the absence of evidence demonstrating the effectiveness of ACEIs/ARBs and EBBBs in this population, whether or not improvements in prescribing are warranted remains unknown.

Decade-Long Trends in Liver Transplant Waitlist Removal Due to Illness Severity: The Impact of Centers for Medicare and Medicaid Services Policy.

BACKGROUND: The central tenet of liver transplant organ allocation is to prioritize the sickest patients first. However, a 2007 Centers for Medicare and Medicaid Services regulatory policy, Conditions of Participation (COP), which mandates publically reported transplant center performance assessment and outcomes-based auditing, critically altered waitlist management and clinical decision making. We examine the extent to which COP implementation is associated with increased removal of the "sickest" patients from the liver transplant waitlist. STUDY DESIGN: This study included 90,765 adult (aged 18 years and older) deceased donor liver transplant candidates listed at 102 transplant centers from April 2002 through December 2012 (Scientific Registry of Transplant Recipients). We quantified the effect of COP implementation on trends in waitlist removal due to illness severity and 1-year post-transplant mortality using interrupted time series segmented Poisson regression analysis. RESULTS: We observed increasing trends in delisting due to illness severity in the setting of comparable demographic and clinical characteristics. Delisting abruptly increased by 16% at the time of COP implementation, and likelihood of being delisted continued to increase by 3% per quarter thereafter, without attenuation (p < 0.001). Results remained consistent after stratifying on key variables (ie, Model for End-Stage Liver Disease and age). The COP did not significantly impact 1-year post-transplant mortality (p = 0.38). CONCLUSIONS: Although the 2007 Centers for Medicare and Medicaid Services COP policy was a quality initiative designed to improve patient outcomes, in reality, it failed to show beneficial effects in the liver transplant population. Patients who could potentially benefit from transplantation are increasingly being denied this lifesaving procedure while transplant mortality rates remain unaffected. Policy makers and clinicians should strive to balance candidate and recipient needs from a population-benefit perspective when designing performance metrics and during clinical decision making for patients on the waitlist.

Offshore Medical Schools Are Buying Clinical Clerkships in U.S. Hospitals: The Problem and Potential Solutions.

U.S. medical education faces a threat from for-profit Caribbean medical schools which purchase clinical rotation slots for their students at U.S. hospitals. These offshore schools are monetizing a system that was previously characterized as a duty-the duty of the current generation of physicians to educate their successors. Offshore schools purchase clinical rotation slots using funds largely derived from federally subsidized student loans. This leads to pressure on U.S. schools to pay for clinical clerkships and is forcing some of them to find new clinical training sites.For-profit Caribbean schools largely escape the type of scrutiny that U.S. schools face from U.S. national accreditation organizations. They also enroll large classes of students with lower undergraduate GPAs and Medical College Admission Test scores than those of students at U.S. medical schools; their students take and pass Step 1 of the United States Medical Licensing Examination at a substantially lower rate than that of U.S. medical students; and their students match for residencies at a fraction of the rate of U.S. medical school graduates.Among the potential solutions proposed by the authors are passing laws to hold for-profit Caribbean schools to standards for board passage rates, placing restrictions on federal student loans, monitoring attrition rates, and denying offshore schools access to U.S. clinical training sites unless they meet accreditation standards equivalent to those of U.S. medical schools.

Reliability of Predicting Early Hospital Readmission After Discharge for an Acute Coronary Syndrome Using Claims-Based Data.

Early rehospitalization after discharge for an acute coronary syndrome, including acute myocardial infarction (AMI), is generally considered undesirable. The Centers for Medicare and Medicaid Services (CMS) base hospital financial incentives on risk-adjusted readmission rates after AMI, using claims data in its adjustment models. Little is known about the contribution to readmission risk of factors not captured by claims. For 804 consecutive patients >65 years discharged in 2011 to 2013 from 6 hospitals in Massachusetts and Georgia after an acute coronary syndrome, we compared a CMS-like readmission prediction model with an enhanced model incorporating additional clinical, psychosocial, and sociodemographic characteristics, after principal components analysis. Mean age was 73 years, 38% were women, 25% college educated, and 32% had a previous AMI; all-cause rehospitalization occurred within 30 days for 13%. In the enhanced model, previous coronary intervention (odds ratio [OR] = 2.05, 95% confidence interval [CI] 1.34 to 3.16; chronic kidney disease OR 1.89, 95% CI 1.15 to 3.10; low health literacy OR 1.75, 95% CI 1.14 to 2.69), lower serum sodium levels, and current nonsmoker status were positively associated with readmission. The discriminative ability of the enhanced versus the claims-based model was higher without evidence of overfitting. For example, for patients in the highest deciles of readmission likelihood, observed readmissions occurred in 24% for the claims-based model and 33% for the enhanced model. In conclusion, readmission may be influenced by measurable factors not in CMS' claims-based models and not controllable by hospitals. Incorporating additional factors into risk-adjusted readmission models may improve their accuracy and validity for use as indicators of hospital quality.

Culturally adaptive storytelling method to improve hypertension control in Vietnam - "We talk about our hypertension": study protocol for a feasibility cluster-randomized controlled trial.

BACKGROUND: Vietnam is experiencing an epidemiologic transition with an increased prevalence of non-communicable diseases. At present, the major risk factors for cardiovascular disease (CVD) are either on the rise or at alarming levels in Vietnam; inasmuch, the burden of CVD will continue to increase in this country unless effective prevention and control measures are put in place. A national survey in 2008 found that the prevalence of hypertension (HTN) was approximately 25 % among Vietnamese adults and it increased with advancing age. Therefore, novel, large-scale, and sustainable interventions for public health education to promote engagement in the process of detecting and treating HTN in Vietnam are urgently needed. METHODS: A feasibility randomized trial will be conducted in Hung Yen province, Vietnam to evaluate the feasibility and acceptability of a novel community-based intervention using the "storytelling" method to enhance the control of HTN in adults residing in four rural communities. The intervention will center on stories about living with HTN, with patients speaking in their own words. The stories will be obtained from particularly eloquent patients, or "video stars," identified during Story Development Groups. The study will involve two phases: (i) developing a HTN intervention using the storytelling method, which is designed to empower patients to facilitate changes in their lifestyle practices, and (ii) conducting a feasibility cluster-randomized trial to investigate the feasibility, acceptability, and potential efficacy of the intervention compared with usual care in HTN control among rural residents. The trial will be conducted at four communes, and within each commune, 25 individuals 50 years or older with HTN will be enrolled in the trial resulting in a total sample size of 100 patients. DISCUSSION: This feasibility trial will provide the necessary groundwork for a subsequent large-scale, fully powered, cluster-randomized controlled trial to test the efficacy of our novel community-based intervention. Results from the full-scale trial will provide health policy makers with practical evidence on how to combat a key risk factor for CVD using a feasible, sustainable, and cost-effective intervention that could be used as a national program for controlling HTN in Vietnam and other developing countries. TRIAL REGISTRATION: ClinicalTrials.gov. REGISTRATION NUMBER: https://clinicaltrials.gov/ct2/show/NCT02483780 (registration date June 22, 2015).

Characteristics of contemporary patients discharged from the hospital after an acute coronary syndrome.

BACKGROUND: Limited contemporary data compare the clinical and psychosocial characteristics and acute management of patients hospitalized with an initial vs a recurrent episode of acute coronary disease. We describe these factors in a cohort of patients recruited from 6 hospitals in Massachusetts and Georgia after an acute coronary syndrome. MATERIALS AND METHODS: We performed structured baseline in-person interviews and medical record abstractions for 2174 eligible and consenting patients surviving hospitalization for an acute coronary syndrome between April 2011 and May 2013. RESULTS: The average patient age was 61 years, 64% were men, and 47% had a high school education or less; 29% had a low general quality of life, and 1 in 5 were cognitively impaired. Patients with a recurrent coronary episode had a greater burden of previously diagnosed comorbidities. Overall, psychosocial burden was high, and more so in those with a recurrent vs those with an initial episode. Patients with an initial coronary episode were as likely to have been treated with all 4 effective cardiac medications (51.6%) as patients with a recurrent episode (52.3%), but were significantly more likely to have undergone cardiac catheterization (97.9% vs 92.9%) and a percutaneous coronary intervention (73.7% vs 60.9%) (P < .001) during their index hospitalization. CONCLUSIONS: Patients with a first episode of acute coronary artery disease have a more favorable psychosocial profile, less comorbidity, and receive more invasive procedures but similar medical management, than patients with previously diagnosed coronary disease. Implications of the high psychosocial burden on various patient-related outcomes require investigation.

Follow-up compliance after endovascular abdominal aortic aneurysm repair in Medicare beneficiaries.

OBJECTIVE: Lifelong imaging follow-up is essential to the safe and appropriate management of patients who undergo endovascular abdominal aortic aneurysm repair (EVAR). We sought to evaluate the rate of compliance with imaging follow-up after EVAR and to identify factors associated with being lost to imaging follow-up. METHODS: We identified a 20% sample of continuously enrolled Medicare beneficiaries who underwent EVAR between 2001 and 2008. Using data through 2010 from Medicare Inpatient, Outpatient, and Carrier files, we identified all abdominal imaging studies that may have been performed for EVAR follow-up. Patients were considered lost to annual imaging follow-up if they did not undergo any abdominal imaging study within their last 2 years of follow-up. Multivariable models were constructed to identify independent factors associated with being lost to annual imaging follow-up. RESULTS: Among 19,962 patients who underwent EVAR, the incidence of loss to annual imaging follow-up at 5 years after EVAR was 50%. Primary factors associated with being lost to annual imaging follow-up were advanced age (age 65-69 years, reference; age 75-79 years: hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.15-1.32; age 80-85 years: HR, 1.45; 95% CI, 1.35-1.55; age >85 years: HR, 2.03; 95% CI, 1.88-2.20) and presentation with an urgent/emergent intact aneurysm (HR, 1.27; 95% CI, 1.20-1.35) or ruptured aneurysm (HR, 1.84; 95% CI, 1.63-2.08). Additional independent factors included several previously diagnosed chronic diseases and South and West regions of the United States. CONCLUSIONS: Annual imaging follow-up compliance after EVAR in the United States is significantly below recommended levels. Quality improvement efforts to encourage improved compliance with imaging follow-up, especially in older patients with multiple comorbidities and in those who underwent EVAR urgently or for rupture, are necessary.