Cost-effectiveness of a Digital Health Intervention for Acute Myocardial Infarction Recovery.

BACKGROUND: Acute myocardial infarction (AMI) is a common cause of hospital admissions, readmissions, and mortality worldwide. Digital health interventions (DHIs) that promote self-management, adherence to guideline-directed therapy, and cardiovascular risk reduction may improve health outcomes in this population. The "Corrie" DHI consists of a smartphone application, smartwatch, and wireless blood pressure monitor to support medication tracking, education, vital signs monitoring, and care coordination. We aimed to assess the cost-effectiveness of this DHI plus standard of care in reducing 30-day readmissions among AMI patients in comparison to standard of care alone. METHODS: A Markov model was used to explore cost-effectiveness from the hospital perspective. The time horizon of the analysis was 1 year, with 30-day cycles, using inflation-adjusted cost data with no discount rate. Currencies were quantified in US dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). The results were interpreted as an incremental cost-effectiveness ratio at a threshold of $100,000 per QALY. Univariate sensitivity and multivariate probabilistic sensitivity analyses tested model uncertainty. RESULTS: The DHI reduced costs and increased QALYs on average, dominating standard of care in 99.7% of simulations in the probabilistic analysis. Based on the assumption that the DHI costs $2750 per patient, use of the DHI leads to a cost-savings of $7274 per patient compared with standard of care alone. CONCLUSIONS: Our results demonstrate that this DHI is cost-saving through the reduction of risk for all-cause readmission following AMI. DHIs that promote improved adherence with guideline-based health care can reduce hospital readmissions and associated costs.

Predictors of heart failure self-care in patients who screened positive for mild cognitive impairment.

BACKGROUND: Heart failure (HF) is associated with cognitive impairment, which could negatively affect a patient's abilities to carry out self-care, potentially resulting in higher hospital readmission rates. Factors associated with self-care in patients experiencing mild cognitive impairment (MCI) are not known. OBJECTIVE: This descriptive correlation study aimed to assess levels of HF self-care and knowledge and to determine the predictors of self-care in HF patients who screen positive for MCI. METHODS: The Montreal Cognitive Assessment was used to screen for MCI. In 125 patients with MCI hospitalized with HF, self-care (Self-care of Heart Failure Index) and HF knowledge (Dutch Heart Failure Knowledge Scale) were assessed. We used multiple regression analysis to test a model of variables hypothesized to predict self-care maintenance, management, and confidence. RESULTS: Mean (SD) HF knowledge scores (11.24 [1.84]) were above the level considered to be adequate (defined as >10). Mean (SD) scores for self-care maintenance (63.57 [19.12]), management (68.35 [20.24]), and confidence (64.99 [16.06]) were consistent with inadequate self-care (defined as scores <70). In multivariate analysis, HF knowledge, race, greater disease severity, and social support explained 22% of the variance in self-care maintenance (P < .001); age, education level, and greater disease severity explained 19% of the variance in self-care management (P < .001); and younger age and higher social support explained 20% of the variance in self-care confidence scores (P < .001). Blacks, on average, scored significantly lower in self-care maintenance (P = .03). CONCLUSION: In this sample, patients who screened positive for MCI, on average, had adequate HF knowledge yet inadequate self-care scores. These models show the influence of modifiable and nonmodifiable predictors for patients who screened positive for MCI across the domains of self-care. Health professionals should consider screening for MCI and identifying interventions that address HF knowledge and social support. Further research is needed to explain the racial differences in self-care.

Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities.

BACKGROUND: Although evidence-based guidelines on the management of cardiovascular disease (CVD) and type 2 diabetes have been widely published, implementation of recommended therapies is suboptimal. OBJECTIVE: The aim of this study was to evaluate the cost-effectiveness of a comprehensive program of CVD risk reduction delivered by nurse practitioner/community health worker (NP/CHW) teams versus enhanced usual care to improve lipids, blood pressure (BP), and hemoglobin (Hb) A1c levels in patients in urban community health centers. METHODS: A total of 525 patients with documented CVD, type 2 diabetes, hypercholesterolemia, or hypertension and levels of low-density lipoprotein cholesterol, BP, or Hb A1c that exceeded goals established by national guidelines were randomized to NP/CHW (n = 261) or enhanced usual care (n = 264) groups. Cost-effectiveness ratios were calculated, determining costs per percent and unit change in the primary outcomes. RESULTS: The mean incremental total cost per patient (NP/CHW and physician) was only $627 (confidence interval, 248-1015). The cost-effectiveness of the 1-year intervention was $157 for every 1% drop in systolic BP and $190 for every 1% drop in diastolic BP, $149 per 1% drop in Hb A1c, and $40 per 1% drop in low-density lipoprotein cholesterol. CONCLUSIONS: The findings suggest that management by an NP/CHW team is a cost-effective approach for community health centers to consider in improving the care of patients with existing CVD or at high risk for the development of CVD.

Technology-assisted weight management interventions: systematic review of clinical trials.

INTRODUCTION: More than one-third of U.S. adults are obese, which greatly increases their risks for type 2 diabetes, cardiovascular disease, and some types of cancer. Busy healthcare professionals need effective tools and strategies to facilitate healthy eating and increase physical activity, thus promoting weight loss in their patients. Communication technologies such as the Internet and mobile devices offer potentially powerful methodologies to deliver behavioral weight loss interventions, and researchers have studied a variety of technology-assisted approaches. MATERIALS AND METHODS: The literature from 2002 to 2012 was systematically reviewed by examining clinical trials of technology-assisted interventions for weight loss or weight maintenance among overweight and obese adults. RESULTS: In total, 2,011 citations from electronic databases were identified; 39 articles were eligible for inclusion. Findings suggest that the use of technology-assisted behavioral interventions, particularly those that incorporate text messaging or e-mail, may be effective for producing weight loss among overweight and obese adults. CONCLUSIONS: Only a small percentage of the 39 studies reviewed used mobile platforms such as Android(®) (Google, Mountain View, CA) phones or the iPhone(®) (Apple, Cupertino, CA), only two studies incorporated cost analysis, none was able to identify which features were most responsible for changes in outcomes, and few reported long-term outcomes. All of these areas are important foci for future research.

Mealtime Environment and Feeding Practices in Urban Family Child Care Homes in the United States.

Background: Family Child Care Homes (FCCHs) are the second-largest childcare option in the US. Given that young children are increasingly becoming overweight and obese, it is vital to understand the FCCH mealtime environment. There is much interest in examining the impact of the Child and Adult Care Food Program (CACFP), a federal initiative to support healthy nutrition, by providing cash reimbursements to eligible childcare providers to purchase nutritious foods. This study examines the association among the FCCH provider characteristics, the mealtime environment, and the quality of foods offered to 2-5-year-old children in urban FCCHs and examines the quality of the mealtime environment and foods offered by CACFP participation. Methods: A cross-sectional design with a proportionate stratified random sample of urban FCCHs by the CACFP participation status was used. Data were collected by telephone using the Nutrition and Physical Activity Self-Assessment for Child Care survey. Results: A total of 91 licensed FCCHs (69 CACFP, 22 non-CACFP) participated. FCCH providers with formal nutrition training met significantly more of the quality standards for foods offered than providers without nutrition training (ß = 0.22, p = 0.034). The mealtime environment was not related to any FCCH provider characteristics. CACFP-participating FCCH providers had a healthier mealtime environment (ß = 0.326, p = 0.002) than non-CACFP FCCHs. Conclusions: Findings suggest that nutrition training and CACFP participation contribute to the quality of nutrition-related practices in the FCCH. We recommend more research on strengthening the quality of foods provided in FCCHs and the possible impact on childhood obesity.

Food Desert Status of Family Child Care Homes: Relationship to Young Children's Food Quality.

Family child care homes (FCCHs) are a favored child care choice for parents of young children in the U.S. Most FCCH providers purchase and prepare foods for the children in their care. Although FCCH providers can receive monetary support from the Child and Adult Care Food Program (CACFP), a federal subsidy program, to purchase nutritious foods, little is known about FCCH providers' access to nutritious foods, especially among FCCH providers serving children from communities that have been historically disinvested and predominantly Black. This study aims to describe the food desert status of FCCHs in Baltimore City, Maryland, and examine the relationship between food desert status and the quality of foods and beverages purchased and provided to children. A proportionate stratified random sample of 91 FCCH providers by CACFP participation status consented. Geographic information system mapping (GIS) was used to determine the food desert status of each participating FCCH. Participants reported on their access to food and beverages through telephone-based surveys. Nearly three-quarters (66/91) of FCCHs were located in a food desert. FCCH providers working and living in a food desert had lower mean sum scores M (SD) for the quality of beverages provided than FCCH providers outside a food desert (2.53 ± 0.81 vs. 2.92 ± 0.70, p = 0.036, respectively). Although the significant difference in scores for beverages provided is small, FCCH providers working in food deserts may need support in providing healthy beverages to the children in their care. More research is needed to understand food purchases among FCCH providers working in neighborhoods situated in food deserts.

User Engagement With Smartphone Apps and Cardiovascular Disease Risk Factor Outcomes: Systematic Review.

BACKGROUND: The use of mobile health (mHealth) interventions, including smartphone apps, for the prevention of cardiovascular disease (CVD) has demonstrated mixed results for obesity, hypercholesterolemia, diabetes, and hypertension management. A major factor attributing to the variation in mHealth study results may be mHealth user engagement. OBJECTIVE: This systematic review aims to determine if user engagement with smartphone apps for the prevention and management of CVD is associated with improved CVD health behavior change and risk factor outcomes. METHODS: We conducted a comprehensive search of PubMed, CINAHL, and Embase databases from 2007 to 2020. Studies were eligible if they assessed whether user engagement with a smartphone app used by an individual to manage his or her CVD risk factors was associated with the CVD health behavior change or risk factor outcomes. For eligible studies, data were extracted on study and sample characteristics, intervention description, app user engagement measures, and the relationship between app user engagement and the CVD risk factor outcomes. App user engagement was operationalized as general usage (eg, number of log-ins or usage days per week) or self-monitoring within the app (eg, total number of entries made in the app). The quality of the studies was assessed. RESULTS: Of the 24 included studies, 17 used a randomized controlled trial design, 4 used a retrospective analysis, and 3 used a single-arm pre- and posttest design. Sample sizes ranged from 55 to 324,649 adults, with 19 studies recruiting participants from a community setting. Most of the studies assessed weight loss interventions, with 6 addressing additional CVD risk factors, including diabetes, sleep, stress, and alcohol consumption. Most of the studies that assessed the relationship between user engagement and reduction in weight (9/13, 69%), BMI (3/4, 75%), body fat percentage (1/2, 50%), waist circumference (2/3, 67%), and hemoglobin A1c (3/5, 60%) found statistically significant results, indicating that greater app user engagement was associated with better outcomes. Of 5 studies, 3 (60%) found a statistically significant relationship between higher user engagement and an increase in objectively measured physical activity. The studies assessing the relationship between user engagement and dietary and diabetes self-care behaviors, blood pressure, and lipid panel components did not find statistically significant results. CONCLUSIONS: Increased app user engagement for prevention and management of CVD may be associated with improved weight and BMI; however, only a few studies assessed other outcomes, limiting the evidence beyond this. Additional studies are needed to assess user engagement with smartphone apps targeting other important CVD risk factors, including dietary behaviors, hypercholesterolemia, diabetes, and hypertension. Further research is needed to assess mHealth user engagement in both inpatient and outpatient settings to determine the effect of integrating mHealth interventions into the existing clinical workflow and on CVD outcomes.

Digital Health Intervention in Acute Myocardial Infarction.

BACKGROUND: Thirty-day readmissions among patients with acute myocardial infarction (AMI) contribute to the US health care burden of preventable complications and costs. Digital health interventions (DHIs) may improve patient health care self-management and outcomes. We aimed to determine if patients with AMI using a DHI have lower 30-day unplanned all-cause readmissions than a historical control. METHODS: This nonrandomized controlled trial with a historical control, conducted at 4 US hospitals from 2015 to 2019, included 1064 patients with AMI (DHI n=200, control n=864). The DHI integrated a smartphone application, smartwatch, and blood pressure monitor to support guideline-directed care during hospitalization and through 30-days post-discharge via (1) medication reminders, (2) vital sign and activity tracking, (3) education, and (4) outpatient care coordination. The Patient Activation Measure assessed patient knowledge, skills, and confidence for health care self-management. All-cause 30-day readmissions were measured through administrative databases. Propensity score-adjusted Cox proportional hazard models estimated hazard ratios of readmission for the DHI group relative to the control group. RESULTS: Following propensity score adjustment, baseline characteristics were well-balanced between the DHI versus control patients (standardized differences <0.07), including a mean age of 59.3 versus 60.1 years, 30% versus 29% Women, 70% versus 70% White, 54% versus 54% with private insurance, 61% versus 60% patients with a non ST-elevation myocardial infarction, and 15% versus 15% with high comorbidity burden. DHI patients were predominantly in the highest levels of patient activation for health care self-management (mean score 71.7±16.6 at 30 days). The DHI group had fewer all-cause 30-day readmissions than the control group (6.5% versus 16.8%, respectively). Adjusting for hospital site and a propensity score inclusive of age, sex, race, AMI type, comorbidities, and 6 additional confounding factors, the DHI group had a 52% lower risk for all-cause 30-day readmissions (hazard ratio, 0.48 [95% CI, 0.26-0.88]). Similar results were obtained in a sensitivity analysis employing propensity matching. CONCLUSIONS: Our results suggest that in patients with AMI, the DHI may be associated with high patient activation for health care self-management and lower risk of all-cause unplanned 30-day readmissions. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03760796.

Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure: systematic review.

OBJECTIVE: This systematic review of recent randomized trials was conducted to determine if cardiovascular nursing interventions improve outcomes in patients with coronary artery disease (CAD) and/or heart failure. METHODS: Randomized controlled trials of nursing interventions in patients with CAD or heart failure published from January 2000 to December 2008 were eligible. Pilot studies and trials with greater than 25% attrition with no intention-to-treat analyses were excluded. Study characteristics and results were extracted and trials were graded for methodological quality. RESULTS: A total of 2,039 citations from electronic databases were identified; 55 articles were eligible for inclusion. The primary intervention strategy was education plus behavioral counseling and support (65% of interventions) using a combination of intervention modes. More than half of the trials (57%) reported statistically significant results in at least 1 outcome of blood pressure, lipids, physical activity, dietary intake, cigarette smoking, weight loss, healthcare utilization, mortality, quality of life, and psychosocial outcomes. However, there were no consistent relationships observed between intervention characteristics and the effects of interventions. The average measure of study quality was 2.8 (possible range, 0-4, with higher score equaling higher quality). CONCLUSION: Most trials reviewed demonstrated a beneficial impact of nursing interventions for secondary prevention in patients with CAD or heart failure. However, the optimal combination of intervention components, including strategy, mode of delivery, frequency, and duration, remains unknown. Establishing consensus regarding outcome measures, inclusion of adequate, representative samples, along with cost-effectiveness analyses will promote translation and adoption of cost-effective nursing interventions.

Scrambler therapy improves pain in neuromyelitis optica: A randomized controlled trial.

OBJECTIVE: To determine whether Scrambler therapy is an effective, acceptable, and feasible treatment of persistent central neuropathic pain in patients with neuromyelitis optica spectrum disorder (NMOSD) and to explore the effect of Scrambler therapy on co-occurring symptoms. METHODS: We conducted a randomized single-blind, sham-controlled trial in patients with NMOSD who have central neuropathic pain using Scrambler therapy for 10 consecutive weekdays. Pain severity, pain interference, anxiety, depression, and sleep disturbance were assessed at baseline, at the end of treatment, and at the 30- and 60-day follow-up. RESULTS: Twenty-two patients (11 per arm) were enrolled in and completed this trial. The median baseline numeric rating scale (NRS) pain score decreased from 5.0 to 1.5 after 10 days of treatment with Scrambler therapy, whereas the median NRS score did not significantly decrease in the sham arm. Depression was also reduced in the treatment arm, and anxiety was decreased in a subset of patients who responded to treatment. These symptoms were not affected in the sham arm. The safety profiles were similar between groups. CONCLUSIONS: Scrambler therapy is an effective, feasible, and safe intervention for central neuropathic pain in patients with NMOSD. Decreasing pain with Scrambler therapy may additionally improve depression and anxiety. CLINICALTRIALSGOV IDENTIFIER: NCT03452176. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that Scrambler therapy significantly reduces pain in patients with NMOSD and persistent central neuropathic pain.

Physician cultural competence and patient ratings of the patient-physician relationship.

OBJECTIVE: To determine the association of patients' ratings of the patient-physician relationship with physicians' self-reported cultural competence (CC). METHODS: Physicians completed a survey assessing their CC in three domains: motivation to learn about other cultures (motivation attitudes), awareness of white privilege and acceptance of a racial group's choice to retain distinct customs and values (power assimilation attitudes), and clinical behaviors reflective of CC. Their African-American and white patients completed interviews assessing satisfaction with the medical visit, trust in their physician, perceptions of their physician's respect for them and their participation in care. We conducted regression analyses to explore the associations between CC and patient ratings of the relationship. RESULTS: Patients of physicians reporting more motivation to learn about other cultures were more satisfied (OR = 2.1, 95% CI = 1.0-4.4), perceived their physicians were more facilitative (beta = 0.4, p = 0.02) and reported seeking and sharing more information during the medical visit (beta = 0.2, p = 0.03). Physicians' power assimilation attitudes were associated with patients' ratings of physician facilitation (beta = 0.4, p = 0.02). Patients of physicians reporting more frequent CC behaviors were more satisfied (OR = 3.1, 95% CI = 1.4-6.9) and reported seeking and sharing more information (beta = 0.3, p = 0.04). CONCLUSIONS: Attitudinal and behavioral components of CC are important to developing higher quality, participative relationships between patients and their physicians.

Corrie Health Digital Platform for Self-Management in Secondary Prevention After Acute Myocardial Infarction.

BACKGROUND: Unplanned readmissions after hospitalization for acute myocardial infarction are among the leading causes of preventable morbidity, mortality, and healthcare costs. Digital health interventions could be an effective tool in promoting self-management, adherence to guideline-directed therapy, and cardiovascular risk reduction. A digital health intervention developed at Johns Hopkins-the Corrie Health Digital Platform (Corrie)-includes the first cardiology Apple CareKit smartphone application, which is paired with an Apple Watch and iHealth Bluetooth-enabled blood pressure cuff. Corrie targets: (1) self-management of cardiac medications, (2) self-tracking of vital signs, (3) education about cardiovascular disease through articles and animated videos, and (4) care coordination that includes outpatient follow-up appointments. METHODS AND RESULTS: The 3 phases of the MiCORE study (Myocardial infarction, Combined-device, Recovery Enhancement) include (1) the development of Corrie, (2) a pilot study to assess the usability and feasibility of Corrie, and (3) a prospective research study to primarily compare time to first readmission within 30 days postdischarge among patients with Corrie to patients in the historical standard of care comparison group. In Phase 2, the feasibility of deploying Corrie in an acute care setting was established among a sample of 60 patients with acute myocardial infarction. Phase 3 is ongoing and patients from 4 hospitals are being enrolled as early as possible during their hospital stay if they are 18 years or older, admitted with acute myocardial infarction (ST-segment-elevation myocardial infarction or type I non-ST-segment-elevation myocardial infarction), and own a smartphone. Patients are either being enrolled with their own personal devices or they are provided an iPhone and/or Apple Watch for the duration of the study. Phase 3 started in October 2017 and we aim to recruit 140 participants. CONCLUSIONS: This article will provide an in-depth understanding of the feasibility associated with implementing a digital health intervention in an acute care setting and the potential of Corrie as a self-management tool for acute myocardial infarction recovery.

Provider and clinic cultural competence in a primary care setting.

A multilevel approach that enhances the cultural competence of clinicians and healthcare systems is suggested as one solution to reducing racial/ethnic disparities in healthcare. The primary objective of this cross-sectional study was to determine if there is a relationship between the cultural competence of primary care providers and the clinics where they work. Forty-nine providers from 23 clinics in Baltimore, Maryland and Wilmington, Delaware, USA completed an on-line survey which included items assessing provider and clinic cultural competence. Using simple linear regression, it was found that providers with attitudes reflecting greater cultural motivation to learn were more likely to work in clinics with a higher percent of nonwhite staff, and those offering cultural diversity training and culturally adapted patient education materials. More culturally appropriate provider behavior was associated with a higher percent of nonwhite staff in the clinic, and culturally adapted patient education materials. Enhancing provider and clinic cultural competence may be synergistic strategies for reducing healthcare disparities.

Effect of financial strain on mortality in community-dwelling older women.

OBJECTIVES: Although it is well established that low socioeconomic status is related to mortality, little research has focused on whether financial strain predicts mortality. Still less research has examined this question by race, despite the evidence that African Americans suffer earlier mortality and more financial strain at the same levels of socioeconomic status than their Caucasian counterparts. We examined the extent to which financial strain was associated with increased mortality risk in older women and whether the relationship differed by race. METHODS: The sample was the Women's Health and Aging Studies I and II of community-dwelling older women aged 70 to 79. We used Cox proportional hazards models to estimate the effect of financial strain on 5-year mortality rates. RESULTS: Women who reported financial strain were almost 60% more likely to die within 5 years independent of race, age, education, absolute income, health insurance status, and comorbidities (p <.001) than their counterparts who did not. Although race was not a predictor of mortality, the association between financial strain and mortality was stronger for African Americans than for Caucasians (p <.01). DISCUSSION: For older women, financial strain may be a better predictor of mortality than annual income, particularly in the case of older African American women.

Effect of soy protein-containing isoflavones on lipoproteins in postmenopausal women.

OBJECTIVE: Some clinical trials have demonstrated a beneficial effect of dietary soy protein on improving lipoproteins. Research also has documented that serum lipoproteins and some lipoprotein subclasses are altered as a consequence of menopause, resulting in a more atherogenic lipid profile. The purpose of this study was to determine the effects of isolated soy protein-containing isoflavones on lipoproteins and lipoprotein subclasses in both African American and white postmenopausal women with borderline to moderate low-density lipoprotein cholesterol elevations. DESIGN: This was a randomized, double-blind, controlled clinical trial including 216 postmenopausal women. After a 4-week run-in period with a casein protein-based supplement, participants were randomly assigned to continue the casein placebo or receive soy protein-containing isoflavones for a period of 12 weeks. RESULTS: In the soy group, the total cholesterol, low-density lipoprotein cholesterol, and low-density lipoprotein particle number decreased significantly as compared with the placebo group at 6 weeks. Although this decrease continued at 12 weeks in the soy group, the difference from the placebo group was attenuated for total cholesterol and low-density lipoprotein particle number. Multivariate analyses controlling for age, race, change in weight, change in dietary fat intake, and change in kilocalorie energy expenditure revealed that treatment remained a significant independent predictor of change in total cholesterol (P = 0.01), low-density lipoprotein cholesterol (P = 0.02), and low-density lipoprotein particle number (P = 0.002) after 6 weeks of dietary soy. CONCLUSIONS: Increased consumption of soy protein replacing animal protein that is high in fat may help improve atherogenic lipid profiles.

Recruitment of African American and white postmenopausal women into clinical trials: the beneficial effects of soy trial experience.

OBJECTIVE: To describe the strategies and costs associated with recruiting both African American and White postmenopausal women into a randomized controlled trial. DESIGN: The Beneficial Effects of Soy Trial (BEST) was a randomized, controlled trial designed to determine the effects of a dietary soy supplement on lipoproteins, lipoprotein subclasses, and menopausal symptoms in African American and White postmenopausal women. The goal was to have > or = 80 African American and > or = 80 White women complete the study. RESULTS: A total of 705 postmenopausal women (381 African American, 324 White) were screened, and of those, 217 were randomized (105 African American, 112 White), and 192 (91 African American, 101 White) completed the study. Direct mailings to targeted zip codes proved the most successful recruitment strategy for recruiting African Americans (52% of African Americans recruited) and the second most effective for recruiting Whites (32% of Whites recruited). Newspaper advertisements yielded the highest number of White participants (36%) but proved less successful for recruiting African Americans (8%). Airing advertisements on the radio was the second most effective strategy for recruiting African Americans (15%), yet it was one of the least effective approaches for recruiting Whites (5%). The total cost of recruitment was dollar 49,036.25, which averaged dollar 255.40 per participant who completed the study. The three most successful strategies, direct mailings, newspaper ads, and radio ads, were the three most expensive approaches but yielded 73% of all participants who completed the study.

Cost-effectiveness of nurse practitioner management of hypercholesterolemia following coronary revascularization.

PURPOSE: To evaluate the cost-effectiveness of case management by a nurse practitioner (NP) to lower blood lipids in patients with coronary heart disease (CHD) from a managed care perspective. DATA SOURCES: A total of 228 consecutive, eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization. Patients were randomized to receive lipid management, including individualized lifestyle modification and pharmacologic intervention from an NP for 1 year after discharge in addition to their usual care (NURS) or to receive usual care (EUC) enhanced with feedback on lipids to their primary provider and/or cardiologist. A cost-effectiveness ratio was calculated using incremental costs of the NURS group per unit change and percent change in low-density lipoprotein cholesterol (LDL-C) for 1 year at 2004 values. CONCLUSIONS: The annual incremental cost-effectiveness of NP case management was 26.03 dollars per mg/dL and 39.05 dollars per percent reduction in LDL-C. When costs of NURS care for the second 6 months of management were compared to the first 6 months of management, nursing salary costs were lower as patients were established on cholesterol management regimens, but the reduction in costs was offset by the increase in incremental costs of drug treatment as the NP titrated the patient to higher drug dosages that were more costly. IMPLICATIONS FOR PRACTICE: The findings suggest that case management by an NP is a cost-effective approach for a managed care organization to consider in improving the care of patients with cardiovascular disease.

Fatigue after stroke: relationship to mobility, fitness, ambulatory activity, social support, and falls efficacy.

Fatigue is common and persistent in stroke survivors, yet it is not known how mobility deficits, fitness, or other factors, such as social support, relate to fatigue severity, or whether subjective fatigue contributes to reduced ambulatory activity. The severity of fatigue in a sample of 53 community-dwelling subjects with chronic hemiparetic stroke was examined, and relationships among fatigue and mobility deficit severity, cardiovascular-metabolic fitness, ambulatory activity, social support, and self-efficacy for falls were identified. Measures included the Fatigue Severity Scale, timed 10-meter walks, the Berg Balance Scale, submaximal and peak VO2, total daily step activity derived from microprocessor-linked Step Activity Monitors, the Medical Outcomes Study Social Support Survey, and the Falls Efficacy Scale. Forty-six percent of the sample had severe fatigue. Fatigue showed no relationship to ambulatory activity. Fatigue severity was associated with the Berg Balance Scale (p < .01) and falls efficacy (p < .01), but not with cardiovascular fitness variables. Patients with elevated fatigue severity scores had lower social support (p < .05) and poorer falls efficacy scores (p < .05) than patients reporting less fatigue. Only falls efficacy was predictive of fatigue severity (r2 = 0.216, p < .01). Further studies are needed to evaluate whether rehabilitation strategies that include not only fitness and mobility interventions, but also social/behavioral and self-efficacy components, are associated with reduced fatigue and increased ambulation.