Leveraging Registered Dietitian Nutritionists and Registered Nurses in Medication Management to Reduce Therapeutic Inertia.

Objective: To conduct a systematic review of studies that used registered dietitian nutritionists (RDNs) or registered nurses (RNs) to deliver pharmacological therapy using protocols for diabetes, dyslipidemia, or hypertension. Research Design and Methods: A database search of PubMed, the Cochrane Central Register of Controlled Trials, Ovid, and the Cumulative Index to Nursing and Allied Health Literature was conducted of literature published from 1 January 2000 to 31 December 2019. Results: Twenty studies met the inclusion criteria, representing randomized controlled trials (12), retrospective (1) and prospective cohort design studies (6), and time series (1). In all, the studies include 7,280 participants with a median study duration of 12 months (range 6-25 months). Fifteen studies were led by RNs alone, two by RDNs, and three by a combination of RDNs and RNs. All demonstrated improvements in A1C, blood pressure, or lipids. Thirteen studies provided a lifestyle behavior change component in addition to medication protocols. Conclusion: This systematic review provides evidence that RDN- and RN-led medication management using physician-approved protocols or treatment algorithms can lead to clinically significant improvements in diabetes, dyslipidemia, and hypertension management and is as good or better than usual care.

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

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

An Update on the Mediterranean, Vegetarian, and DASH Eating Patterns in People With Type 2 Diabetes.

When it comes to eating, there is no "one-size-fits-all" solution. This article provides an overview of recommendations and research for three evidence-based eating patterns-Mediterranean, DASH (Dietary Approaches to Stop Hypertension), and vegetarian/vegan-that can be individualized for people with type 2 diabetes. In an effort to improve adherence and health outcomes, practical considerations for improving nutrition are highlighted with the aim of helping patients successfully adopt an eating pattern that meets their individual needs and sociocultural and personal preferences.

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

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

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

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

Clinical characteristics and statin eligibility of patients under 50 with ST-elevation myocardial infarction.

AIMS: This study seeks to understand the clinical characteristics, risk factors, and statin eligibility of younger adults who present with STEMI. METHODS: We performed a retrospective analysis of a prospective cohort of STEMI patients <50 years. Baseline characteristics, medical history, prior medications, drug use, lipid profiles, cardiovascular risk factors were examined. Ten-year ASCVD risk was calculated utilizing the Pooled Cohort Equations. Statin eligibility was determined according to the 2019 American College of Cardiology (ACC)/American Heart Association (AHA) and the 2022 US Preventive Services Task Force (USPSTF) guidelines. RESULTS: Six hundred and thirty-five individuals were included, the majority were men (82.4%) and white (89%), with a median age was 46.9 [42.0-48.0]. The most prevalent risk factors were current smoking (59%), hyperlipidemia (44%), and hypertension (37%). Drug use was rare (8.3%). Preventative medication use was low, aspirin was the most common (14%), followed by ACE inhibitors/ARBs (12%), statins (11%), and beta-blockers (9.1%). Mean HDL-C was low at 36.4 ± 12.0 mg/dL, while mean LDL was unremarkable at 112.4 ± 37.9 mg/dL. According to the 2019 ACC/AHA guidelines, 45.5% were classified as statin recommended, 8.7% were classified as statin considered, and 45.8% were classified as statin not recommended. According to the 2022 USPSTF guidelines, 29% were classified as statin recommended, 12.4% were classified as statin considered, and 58.6% were classified as statin not recommended. CONCLUSIONS: Younger adults with STEMI exhibit high rates of tobacco use and low rates of preventative medications use. Approximately half of the cohort did not meet criteria for statin initiation.

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

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

Estimated versus observed 10-year atherosclerotic cardiovascular event rates in a rural population-based health initiative: The Heart of New Ulm Project.

Objective: Assess discrepancy between estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk and observed 10-year event rates in a rural population participating in cardiovascular health initiative. Methods: The study included a rural sample of individuals participating in the Heart of New Ulm (HONU), a population-based health initiative aimed at reducing ASCVD risk in a rural community. HONU conducted over 100 baseline screening events with 5221 individuals participating in 2009. For this analysis, we included participants who were aged 40-79 years, free of ASCVD at baseline, and had adequate data to calculate 10-year ASCVD risk. Electronic health record data and state death records were used to determine rates of non-fatal myocardial infarction and stroke, and ASCVD death from 2010-2019. ASCVD event rates were compared to estimated 10-year risks calculated using the Pooled Cohort Equations, stratified by sex and clinically relevant risk categories. Results: The sample (n = 2819, mean ± SD age 56.1 ± 9.9 years, 59.6% female) had a low prevalence of tobacco use (8.1% current smokers) and diabetes (6.5%) and a high prevalence of hypertension (44.4%) and hyperlipidemia (56.6%). The median estimated 10-year ASCVD risk for the entire sample was 5.7% (IQR 2.3-13.5%) with an observed 10-year ASCVD event rate of 3.4%. The largest gap between observed and estimated risk was in those at intermediate/high (≥7.5%) ASCVD risk (median 10-year risk 15.8% [IQR 10.4-29.0], observed ASCVD event rate 6.4%). Conclusio: In a sample of rural participants exposed to a multifaceted ASCVD prevention initiative, observed rates of ASCVD were substantially lower compared to estimated ASCVD risk. The potential for significantly lower than predicted ASCVD event rates in certain populations should be included in the clinician-patient risk discussion.

Spontaneous Coronary Artery Dissection and Evidence-Based Medicine.

Spontaneous coronary artery dissection (SCAD) is a relatively newly diagnosed area, and evidence-based medicine (EBM) standards are emerging and currently include an aspirin, ß blocker, clopidogrel, angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker for patients with hypertension, vascular abnormality imaging, and cardiac rehabilitation. Because SCAD is an uncommon condition, many providers are unfamiliar with EBM treatment standards which could affect the implementation of recommended treatment. This study documented the frequency of failure to meet EBM SCAD treatment standards and factors contributing to conformance failure. Patients who presented to a tertiary referral hospital from January 1, 2005, to July 6, 2020, were included. The electronic medical record was reviewed for EBM treatment. Patients who did not meet the criteria of EBM were contacted by phone for a phone interview. The study period included 118 patients with SCAD, 3 of whom (2.5%) died and were not eligible for this study. In the final cohort of 115 patients, the average age was 55 years, female gender (97%) and EBM standards were met in 30%. Of patients who participated in the phone interview, 38 (33%) reported frustration with SCAD misdiagnosis (39%), inadequate mental health resources (37%), and communication failure regarding the need for cardiologist follow-up (26%). Cardiac rehabilitation use was impacted by location, time of day, availability, and cost. The most common medication-limiting factor for ß-blocker usage was fatigue (15%). Most (59%) patients did not undergo fibromuscular dysplasia imaging. In conclusion, in this 15-year SCAD study from a single tertiary care hospital SCAD registry, only 30% met the current EBM for SCAD. Unique solutions that are both patient-informed and evidence-driven are needed to achieve the best clinical outcomes.

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

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

Telephone counseling and home telemonitoring: the Weigh by Day Trial.

OBJECTIVE: To test the effects of telephone counseling and telemonitoring on weight loss. METHODS: A randomized-controlled trial was conducted over 18 months. Participants were assigned to an immediate or delayed-start group. The intervention included a Thin-Link((R)) home telemonitoring scale and biweekly telephone counseling over 6 months. RESULTS: The immediate group lost significantly more weight relative to the delayed group over the first 6 months (-7.5 versus +1.3 pounds) and at subsequent visits. CONCLUSION: Compared to no treatment, the intervention was effective at producing weight loss. Home telemonitoring may enhance standard weight-loss counseling.

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

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

Revascularization in Patients With Spontaneous Coronary Artery Dissection and ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction (MI) in younger women, often treated conservatively due to revascularization risks. Revascularization outcomes are largely unknown in SCAD presenting with ST-segment elevation myocardial infarction (STEMI). OBJECTIVES: The purpose of this study was to compare revascularization strategies and outcomes of STEMI-SCAD with STEMI atherosclerosis (STEMI-ATH). METHODS: Consecutive STEMI patients were retrospectively analyzed (2003 to 2017) at 2 regional STEMI programs (Minneapolis Heart Institute and Cedars-Sinai Smidt Heart Institute) with 3-year outcomes. RESULTS: Among 5,208 STEMI patients, SCAD was present in 53 (1%; 93% female). SCAD prevalence was 19% in female STEMI patients age ≤50 years. Compared with STEMI-ATH, STEMI-SCAD patients were younger (age 49 ± 10 years vs. 63 ± 13 years), were more often female (93% vs. 27%), and had more frequent cardiogenic shock (19% vs. 9%); all p ≤ 0.03. In STEMI-SCAD, the culprit artery was more commonly left main (13% vs. 1%) or left anterior descending (47% vs. 38%); both p = 0.003. Acute revascularization was lower in STEMI-SCAD (70% vs. 97%); p < 0.001. In STEMI-SCAD, acute revascularization included percutaneous coronary intervention (PCI), n = 33 (62%), or bypass grafting, n = 4 (8%); PCI success was 91%. Those with revascularization were more likely to have shock, left main culprit, proximal dissection, and initial TIMI (Thrombolysis In Myocardial Infarction) flow grade 0 to 1. The 3-year survival was 98% for STEMI-SCAD versus 84% for STEMI-ATH; p < 0.001. CONCLUSIONS: STEMI-SCAD represents an important STEMI subset, particularly among younger women, characterized by significantly greater frequency of left main or left anterior descending culprit and cardiogenic shock than STEMI-ATH. Primary PCI is successful in most STEMI-SCAD patients, with low 3-year mortality.

Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes.

BACKGROUND: Clinical care for type 2 diabetes has improved but remains suboptimal. Collaborative, team-based models that maximize skills of different disciplines may improve care for individuals with diabetes, but few have been tested using rigorous research designs. OBJECTIVE: To investigate the efficacy of a registered dietitian nutritionist-led telemedicine program compared with that of a control group in terms of diabetes optimal care goals. DESIGN: A randomized controlled trial in which participants were assigned to a control or intervention group. PARTICIPANTS/SETTING: One hundred eighteen adults with type 2 diabetes (mean age, 60 years; 45% female) participated in the study between April 2016 and December 2017. Participants were recruited from separate primary care clinics in two rural Minnesota communities. INTERVENTION: For those assigned to the intervention, registered dietitian nutritionists used a treatment protocol to initiate and titrate therapies for blood glucose, hypertension, and lipid levels in addition to providing medical nutrition therapy; telemedicine visits supplemented usual care. MAIN OUTCOME MEASURES: Primary outcomes included composite and individual diabetes optimal care goals: hemoglobin A1c, blood pressure, not using tobacco, and taking a statin and aspirin (as appropriate). Secondary measures included physical activity, breakfast, fruits and vegetables, whole grains, body mass index, low-density lipoprotein, and medication adherence. STATISTICAL ANALYSIS: Mixed-model regression was used to examine outcomes between baseline and 1-year follow-up. RESULTS: A modest but significantly greater improvement in the number of diabetes optimal care measures met at follow-up was found in the intervention group (3.7 vs 3.2 in the control group [P=0.017]). Among individual measures, the intervention group had significantly greater medication use, with 2.5 and 2.2 higher odds (compared with the control group) of taking a statin [95% CI, 1.0 to 6.24]) and aspirin [95% CI, 0.90 to 5.19] as appropriate, respectively. CONCLUSIONS: ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) findings suggest that registered dietitian nutritionists following medication treatment protocols can effectively improve care for adults with type 2 diabetes and can serve an instrumental role as part of the health care team in providing evidence-based, patient-centered care.

Reach and effectiveness of the HeartBeat Connections telemedicine pilot program.

Introduction Innovative care delivery programs that support primary care providers are needed to reduce the burden of cardiovascular disease (CVD). HeartBeat Connections (HBC) is a primary prevention telemedicine program utilizing registered dietitian nutritionists (RDNs) and registered nurses (RNs) to deliver health coaching and medication therapy protocols for dyslipidaemia and hypertension among patients at high risk for developing CVD. Methods This retrospective cohort study documents the reach and six-month effectiveness of the HBC program for improving CVD risk factors. The sample included 1028 high-risk individuals aged 40-79 (without CVD or diabetes) served between 2010 and 2013 (326 participants, 702 eligible non-participants). Mixed-model analyses of variance were used to compare changes in outcome measures between baseline and six-month follow-up for participants and non-participants. Outcomes were also examined for three groups: non-participants, participants with 1-4 encounters, and participants with > 5 encounters. Results Nearly one-third of all eligible patients participated. There were no significant differences over time between HBC participants and non-participants in blood pressure or body mass. A higher proportion of HBC participants quit using tobacco (7.0 vs. 3.2%, p = 0.004) and achieved the low-density lipoprotein (LDL) program goal of < 100 mg/dL (8.9 vs. -1.1%, p = 0.009). Also, more favourable improvements in total and LDL cholesterol were observed among HBC participants with higher program engagement ( p < 0.05). Discussion The HBC telemedicine program resulted in significant improvement in some, but not all, CVD risk factors over six months. HBC reached many high-CVD-risk patients in the target region, which may confer population-level health benefits if this program can be scaled and sustained. Innovative, collaborative care delivery models like HBC can serve as a platform to systematically target and proactively engage at-risk populations, perhaps reducing patients' CVD risk.