Assessing Priorities in a Statewide Cardiovascular and Diabetes Health Collaborative Based on the Results of a Needs Assessment: Cross-Sectional Survey Study.

BACKGROUND: The Ohio Cardiovascular and Diabetes Health Collaborative (Cardi-OH) unites general and subspecialty medical staff at the 7 medical schools in Ohio with community and public health partnerships to improve cardiovascular and diabetes health outcomes and eliminate disparities in Ohio's Medicaid population. Although statewide collaboratives exist to address health improvements, few deploy needs assessments to inform their work. OBJECTIVE: Cardi-OH conducts an annual needs assessment to identify high-priority clinical topics, screening practices, policy changes for home monitoring devices and referrals, and preferences for the dissemination and implementation of evidence-based best practices. The results of the statewide needs assessment could also be used by others interested in disseminating best practices to primary care teams. METHODS: A cross-sectional survey was distributed electronically via REDCap (Research Electronic Data Capture; Vanderbilt University) to both Cardi-OH grant-funded and non-grant-funded members (ie, people who have engaged with Cardi-OH but are not funded by the grant). RESULTS: In total, 88% (103/117) of Cardi-OH grant-funded members and 8.14% (98/1204) of non-grant-funded members completed the needs assessment survey. Of these, 51.5% (53/103) of Cardi-OH grant-funded members and 47% (46/98) of non-grant-funded members provided direct clinical care. The top cardiovascular medicine and diabetes clinical topics for Cardi-OH grant-funded members (clinical and nonclinical) were lifestyle prescriptions (50/103, 48.5%), atypical diabetes (38/103, 36.9%), COVID-19 and cardiovascular disease (CVD; 38/103, 36.9%), and mental health and CVD (38/103, 36.9%). For non-grant-funded members, the top topics were lifestyle prescriptions (53/98, 54%), mental health and CVD (39/98, 40%), alcohol and CVD (27/98, 28%), and cardiovascular complications (27/98, 28%). Regarding social determinants of health, Cardi-OH grant-funded members prioritized 3 topics: weight bias and stigma (44/103, 42.7%), family-focused interventions (40/103, 38.8%), and adverse childhood events (37/103, 35.9%). Non-grant-funded members' choices were family-focused interventions (51/98, 52%), implicit bias (43/98, 44%), and adverse childhood events (39/98, 40%). Assessment of other risk factors for CVD and diabetes across grant- and non-grant-funded members revealed screening for social determinants of health in approximately 50% of patients in each practice, whereas some frequency of depression and substance abuse screening occurred in 80% to 90% of the patients. Access to best practice home monitoring devices was challenging, with 30% (16/53) and 41% (19/46) of clinical grant-funded and non-grant-funded members reporting challenges in obtaining home blood pressure monitoring devices and 68% (36/53) and 43% (20/46) reporting challenges with continuous glucose monitors. CONCLUSIONS: Cardi-OH grant- and non-grant-funded members shared the following high-priority topics: lifestyle prescriptions, CVD and mental health, family-focused interventions, alcohol and CVD, and adverse childhood experiences. Identifying high-priority educational topics and preferred delivery modalities for evidence-based materials is essential for ensuring that the dissemination of resources is practical and useful for providers.

A Medicaid-Funded Statewide Diabetes Quality Improvement Collaborative: Ohio 2020‒2022.

We used a collective impact model to form a statewide diabetes quality improvement collaborative to improve diabetes outcomes and advance diabetes health equity. Between 2020 and 2022, in collaboration with the Ohio Department of Medicaid, Medicaid Managed Care Plans, and Ohio's seven medical schools, we recruited 20 primary care practices across the state. The percentage of patients with hemoglobin A1c greater than 9% improved from 25% to 20% over two years. Applying our model more broadly could accelerate improvement in diabetes outcomes. (Am J Public Health. 2023;113(12):1254-1257. https://doi.org/10.2105/AJPH.2023.307410).

Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association.

Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.

A Medicaid Statewide Hypertension Quality Improvement Project: Initial Results.

Background Hypertension control is critical to reducing cardiovascular disease, challenging to achieve, and exacerbated by socioeconomic inequities. Few states have established statewide quality improvement (QI) infrastructures to improve blood pressure (BP) control across economically disadvantaged populations. In this study, we aimed to improve BP control by 15% for all Medicaid recipients and by 20% for non-Hispanic Black participants. Methodology This QI study used repeated cross-sections of electronic health record data and, for Medicaid enrollees, linked Medicaid claims data for 17,672 adults with hypertension seen at one of eight high-volume Medicaid primary care practices in Ohio from 2017 to 2019. Evidence-based strategies included (1) accurate BP measurement; (2) timely follow-up; (3) outreach; (4) a standardized treatment algorithm; and (5) effective communication. Payers focused on a 90-day supply (vs. 30-day) of BP medications, home BP monitor access, and outreach. Implementation efforts included an in-person kick-off followed by monthly QI coaching and monthly webinars. Weighted generalized estimating equations were used to estimate the baseline, one-year, and two-year implementation change in the proportion of visits with BP control (<140/90 mm Hg) stratified by race/ethnicity. Results For all practices, the percentage of participants with controlled BP increased from 52% in 2017 to 60% in 2019. Among non-Hispanic Whites, the odds of achieving BP control in year one and year two were 1.24 times (95% confidence interval: 1.14, 1.34) and 1.50 times (1.38, 1.63) higher relative to baseline, respectively. Among non-Hispanic Blacks, the odds for years one and two were 1.18 times (1.10, 1.27) and 1.34 times (1.24, 1.45) higher relative to baseline, respectively. Conclusions A hypertension QI project as part of establishing a statewide QI infrastructure improved BP control in practices with a high volume of disadvantaged patients. Future efforts should investigate ways to reduce inequities in BP control and further explore factors associated with greater BP improvements and sustainability.

Food as Medicine Clinic: Early Results and Lessons Learned.

INTRODUCTION: Hospital-based food pantries are commonly used to address food insecurity. However, few studies have examined the impact of these food pantries on patients with chronic health conditions. In this study, we sought to assess the effect of a hospital-based food pantry clinic on self-reported dietary changes, health outcomes, and resource utilization. METHODS: This study included food insecure participants with suboptimally controlled congestive heart failure, hypertension, or diabetes who visited a Food as Medicine (FAM) clinic at an academic healthcare system between October 2018 and November 2019. The clinic provided a three-day supply of food for participants and their families up to two times per month for up to 12 months. Baseline, three-month, and six-month surveys were used to assess dietary behaviors, and electronic health record (EHR) data were used to assess health outcomes and utilization. Multivariable Poisson regression was used to explore variables associated with FAM clinic use. RESULTS: At three months, participants self-reported improved dietary behaviors, including increased consumption of fruits and vegetables as snacks and an increased variety of fruits and vegetables consumed. There were no statistically significant changes in clinical or healthcare utilization measures, despite small absolute improvements in systolic blood pressure (SBP), hospitalizations, and emergency department (ED) visits. There was a weak association between FAM clinic visit frequency and changes in dietary behaviors. CONCLUSION: Among patients with chronic diseases, the use of the FAM clinic was associated with improved self-reported dietary behaviors and a nonsignificant improvement in health outcomes and resource utilization.

Forming Cardi-OH: A Statewide Collaborative to Improve Cardiovascular Health in Ohio.

Background Cardiovascular risk factor control is challenging, especially in disadvantaged populations. However, few statewide efforts exist to tackle this challenge. Therefore, our objective is to describe the formation of a unique statewide cardiovascular health collaborative so others may learn from this approach. Methodology With funding from the Ohio Department of Medicaid's Ohio Medicaid Technical Assistance and Policy Program, we used a collective impact model to link the seven medical schools in Ohio, primary care clinics across the state, the Ohio Department of Medicaid, and Ohio's Medicaid Managed Care Plans in a statewide health improvement collaborative for expanding primary care capacity to improve cardiovascular health in Ohio. Results Initial dissemination activities for primary care teams included a virtual case-based learning series focused on hypertension and social determinants of health, website resources, a monthly newsletter with clinical tips, webinars, and in-person conferences. The collaborative is aligned with a separately funded hypertension quality improvement project for paired implementation. Conclusions The collective impact model is a useful framework for developing a statewide collaborative focused on the dissemination and implementation of evidence-based best practices for cardiovascular health improvement and disparity reduction. Statewide collaboratives bringing payers, clinicians, and academic partners together have the potential to substantially impact cardiovascular health.

Coaching quality improvement in primary care to improve hypertension control.

BACKGROUND: Effective management of hypertension (HTN) is a priority in primary care, necessary to decrease the costs, morbidity, and mortality associated with cardiovascular disease. Strategies to support quality improvement (QI) efforts in primary care are needed to make significant improvements in population health, especially for patients who experience socioeconomic inequalities. LOCAL PROBLEM: To address the high rate (>50%) of uncontrolled HTN in the state of Ohio, a statewide QI project was implemented in high-volume Medicaid practices, aimed at improving blood pressure control and addressing racial disparities. The initiative expanded to include coaching QI to support efforts in primary care practices. METHODS: The Model for Improvement guided development of Plan-Do-Study-Act (PDSA) cycles facilitated by QI coaching and APRN collaboration to implement key components of HTN guidelines: accurate blood pressure measurement, effective treatment, and timely follow-up. INTERVENTIONS: Interventions were implemented after PDSA cycles over 18 months in two practice sites to address HTN control. Linking multiple PDSA test cycles and review of data bimonthly allowed for reflection on the impact of interventions for non-Hispanic Black patients and the overall patient population. RESULTS: The percentage of patients with controlled HTN, repeat blood pressure measurement, and timely follow-up improved in an urban primary care practice associated with an academic medical center and in a rural federally qualified health center. CONCLUSIONS: Primary care practices can benefit from the external support of coaching when implementing QI processes to make meaningful change. APRNs are key collaborators for expanding QI efforts in primary care.

Treatments for Female Victims of Intimate Partner Violence: Systematic Review and Meta-Analysis.

Intimate partner violence (IPV) is an important problem that has significant detrimental effects on the wellbeing of female victims. The chronic physical and psychological effects of intimate partner violence (IPV) are complex, long-lasting, chronic, and require treatments focusing on improving mental health issues, safety, and support. Various psycho-social intervention programs are being implemented to improve survivor wellbeing. However, little is known about the effectiveness of different treatments on IPV survivors' wellbeing. For this purpose, we conducted a systematic review and meta-analysis to assess the effectiveness of interventions on improving outcomes that describe the wellbeing of adult female survivors of IPV. We searched PubMed, PsycINFO, and Cochrane Library. We explored the effectiveness of available interventions on multiple outcomes that are critical for the wellbeing of adult female victims of IPV. To provide a broad and comprehensive view of survivors' wellbeing, we considered outcomes including mental health, physical health, diminishing further violence, social support, safety, self-efficacy, and quality of life. We reviewed 2,770 citations. Among these 25 randomized-controlled-study with a total of 4,683 participants met inclusion criteria. Findings of meta-analyses on interventions indicated promising results in improving anxiety [standardized mean difference (SMD) -7.15, 95% confidence interval (CI) -8.39 to -5.92], depression (SMD -0.26, CI -0.56 to -0.05), safety (SMD = 0.43, CI 0.4 to -0.83), violence prevention (SMD = -0.92, CI -1.66 to -0.17), health (SMD = 0.39, CI 0.12 to 0.66), self-esteem (SMD = 1.33, CI -0.73 to 3.39), social support (SMD =0.40, CI 0.20 to 0.61), and stress management (SMD = -8.94, CI -10.48 to -7.40) at the post-test. We found that empowerment plays a vital role, especially when treating depression and Post-Traumatic Stress Disorder (PTSD), which are difficult to improve across interventions. We found mixed findings on self-efficacy and quality of life. The effects of IPV are long-lasting and require treatments targeting co-morbid issues including improving safety and mental health issues.

Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach.

BACKGROUND: Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities. OBJECTIVE: To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems. DESIGN: Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017). PARTICIPANTS: Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative. INTERVENTIONS: Identification of a "positive deviant" and dissemination of this system's best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching). MAIN MEASURES: We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics. KEY RESULTS: BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0-9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5-13.5), Hispanic (10.5%, 95% CI 8.4-12.5), and African American (9.0%, 95% CI 7.7-10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2-19.5; moderate: 5.2%, 95% CI 0.8-9.5; low: 0.2%, 95% CI-3.9 to 4.3). CONCLUSIONS: Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.

"The coupons and stuff just made it possible": economic constraints and patient experiences of a produce prescription program.

Although produce prescription (PRx) programs have been shown to improve fruit and vegetable (FV) consumption, few studies have examined how economic constraints influence participant experience. We conducted a qualitative study of patient experience of a 3-month PRx program for hypertension (PRxHTN) including 3 safety-net clinics and 20 farmers' markets (FMs). We interviewed 23 PRxHTN participants using semistructured guides to understand their program experiences. Interviews were audio-taped, transcribed, and analyzed to identify a priori and emergent themes. PRxHTN participants completing qualitative interviews were mostly middle-aged (mean: 62 years) African American (100%) women (78%). Economic hardship as a barrier to maximum program participation and sustainability was a main theme identified, with three subthemes: (i) transportation issues shaped shopping and eating patterns and limited participant ability to access FMs to utilize PRxHTN vouchers; (ii) limited and unstable income shaped participant shopping and eating behavior before, during, and after PRxHTN; and (iii) participants emphasized individual-level influences like personal or perceived motivations for program participation, despite significant structural constraints, such as economic hardship, shaping their program engagement. Future PRx programs should bolster economic and institutional supports beyond FM vouchers such as transportation assistance, partnering with local food banks and expansion to local grocery stores offering year-round FV access to support sustained behavior change. Additionally, structural competency tools for providers may be warranted to reorient focus on structural influences on program engagement and away from potentially stigmatizing individual-level explanations for program success. These efforts have potential to enhance the translation of PRx programs to the needs of economically vulnerable patients who struggle to manage chronic illness and access basic nutrition.

Implementing a Produce Prescription Program for Hypertensive Patients in Safety Net Clinics.

INTRODUCTION: Although community-clinical linkages can improve chronic disease management, little is known regarding strategies for program implementation. We describe implementation of a unique produce prescription program for patients with hypertension (PRxHTN) involving 3 safety net clinics and 20 farmers' markets (FMs). STRATEGY: Safety net clinics were invited to participate, and provider-leads received assistance in (1) developing a process flow to screen for food insecurity among hypertensive adults for program referral, (2) integrating the program into their electronic health record for scheduling, and (3) counseling patients on PRxHTN/FM use. Research staff met with clinics twice monthly. FM managers were trained on maintaining PRxHTN voucher redemption logs. DISCUSSION: A total of 7 diverse providers screened 266 patients over 3 months; 224 were enrolled. Twelve FM, including one newly established at a clinic through provider-FM manager collaboration, redeemed over $14,500 of the $10 PRxHTN vouchers. We describe several strategies that can be used to prepare for and overcome implementation challenges including organizational and staff selection, facilitative administration, and clinical training and consultation. CONCLUSION: The PRxHTN program offers a flexible implementation process allowing clinics to successfully adapt their workflow to suit their staffing and resources.

Outcome measures in pediatric polypharmacy research: a scoping review.

INTRODUCTION: Various methods have been used to interpret the reports of pediatric polypharmacy across the literature. This is the first scoping review that explores outcome measures in pediatric polypharmacy research. OBJECTIVES: The aim of our study was to describe outcome measures assessed in pediatric polypharmacy research. METHODS: A search of electronic databases was conducted in July 2017, including Ovid Medline, PubMed, Elsevier Embase, Wiley Cochrane Central Register of Controlled Trials (CENTRAL), EBSCO CINAHL, Ovid PsyclNFO, Web of Science Core Collection, ProQuest Dissertations and Thesis A&I. Data were extracted about study characteristics and outcome measures, and also synthesized by harms or benefits mentioned. RESULTS: The search strategy initially identified 8169 titles and screened 4398 using the inclusion criteria after de-duplicating. After the primary screening, a total of 363 studies were extracted for the data analysis. Polypharmacy (prevalence) was identified as an outcome in 31.4% of the studies, prognosis-related outcomes in 25.6%, and adverse drug reactions in 16.5%. A total of 265 articles (73.0%) mentioned harms, including adverse drug reactions (26.4%), side effects (24.2%), and drug-drug interactions (20.9%). A total of 83 studies (22.9%) mentioned any benefit, 48.2% of which identified combination for efficacy, 24.1% combination for treatment of complex diseases, and 19.3% combination for treatment augmentation. Thirty-eight studies reported adverse drug reaction as an outcome, where polypharmacy was a predictor, with various designs. CONCLUSIONS: Most studies of pediatric polypharmacy evaluate prevalence, prognosis, or adverse drug reaction-related out-comes, and underscore harms related to polypharmacy. Clinicians should carefully weigh benefits and harms when introducing medications to treatment regimens.

Defining pediatric polypharmacy: A scoping review.

OBJECTIVES: Lack of consensus regarding the semantics and definitions of pediatric polypharmacy challenges researchers and clinicians alike. We conducted a scoping review to describe definitions and terminology of pediatric polypharmacy. METHODS: Medline, PubMed, EMBASE, CINAHL, PsycINFO, Cochrane CENTRAL, and the Web of Science Core Collection databases were searched for English language articles with the concepts of "polypharmacy" and "children". Data were extracted about study characteristics, polypharmacy terms and definitions from qualifying studies, and were synthesized by disease conditions. RESULTS: Out of 4,398 titles, we included 363 studies: 324 (89%) provided numeric definitions, 131 (36%) specified duration of polypharmacy, and 162 (45%) explicitly defined it. Over 81% (n = 295) of the studies defined polypharmacy as two or more medications or therapeutic classes. The most common comprehensive definitions of pediatric polypharmacy included: two or more concurrent medications for ≥1 day (n = 41), two or more concurrent medications for ≥31 days (n = 15), and two or more sequential medications over one year (n = 12). Commonly used terms included polypharmacy, polytherapy, combination pharmacotherapy, average number, and concomitant medications. The term polypharmacy was more common in psychiatry literature while epilepsy literature favored the term polytherapy. CONCLUSIONS: Two or more concurrent medications, without duration, for ≥1 day, ≥31 days, or sequentially for one year were the most common definitions of pediatric polypharmacy. We recommend that pediatric polypharmacy studies specify the number of medications or therapeutic classes, if they are concurrent or sequential, and the duration of medications. We propose defining pediatric polypharmacy as "the prescription or consumption of two or more distinct medications for at least one day". The term "polypharmacy" should be included among key words and definitions in manuscripts.

A transdisciplinary team approach to scoping reviews: the case of pediatric polypharmacy.

BACKGROUND: Polypharmacy can be either beneficial or harmful to children. We conducted a scoping review to examine the concept of pediatric polypharmacy: its definition, prevalence, extent and gaps in research. In this manuscript, we report our transdisciplinary scoping review methodology. METHODS: After establishing a transdisciplinary team, we iteratively developed standard operating procedures for the study's search strategy, inclusion/exclusion criteria, screening, and data extraction. We searched eight bibliographic databases, screened abstracts and full text articles, and extracted data from included studies using standardized forms. We held regular team meetings and performed ongoing internal validity measurements to maintain consistent and quality outputs. RESULTS: With the aid of EPPI Reviewer collaborative software, our transdisciplinary team of nine members performed dual reviews of 363 included studies after dual screening of 4398 abstracts and 1082 full text articles. We achieved overall agreement of 85% and a kappa coefficient of 0.71 (95% CI 0.68-0.74) while screening full text articles. The screening and review processes required about seven hours per extracted study. The two pharmacists, an epidemiologist, a neurologist, and a librarian on the review team provided internal consultation in these key disciplines. A stakeholder group of 10 members with expertise in evidence synthesis, research implementation, pediatrics, mental health, epilepsy, pharmacoepidemiology, and pharmaceutical outcomes were periodically consulted to further characterize pediatric polypharmacy. CONCLUSIONS: A transdisciplinary approach to scoping reviews, including internal and external consultation, should be considered when addressing complex cross-disciplinary questions.

Are Providers Prepared to Engage Younger Women in Shared Decision-Making for Mammography?

BACKGROUND: The U.S. Preventive Services Task Force recommends providers engage women aged 40-49 years in shared decision-making (SDM) for mammography. This requires mammography knowledge, adequate time to discuss screening, and self-confidence in doing so. Yet, to date, no studies have assessed provider readiness to engage younger women in SDM. METHODS: An online survey of primary care providers was conducted in Cleveland in 2015. It inquired about knowledge of screening benefits and harms, including the impact of screening on mortality, risk of additional imaging, biopsy, overtreatment following screening, and likelihood of a true-positive result. Key knowledge was defined as accurate estimation of the impact of screening on mortality and risk of overtreatment. Respondents reported time typically spent with patients discussing mammography, self-assessed competence in engaging patients in screening discussions, and perspectives on SDM for mammography. RESULTS: Of 612 providers invited, 220 completed the survey (response rate: 36%). Knowledge of harms was low: 90% and 82% underestimated the risk of additional imaging or breast biopsy, respectively. Sixty-two percent correctly estimated screening's impact on mortality. The majority (83%) believed in SDM for mammography, yet, most (77%) spent less than 5 minutes with patients discussing screening. Of those who believed in SDM, only 10% had key mammography knowledge and also felt highly competent at engaging women in screening discussions. CONCLUSIONS: Most providers in our sample were inadequately equipped to engage women in SDM for mammography. Broad-based efforts are needed to increase the capacity of providers to engage younger women in decision-making.

Hemodialysis in neonates and infants: A systematic review.

Hemodialysis (HD) in neonates and infants poses unique challenges due to high risks of mortality attributable to obligatory small blood flow volumes. Although HD is often necessary in neonates, its effectiveness and feasibility are poorly understood. The aim of this review is to describe in detail the few studies reporting on HD in neonates and infants (<12 months old) and then dissertate more broadly on the subject with an emphasis on recent innovations with potential to overcome traditional barriers for effective HD in this population. We detail the clinical characteristics, outcomes, technical considerations, maintenance and complications associated with HD, and provide guidance for addressing challenges associated with HD in this population.