Assessment of Hypertension Complications and Health Service Use 5 Years After Implementation of a Multicomponent Intervention.

Importance: There is a lack of information regarding the impact of implementing a protocol-driven, team-based, multicomponent intervention in public primary care settings on hypertension-related complications and health care burden over the long term. Objective: To compare hypertension-related complications and health service use at 5 years among patients managed with Risk Assessment and Management Program for Hypertension (RAMP-HT) vs usual care. Design, Setting, and Participants: In this population-based prospective matched cohort study, patients were followed up until the date of all-cause mortality, an outcome event, or last follow-up appointment before October 2017, whichever occurred first. Participants included 212 707 adults with uncomplicated hypertension managed at 73 public general outpatient clinics in Hong Kong between 2011 and 2013. RAMP-HT participants were matched to patients receiving usual care using propensity score fine stratification weightings. Statistical analysis was conducted from January 2019 to March 2023. Interventions: Nurse-led risk assessment linked to electronic action reminder system, nurse intervention, and specialist consultation (as necessary), in addition to usual care. Main Outcomes and Measures: Hypertension-related complications (cardiovascular diseases, end-stage kidney disease), all-cause mortality, public health service use (overnight hospitalization, attendances at accident and emergency department, specialist outpatient clinic, and general outpatient clinic). Results: A total of 108 045 RAMP-HT participants (mean [SD] age: 66.3 [12.3] years; 62 277 [57.6%] female) and 104 662 patients receiving usual care (mean [SD] age 66.3 [13.5] years; 60 497 [57.8%] female) were included. After a median (IQR) follow-up of 5.4 (4.5-5.8) years, RAMP-HT participants had 8.0% absolute risk reduction in cardiovascular diseases, 1.6% absolute risk reduction in end-stage kidney disease, and 10.0% absolute risk reduction in all-cause mortality. After adjusting for baseline covariates, the RAMP-HT group was associated with lower risk of cardiovascular diseases (hazard ratio [HR], 0.62; 95% CI, 0.61-0.64), end-stage kidney disease (HR, 0.54; 95% CI, 0.50-0.59), and all-cause mortality (HR, 0.52; 95% CI, 0.50-0.54) compared with the usual care group. The number needed to treat to prevent 1 cardiovascular disease event, end-stage kidney disease, and all-cause mortality was 16, 106, and 17, respectively. RAMP-HT participants had lower hospital-based health service use (incidence rate ratios ranging from 0.60 to 0.87) but more general outpatient clinic attendances (IRR, 1.06; 95% CI, 1.06-1.06) compared with usual care patients. Conclusions and Relevance: In this prospective matched cohort study involving 212 707 primary care patients with hypertension, participation in RAMP-HT was associated with statistically significant reductions in all-cause mortality, hypertension-related complications, and hospital-based health service use after 5 years.

Ten-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Macrovascular and Microvascular Complications and All-Cause Mortality: A Population-Based Cohort Study.

OBJECTIVE: The Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) is a protocol-driven, risk-stratified, and individualized management program offered by a multidisciplinary team in addition to usual care for primary care patients with diabetes. This study aimed to evaluate the effectiveness of RAMP-DM for preventing complications and mortality over 10 years. RESEARCH DESIGN AND METHODS: A population-based, prospective cohort study of adult patients with type 2 diabetes managed in the Hong Kong public primary health care system between 2009 and 2010 was conducted. RAMP-DM participants and usual care patients were matched using one-to-one propensity score matching and followed for 10 years. Risks of macrovascular and microvascular complications and all-cause mortality were estimated by Cox proportional hazards regression. RESULTS: A total of 36,746 patients (18,373 in each group) were included after propensity score matching, with a median follow-up of 9.5 years and 306,802 person-years. RAMP-DM participants had significantly lower risks of macrovascular (hazard ratio [HR] 0.52, 95% CI 0.50-0.54) and microvascular (HR 0.68, 95% CI 0.64-0.72) complications and all-cause mortality (HR 0.45, 95% CI 0.43-0.47) than patients who received usual care only. However, the effect of RAMP-DM on macrovascular and microvascular complications attenuated after the 9th and 8th year of follow-up, respectively. RAMP-DM participants also showed better control of hemoglobin A1c, blood pressure, triglycerides, and BMI and a slower decline in renal function. CONCLUSIONS: Significant reductions in diabetes-related complications and all-cause mortality were observed among RAMP-DM participants over a 10-year follow-up, yet the effect of preventing complications attenuated after 8 years.

Retrospective cohort study to investigate the 10-year trajectories of disease patterns in patients with hypertension and/or diabetes mellitus on subsequent cardiovascular outcomes and health service utilisation: a study protocol.

INTRODUCTION: Hypertension (HT) and diabetes mellitus (DM) and are major disease burdens in all healthcare systems. Given their high impact on morbidity, premature death and direct medical costs, we need to optimise effectiveness and cost-effectiveness of primary care for patients with HT/DM. This study aims to find out the association of trajectories in disease patterns and treatment of patients with HT/DM including multimorbidity and continuity of care with disease outcomes and service utilisation over 10 years in order to identify better approaches to delivering primary care services. METHODS AND ANALYSIS: A 10-year retrospective cohort study on a population-based primary care cohort of Chinese patients with documented doctor-diagnosed HT and/or DM, managed in the Hong Kong Hospital Authority (HA) public primary care clinics from 1 January 2006 to 31 December 2019. Data will be extracted from the HA Clinical Management System to identify trajectory patterns of patients with HT/DM. Complications defined by ICPC-2/International Classification of Diseases-Ninth Revision, Clinical Modification diagnosis codes, all-cause mortality rates and public service utilisation rates are included as independent variables. Changes in clinical parameters will be investigated using a growth mixture modelling analysis with standard quadratic trajectories. Dependent variables including effects of multimorbidity, measured by (1) disease count and (2) Charlson's Comorbidity Index, and continuity of care, measured by the Usual Provide Continuity Index, on patient outcomes and health service utilisation will be investigated. Multivariable Cox proportional hazards regression will be conducted to estimate the effect of multimorbidity and continuity of care after stratification of patients into groups according to respective definitions. ETHICS AND DISSEMINATION: This study was approved by the institutional review board of the University of Hong Kong-the HA Hong Kong West Cluster, reference no: UW 19-329. The study findings will be disseminated through peer-reviewed publications and international conferences. TRIAL REGISTRATION NUMBER: NCT04302974.

Utility of short-interval follow-up mammography after a benign-concordant stereotactic breast biopsy result.

BACKGROUND: There is currently no clear consensus recommendation for the use of short-interval follow-up mammography after a benign-concordant breast biopsy (BCBB), and practice patterns vary widely. The objectives of this study were to evaluate whether a short-interval follow-up mammogram provided clinical utility after stereotactic BCBB and to examine the costs associated with this surveillance strategy. METHODS: A retrospective review of women who underwent a stereotactic breast biopsy yielding benign-concordant results between January 2005 and October 2014 was performed to evaluate findings on subsequent imaging, to calculate compliance with recommended short-interval imaging, and to examine whether subsequent imaging revealed an abnormality at the site of the initial stereotactic BCBB. A cost analysis was performed utilizing Medicare reimbursement rates to calculate projected and actual costs of short-interval follow-up imaging after stereotactic BCBB. RESULTS: Of the 470 stereotactic BCBB performed, a short-interval mammogram was completed in 207 (44.0%), 9 (4.3%) of which had suspicious mammographic findings at the initial biopsy site, and 6 subsequently underwent biopsy, with none resulting in malignant or high-risk pathology. The cost of short-interval mammographic follow-up (n = 207) was calculated at $28,541.16. CONCLUSIONS: This study provides evidence that 6-month follow-up mammography has low clinical utility and unnecessarily increases costs after stereotactic BCBB. A safe and more cost-effective strategy may be resumption of routine mammography at 12 months post-biopsy.

Symptomatic Fluid Drainage: Tunneled Peritoneal and Pleural Catheters.

Malignant ascites and pleural effusion are significant contributors to patient symptoms such as shortness of breath, abdominal distension, and nausea in the setting of cancer. There are numerous methods employed to control such symptoms such as serial drainages, pleurodesis, and tunneled drainage catheters. Tunneled drainage catheters are a safe, effective, and a minimally invasive procedure to palliate the symptoms of malignant ascites and pleural effusion.

Exercise, antidepressant treatment, and BDNF mRNA expression in the aging brain.

Principal mental disorders affecting the geriatric population include dementia and depression. A lack of trophic support is thought to contribute to the pathology of these disorders. Physical activity and antidepressant treatment increase the expression of brain-derived neurotrophic factor (BDNF) in the young rat hippocampus. Herein, we investigated the responsiveness of the aging rat hippocampus to antidepressant treatment and voluntary exercise. In situ hybridization revealed that, in young animals, exercise, antidepressant treatment, or their combination elevated BDNF mRNA levels in several hippocampal regions, most notably in the CA3, CA4, and dentate gyrus (DG). This effect was rapid (detectable at 2 days) and sustainable to 20 days. In aged (22-month-old) rats, hippocampal responsiveness to antidepressant treatment and exercise was also rapid and sustainable, but evident mostly in the CA1 and CA2. Daily swimming also revealed that small amounts of activity led to marked elevations in hippocampal BDNF mRNA. The differences in regional patterns of BDNF mRNA elevations between young and aged animals observed with running were maintained with this different exercise modality. Our results indicate that the aged brain is responsive to exercise and antidepressant treatment, and changes in regional response patterns may reflect shifts in hippocampal physiology during the lifespan.