Enhancing availability of services to control hypertension through a team-based care approach that includes pharmacists.

BACKGROUND: Primary care physician (PCP) shortages are expected to increase. The Michigan Medicine Hypertension Pharmacists' Program uses a team-based care (TBC) approach to redistribute some patient care responsibilities from PCPs to pharmacists for patients with diagnosed hypertension. OBJECTIVE: This evaluation analyzed whether the Michigan Medicine Hypertension Pharmacists' Program increased the availability of hypertension management services and described facilitators that addressed barriers to program sustainability and replicability. METHODS: We conducted a retrospective observational study that used a mixed methods approach. We examined the availability of hypertension management services using the number of pharmacists' referrals of patients to other services and the number of PCP appointments. We analyzed qualitative interviews with program staff and site-level quantitative data to examine the program's impact on the availability of services, the impact of TBC that engaged pharmacists, and program barriers and facilitators. RESULTS: Patients who visited a pharmacist had fewer PCP visits over 3- and 6-month periods compared to a matched comparison group that did not see a pharmacist and were 1.35 times more likely to receive a referral to a specialist within a 3-month period. Support from leaders and physicians, shared electronic health record access, and financial backing emerged as leading factors for program sustainability and replicability. CONCLUSION: Adding pharmacists to the care team reduced the number of PCP appointments per patient while increasing the availability of hypertension management services; this may in turn improve PCPs' availability. Similar models may be sustainable and replicable by relying on organizational buy-in, accessible infrastructure, and financing.

A National Approach to Promoting Health Equity in Cardiovascular Disease Prevention: Implementation Science Strengths, Opportunities, and a Changing Chronic Disease Context.

In the USA, structural racism contributes to higher rates of cardiovascular disease (CVD) including hypertension, heart disease, and stroke among African American persons. Evidence-based interventions (EBIs), which include programs, policies, and practices, can help mitigate health inequities, but have historically been underutilized or misapplied among communities experiencing discrimination and exclusion. This commentary on the special issue of Prevention Science, "Advancing the Adaptability of Chronic Disease Prevention and Management Through Implementation Science," describes the Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention's (DHDSP's) efforts to support implementation practice and highlights several studies in the issue that align with DHDSP's methods and mission. This work includes EBI identification, scale, and spread as well as health services and policy research. We conclude that implementation practice to enhance CVD health equity will require greater coordination with diverse implementation science partners as well as continued innovation and capacity building to ensure meaningful community engagement throughout EBI development, translation, dissemination, and implementation.

Policy implementation strategies to address rural disparities in access to care for stroke patients.

Context: Stroke systems of care (SSOC) promote access to stroke prevention, treatment, and rehabilitation and ensure patients receive evidence-based treatment. Stroke patients living in rural areas have disproportionately less access to emergency medical services (EMS). In the United States, rural counties have a 30% higher stroke mortality rate compared to urban counties. Many states have SSOC laws supported by evidence; however, there are knowledge gaps in how states implement these state laws to strengthen SSOC. Objective: This study identifies strategies and potential challenges to implementing state policy interventions that require or encourage evidence-supported pre-hospital interventions for stroke pre-notification, triage and transport, and inter-facility transfer of patients to the most appropriate stroke facility. Design: Researchers interviewed representatives engaged in implementing SSOC across six states. Informants (n = 34) included state public health agency staff and other public health and clinical practitioners. Outcomes: This study examined implementation of pre-hospital SSOCs policies in terms of (1) development roles, processes, facilitators, and barriers; (2) implementation partners, challenges, and solutions; (3) EMS system structure, protocols, communication, and supervision; and (4) program improvement, outcomes, and sustainability. Results: Challenges included unequal resource allocation and EMS and hospital services coverage, particularly in rural settings, lack of stroke registry usage, insufficient technologies, inconsistent use of standardized tools and protocols, collaboration gaps across SSOC, and lack of EMS stroke training. Strategies included addressing scarce resources, services, and facilities; disseminating, training on, and implementing standardized statewide SSOC protocols and tools; and utilizing SSOC quality and performance improvement systems and approaches. Conclusions: This paper identifies several strategies that can be incorporated to enhance the implementation of evidence-based stroke policies to improve access to timely stroke care for all patient populations, particularly those experiencing disparities in rural communities.

Impact of State Stroke Systems of Care Laws on Stroke Outcomes.

Since 2003, 38 US states and Washington, DC have adopted legislation and/or regulations to strengthen stroke systems of care (SSOCs). This study estimated the impact of SSOC laws on stroke outcomes. We used a coded legal dataset of 50 states and DC SSOC laws (years 2003-2018), national stroke accreditation information (years 1997-2018), data from the Healthcare Cost and Utilization Project (years 2012-2018), and National Vital Statistics System (years 1979-2019). We applied a natural experimental design paired with longitudinal modeling to estimate the impact of having one or more SSOC policies in effect on outcomes. On average, states with one or more SSOC policies in effect achieved better access to primary stroke centers (PSCs) than expected without SSOC policies (ranging from 2.7 to 8.0 percentage points (PP) higher), lower inpatient hospital costs (USD 610-1724 less per hospital stay), lower age-adjusted stroke mortality (1.0-1.6 fewer annual deaths per 100,000), a higher proportion of stroke patients with brain imaging results within 45 min of emergency department arrival (3.6-5.0 PP higher), and, in some states, lower in-hospital stroke mortality (5 fewer deaths per 1000). Findings were mixed for some outcomes and there was limited evidence of model fit for others. No effect was observed in racial and/or rural disparities in stroke mortality.

Evaluation of a Pharmacists' Patient Care Process Approach for Hypertension.

INTRODUCTION: An estimated 116 million American adults (47.3%) have hypertension. Most adults with hypertension do not have it controlled-3 in 4 (92.1 million) U.S. adults with hypertension have a blood pressure ≥130/80 mmHg. The Pharmacists' Patient Care Process is a standardized patient-centered approach to the provision of pharmacist care that is done in collaboration with other healthcare providers. Through the Michigan Medicine Hypertension Pharmacists' Program, pharmacists use the Pharmacists' Patient Care Process to provide hypertension management services in collaboration with physicians in primary care and community pharmacy settings. In 2019, the impact of Michigan Medicine Hypertension Pharmacists' Program patient participation on blood pressure control was evaluated. METHODS: Propensity scoring was used to match patients in the intervention group with patients in the comparison group and regression analyses were then conducted to compare the 2 groups on key patient outcomes. Negative binomial regression was used to examine the number of days with blood pressure under control. The findings presented in this brief are part of a larger multimethod evaluation. RESULTS: More patients in the intervention group than in the comparison group achieved blood pressure control at 3 months (66.3% vs 42.4%) and 6 months (69.1% vs 56.5%). The intervention group experienced more days with blood pressure under control within a 3-month (18.6 vs 9.5 days) and 6-month period (57.0 vs 37.4 days) than the comparison group did. CONCLUSIONS: Findings support the effectiveness of the Michigan Medicine Hypertension Pharmacists' Program approach to implementing the Pharmacists' Patient Care Process to improve blood pressure control.

Processes for Implementing Community Health Worker Workforce Development Initiatives.

Introduction: The objective of this observational, cross-sectional study was to identify, document, and assess the progress made to date in implementing various processes involved in statewide community health worker (CHW) workforce development initiatives. Methods: From September 2017 to December 2020, we developed and applied a conceptual model of processes involved in implementing statewide CHW initiatives. One or more outputs were identified for each model process and assessed across the 50 states, D.C., and Puerto Rico using peer-reviewed and gray literature available as of September 2020. Results: Twelve statewide CHW workforce development processes were identified, and 21 outputs were assessed. We found an average of eight processes implemented per state, with seven states implementing all 12 processes. As of September 2020, 45 states had a multi-stakeholder CHW coalition and 31 states had a statewide CHW organization. In 20 states CHWs were included in Medicaid Managed Care Organizations or Health Plans. We found routine monitoring of statewide CHW employment in six states. Discussion: Stakeholders have advanced statewide CHW workforce development initiatives using the processes reflected in our conceptual model. Our results could help to inform future CHW initiative design, measurement, monitoring, and evaluation efforts, especially at the state level.

"Nothing About Us Without Us": Insights from State-level Efforts to Implement Community Health Worker Certification.

As community health workers (CHWs) have increasingly become recognized as members of health care teams, several states have considered or implemented processes to certify them. Between April and September 2017, we interviewed 41 stakeholders (e.g., CHWs, employers, and state health officials) in seven states that had considered or developed CHW certification to gather information about their processes and lessons learned. Interviewees reported several areas to consider in developing certification such as requiring training and education, deciding whether to certify based on experience, ensuring that CHWs are members of communities served, and avoiding marginalization of some groups of CHWs. Participants highlighted strategies for ensuring active CHW leadership in decision-making about certification. Interviewees identified best practices for supporting CHW workforce development such as using national models and standardized training, supporting CHW leadership, involving CHW professional groups, convening workgroups, and educating stakeholders. Findings are relevant to states seeking to grow their CHW workforce.

Timing of State and Territorial COVID-19 Stay-at-Home Orders and Changes in Population Movement - United States, March 1-May 31, 2020.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to spread from person to person primarily by the respiratory route and mainly through close contact (1). Community mitigation strategies can lower the risk for disease transmission by limiting or preventing person-to-person interactions (2). U.S. states and territories began implementing various community mitigation policies in March 2020. One widely implemented strategy was the issuance of orders requiring persons to stay home, resulting in decreased population movement in some jurisdictions (3). Each state or territory has authority to enact its own laws and policies to protect the public's health, and jurisdictions varied widely in the type and timing of orders issued related to stay-at-home requirements. To identify the broader impact of these stay-at-home orders, using publicly accessible, anonymized location data from mobile devices, CDC and the Georgia Tech Research Institute analyzed changes in population movement relative to stay-at-home orders issued during March 1-May 31, 2020, by all 50 states, the District of Columbia, and five U.S. territories.* During this period, 42 states and territories issued mandatory stay-at-home orders. When counties subject to mandatory state- and territory-issued stay-at-home orders were stratified along rural-urban categories, movement decreased significantly relative to the preorder baseline in all strata. Mandatory stay-at-home orders can help reduce activities associated with the spread of COVID-19, including population movement and close person-to-person contact outside the household.

Public Attitudes, Behaviors, and Beliefs Related to COVID-19, Stay-at-Home Orders, Nonessential Business Closures, and Public Health Guidance - United States, New York City, and Los Angeles, May 5-12, 2020.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to be transmitted mainly by person-to-person contact (1). Implementation of nationwide public health orders to limit person-to-person interaction and of guidance on personal protective practices can slow transmission (2,3). Such strategies can include stay-at-home orders, business closures, prohibitions against mass gatherings, use of cloth face coverings, and maintenance of a physical distance between persons (2,3). To assess and understand public attitudes, behaviors, and beliefs related to this guidance and COVID-19, representative panel surveys were conducted among adults aged ≥18 years in New York City (NYC) and Los Angeles, and broadly across the United States during May 5-12, 2020. Most respondents in the three cohorts supported stay-at-home orders and nonessential business closures* (United States, 79.5%; New York City, 86.7%; and Los Angeles, 81.5%), reported always or often wearing cloth face coverings in public areas (United States, 74.1%, New York City, 89.6%; and Los Angeles 89.8%), and believed that their state's restrictions were the right balance or not restrictive enough (United States, 84.3%; New York City, 89.7%; and Los Angeles, 79.7%). Periodic assessments of public attitudes, behaviors, and beliefs can guide evidence-based public health decision-making and related prevention messaging about mitigation strategies needed as the COVID-19 pandemic evolves.

Translating Workforce Development Policy Interventions for Community Health Workers: Application of a Policy Research Continuum.

CONTEXT: There is a need for knowledge translation to advance health equity in the prevention and control of cardiovascular disease and type 2 diabetes. One recommended strategy is engaging community health workers (CHWs) to have a central role in related interventions. Despite strong evidence of effectiveness for CHWs, there is limited information examining the impact of state CHW policy interventions. This article describes the application of a policy research continuum to enhance knowledge translation of CHW workforce development policy in the United States. METHODS: During 2016-2019, a team of public health researchers and practitioners applied the policy research continuum, a multiphased systematic assessment approach that incorporates legal epidemiology to enhance knowledge translation of CHW workforce development policy interventions in the United States. The continuum consists of 5 discrete, yet interconnected, phases including early evidence assessments, policy surveillance, implementation studies, policy ratings, and impact studies. RESULTS: Application of the first 3 phases of the continuum demonstrated (1) how CHW workforce development policy interventions are linked to strong evidence bases, (2) whether existing state CHW laws are evidence-informed, and (3) how different state approaches were implemented. DISCUSSION: As a knowledge translation tool, the continuum enhances dissemination of timely, useful information to inform decision making and supports the effective implementation and scale-up of science-based policy interventions. When fully implemented, it assists public health practitioners in examining the utility of different policy intervention approaches, the effects of adaptation, and the linkages between policy interventions and more distal public health outcomes.

Establishing a Baseline: Evidence-Supported State Laws to Advance Stroke Care.

OBJECTIVE: Approximately 800 000 strokes occur annually in the United States. Stroke systems of care policies addressing prehospital and in-hospital care have been proposed to improve access to time-sensitive, lifesaving treatments for stroke. Policy surveillance of stroke systems of care laws supported by best available evidence could reveal potential strengths and weaknesses in how stroke care delivery is regulated across the nation. DESIGN: This study linked the results of an early evidence assessment of 15 stroke systems of care policy interventions supported by best available evidence to a legal data set of the body of law in effect on January 1, 2018, for the 50 states and Washington, District of Columbia. RESULTS: As of January 1, 2018, 39 states addressed 1 or more aspects of prehospital or in-hospital stroke care in law; 36 recognized at least 1 type of stroke center. Thirty states recognizing stroke centers also had evidence-supported prehospital policy interventions authorized in law. Four states authorized 10 or more of 15 evidence-supported policy interventions. Some combinations of prehospital and in-hospital policy interventions were more prevalent than other combinations. CONCLUSION: The analysis revealed that many states had a stroke regulatory infrastructure for in-hospital care that is supported by best available evidence. However, there are gaps in how state law integrates evidence-supported prehospital and in-hospital care that warrant further study. This study provides a baseline for ongoing policy surveillance and serves as a basis for subsequent stroke systems of care policy implementation and policy impact studies.

National and State Trends in Sales of Cigarettes and E-Cigarettes, U.S., 2011-2015.

INTRODUCTION: In recent years, self-reported cigarette smoking has declined among youth and adults, while electronic cigarette (e-cigarette) use has increased. However, sales trends for these products are less certain. This study assessed national and state patterns of U.S. cigarette and e-cigarette unit sales. METHODS: Trends in cigarette and e-cigarette unit sales were analyzed using retail scanner data from September 25, 2011 through January 9, 2016 for: (1) convenience stores; and (2) all other outlets combined, including supermarkets, mass merchandisers, drug, dollar, and club stores, and military commissaries (online, tobacco-only, and "vape" shops were not available). Data by store type were available for the total contiguous U.S. and 29 states; combined data were available for the remaining states, except Alaska, Hawaii, and DC. RESULTS: During 2011-2015, cigarette sales exhibited a small, significant decrease; however, positive year-over-year growth occurred in convenience stores throughout most of 2015. E-cigarette unit sales significantly increased during 2011-2015, but year-over-year growth slowed and was occasionally negative. Cigarette unit sales exceeded e-cigarettes by 64:1 during the last 4-week period. During 2014-2015, cigarette sales increases occurred in 15 of 48 assessed states; e-cigarette sales increased in 18 states. CONCLUSIONS: Despite overall declines during 2011-2015, cigarette sales in 2015 grew for the first time in a decade. E-cigarette sales growth was positive, but slowed over the study period in assessed stores. Cigarette sales continued to exceed e-cigarette sales, reinforcing the importance of efforts to reduce the appeal and accessibility of cigarettes and other combusted tobacco products.

Effect of price changes in little cigars and cigarettes on little cigar sales: USA, Q4 2011-Q4 2013.

INTRODUCTION: Little cigars are comparable to cigarettes in terms of shape, size, filters and packaging. Disproportionate tobacco excise taxes, which directly affect purchase price, may lead consumers to substitute cigarettes with less expensive little cigars. This study estimated the effects of little cigar and cigarette prices on little cigar sales. METHODS: Sales data from a customised retail scanner database were used to model a log-log equation to infer own-price and cross-price elasticity of demand for little cigars relative to little cigar and cigarette prices, respectively, from quarter 4 of 2011 to quarter 4 of 2013. Data were available for convenience stores (C-stores) (n=29 states); food, drug and mass merchandisers (FDMs) (n=44 states); and C-stores and FDMs combined (n=27 states). The dependent variable was per capita little cigar pack sales, and key independent variables were the price index for little cigars and cigarettes. RESULTS: A 10% increase in little cigar price was associated with a 25% (p<0.01) decrease in little cigar sales in C-stores alone, and a 31.7% (p<0.01) decrease in C-stores and FDMs combined. A 10% increase in cigarette price was associated with a 21.5% (p<0.05) increase in little cigar sales in C-stores, and a 27.3% (p<0.01) increase in C-stores and FDMs combined. CONCLUSIONS: Our results suggest that US cigarette smokers are avoiding the high cost of cigarettes by switching to lower priced little cigars. Increasing and equalising prices among comparable products, like cigarettes and little cigars, may motivate cost-conscious smokers to quit.

National and State-Specific Sales and Prices for Electronic Cigarettes-U.S., 2012-2013.

INTRODUCTION: The growing market for electronic cigarettes (e-cigarettes) has been widely reported in the media, but very little objective data exist in the scientific literature, and no data have been published on state-specific trends in prices or sales. Our objective is to assess state-specific annual sales and average prices for e-cigarettes in the U.S. METHODS: Commercial retail scanner data were used to assess total dollar sales and average price per unit for disposable e-cigarettes, starter kits, and cartridge refills for selected states and the total U.S. during 2012-2013. Data were analyzed in 2014. Data were available for convenience stores (29 states) and food, drug, and mass merchandisers (44 states). RESULTS: In convenience stores, dollar sales increased markedly during 2012-2013: 320.8% for disposable e-cigarettes, 72.4% for starter kits, and 82% for cartridges. In food, drug, and mass merchandisers, dollar sales increased 49.5% for disposable e-cigarettes, 89.4% for starter kits, and 126.2% for cartridges. Average prices across all product categories increased in convenience stores and decreased in food, drug, and mass merchandisers. Sales and prices varied substantially across states included in the analyses. CONCLUSIONS: Sales of all e-cigarette device types grew considerably in convenience stores and food, drug, and mass merchandisers during 2012-2013. The market for e-cigarettes is growing rapidly, resulting in dynamic sales and price changes that vary across the U.S. Continued state-specific surveillance of the e-cigarette market is warranted.

Protobacco Media Exposure and Youth Susceptibility to Smoking Cigarettes, Cigarette Experimentation, and Current Tobacco Use among US Youth.

PURPOSE: Youth are exposed to many types of protobacco influences, including smoking in movies, which has been shown to cause initiation. This study investigates associations between different channels of protobacco media and susceptibility to smoking cigarettes, cigarette experimentation, and current tobacco use among US middle and high school students. METHODS: By using data from the 2012 National Youth Tobacco Survey, structural equation modeling was performed in 2013. The analyses examined exposure to tobacco use in different channels of protobacco media on smoking susceptibility, experimentation, and current tobacco use, accounting for perceived peer tobacco use. RESULTS: In 2012, 27.9% of respondents were never-smokers who reported being susceptible to trying cigarette smoking. Cigarette experimentation increased from 6.3% in 6th grade to 37.1% in 12th grade. Likewise, current tobacco use increased from 5.2% in 6th grade to 33.2% in 12th grade. Structural equation modeling supported a model in which current tobacco use is associated with exposure to static advertising through perception of peer use, and by exposure to tobacco use depicted on TV and in movies, both directly and through perception of peer use. Exposure to static advertising appears to directly increase smoking susceptibility but indirectly (through increased perceptions of peer use) to increase cigarette experimentation. Models that explicitly incorporate peer use as a mediator can better discern the direct and indirect effects of exposure to static advertising on youth tobacco use initiation. CONCLUSIONS: These findings underscore the importance of reducing youth exposure to smoking in TV, movies, and static advertising.