One In Five Fewer Heart Attacks: Impact, Savings, And Sustainability In San Diego County Collaborative.

Before 2011 rates of hospitalization for heart attacks were about the same in San Diego County as they were in the rest of California. In 2011 a multistakeholder population health collaborative consisting of partners at the federal, state, and local levels launched Be There San Diego. The collaborative's goal was to reduce cardiovascular events through the spread of best practices aimed at improving control of hypertension, lipid levels, and blood sugar and through patient and medical community activation. Using hospital discharge data for the period 2007-16, we compared acute myocardial infarction (AMI) hospitalization rates in San Diego County and the rest of the state before and after the demonstration project started. AMI hospitalization rates decreased by 22 percent in San Diego County versus 8 percent in the rest of the state, with an estimated 3,826 AMI hospitalizations avoided and $86 million in savings in San Diego. Results show that a science-based health collaborative can improve outcomes while lowering costs, and efforts are under way to ensure the collaborative's sustainability.

Community Implementation and Translation of Kaiser Permanente's Cardiovascular Disease Risk-Reduction Strategy.

INTRODUCTION: Since 2003, Kaiser Permanente (KP) has implemented innovative cardiovascular disease (CVD) risk-reduction clinical practices in Northern and Southern California that emphasize the use of cardioprotective medications-aspirin, angiotensin-converting enzyme inhibitors, and statins-in individuals at very high risk of experiencing heart attacks and strokes. Because an internal KP retrospective analysis demonstrated decreased morbidity and mortality among KP patients with diabetes, there is significant value in implementing this strategy in the broader community population, particularly in safety-net clinics serving the uninsured. METHODS: To implement this risk-reduction clinical practice in the community, clinical and programmatic sections of KP had to connect with a set of community partners that share a similar approach of evidence-based prevention. Successful implementation required a well-planned and coordinated collaboration between KP and the community entities that allowed for and supported adaptation in local delivery structures. RESULTS: Forty-six ambulatory clinic sites based at community health centers and in public hospital/health systems in California's safety net have initiated KP's CVD risk-reduction program. This resulted in 1125 community-clinic patients in Southern California and 1120 patients in Northern California receiving their first prescription for at least 1 of the 3 cardiovascular medications within the first 18 months of implementation. KP Colorado, KP Georgia, and KP Northwest are also implementing these strategies in their local communities. DISCUSSION: The results of program initiation demonstrate successful translation of the KP CVD risk-reduction strategy to the broader, non-KP member community: uptake of 46 community clinic sites in 2 KP Regions, with a projection of >11,000 patients being prescribed the 3 cardioprotective medications in subsequent years and in multiple Regions. This may be a model for further spread of CVD prevention measures, and prevention programs for other diseases, to all populations throughout the US, notably underserved communities disproportionately affected by chronic conditions.

The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study.

OBJECTIVE: To determine whether there is a link between hypoglycaemia and mortality among participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. DESIGN: Retrospective epidemiological analysis of data from the ACCORD trial. Setting Diabetes clinics, research clinics, and primary care clinics. PARTICIPANTS: Patients were eligible for the ACCORD study if they had type 2 diabetes, a glycated haemoglobin (haemoglobin A(1C)) concentration of 7.5% or more during screening, and were aged 40-79 years with established cardiovascular disease or 55-79 years with evidence of subclinical disease or two additional cardiovascular risk factors. Intervention Intensive (haemoglobin A(1C) <6.0%) or standard (haemoglobin A(1C) 7.0-7.9%) glucose control. OUTCOME MEASURES: Symptomatic, severe hypoglycaemia, manifest as either blood glucose concentration of less than 2.8 mmol/l (<50 mg/dl) or symptoms that resolved with treatment and that required either the assistance of another person or medical assistance, and all cause and cause specific mortality, including a specific assessment for involvement of hypoglycaemia. RESULTS: 10 194 of the 10 251 participants enrolled in the ACCORD study who had at least one assessment for hypoglycaemia during regular follow-up for vital status were included in this analysis. Unadjusted annual mortality among patients in the intensive glucose control arm was 2.8% in those who had one or more episodes of hypoglycaemia requiring any assistance compared with 1.2% for those with no episodes (53 deaths per 1924 person years and 201 deaths per 16 315 person years, respectively; adjusted hazard ratio (HR) 1.41, 95% CI 1.03 to 1.93). A similar pattern was seen among participants in the standard glucose control arm (3.7% (21 deaths per 564 person years) v 1.0% (176 deaths per 17 297 person years); adjusted HR 2.30, 95% CI 1.46 to 3.65). On the other hand, among participants with at least one hypoglycaemic episode requiring any assistance, a non-significantly lower risk of death was seen in those in the intensive arm compared with those in the standard arm (adjusted HR 0.74, 95% 0.46 to 1.23). A significantly lower risk was observed in the intensive arm compared with the standard arm in participants who had experienced at least one hypoglycaemic episode requiring medical assistance (adjusted HR 0.55, 95% CI 0.31 to 0.99). Of the 451 deaths that occurred in ACCORD up to the time when the intensive treatment arm was closed, one death was adjudicated as definitely related to hypoglycaemia. CONCLUSION: Symptomatic, severe hypoglycaemia was associated with an increased risk of death within each study arm. However, among participants who experienced at least one episode of hypoglycaemia, the risk of death was lower in such participants in the intensive arm than in the standard arm. Symptomatic, severe hypoglycaemia does not appear to account for the difference in mortality between the two study arms up to the time when the ACCORD intensive glycaemia arm was discontinued. TRIAL REGISTRATION: NCT00000620.

Preventing myocardial infarction and stroke with a simplified bundle of cardioprotective medications.

OBJECTIVE: To assess the effect of promoting a bundle of fixed doses of a generic statin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), delivered with minimal outpatient visits, laboratory testing, and dosage titration, to people with diabetes, coronary artery disease (CAD), or both in a large integrated healthcare system. STUDY DESIGN: Three-year observational study of 170,024 Kaiser Permanente members with diabetes, CAD, or both. METHODS: Using instrumental variable analysis, we assessed the impact of promoting the cardioprotective bundle on hospitalization rates for stroke and myocardial infarction (MI). RESULTS: In 2004 and 2005, 47,268 of 170,024 individuals received "low exposure" (medication possession on 1 to 365 days). Their risk of hospitalization for MI or stroke in 2006 was lowered by 15 events per 1000 person-years (95% confidence interval [CI] = 1, 30), preventing events in 726 people. Furthermore, 21,292 of 170,024 individuals received "high exposure" (medication possession on 366 to 730 days). Their risk of hospitalization for MI or stroke was reduced by 26 events per 1000 person-years (95% CI = 17, 34), preventing events in 545 people. CONCLUSION: A simplified method for bundling fixed doses of a generic statin and an ACEI/ARB was successfully implemented in a large, diverse population in an integrated healthcare delivery system, reducing the risk of hospitalization for MI and stroke.

Assessing psychosocial distress in diabetes: development of the diabetes distress scale.

OBJECTIVE: The purpose of this study was to describe the development of the Diabetes Distress Scale (DDS), a new instrument for the assessment of diabetes-related emotional distress, based on four independent patient samples. RESEARCH DESIGN AND METHODS: In consultation with patients and professionals from multiple disciplines, a preliminary scale of 28 items was developed, based a priori on four distress-related domains: emotional burden subscale, physician-related distress subscale, regimen-related distress subscale, and diabetes-related interpersonal distress. The new instrument was included in a larger battery of questionnaires used in diabetes studies at four diverse sites: waiting room at a primary care clinic (n = 200), waiting room at a diabetes specialty clinic (n = 179), a diabetes management study program (n = 167), and an ongoing diabetes management program (n = 158). RESULTS: Exploratory factor analyses revealed four factors consistent across sites (involving 17 of the 28 items) that matched the critical content domains identified earlier. The correlation between the 28-item and 17-item scales was very high (r = 0.99). The mean correlation between the 17-item total score (DDS) and the four subscales was high (r = 0.82), but the pattern of interscale correlations suggested that the subscales, although not totally independent, tapped into relatively different areas of diabetes-related distress. Internal reliability of the DDS and the four subscales was adequate (alpha > 0.87), and validity coefficients yielded significant linkages with the Center for Epidemiological Studies Depression Scale, meal planning, exercise, and total cholesterol. Insulin users evidenced the highest mean DDS total scores, whereas diet-controlled subjects displayed the lowest scores (P < 0.001). CONCLUSIONS: The DDS has a consistent, generalizable factor structure and good internal reliability and validity across four different clinical sites. The new instrument may serve as a valuable measure of diabetes-related emotional distress for use in research and clinical practice.