Surveillance of Hypertension Among Women of Reproductive Age: A Review of Existing Data Sources and Opportunities for Surveillance Before, During, and After Pregnancy.

Hypertension is one of the largest modifiable risk factors for cardiovascular disease in the United States, and when it occurs during pregnancy, it can lead to serious risks for both the mother and child. There is currently no nationwide or state surveillance system that specifically monitors hypertension among women of reproductive age (WRA). We reviewed hypertension information available in the Behavioral Risk Factor Surveillance System (BRFSS), National Health and Nutrition Examination Survey (NHANES), National Health Interview Survey (NHIS), and Pregnancy Risk Assessment and Monitoring System (PRAMS) health surveys, the Health care Cost and Utilization Project administrative data sets (National Inpatient Sample, State Inpatient Databases, Nationwide Emergency Department Sample, and State Emergency Department Database and the Nationwide Readmissions Database), and the National Vital Statistics System. BRFSS, NHIS, and NHANES and administrative data sets have the capacity to segment nonpregnant WRA from pregnant women. PRAMS collects information on hypertension before and during pregnancy only among women with a live birth. Detailed information on hypertension in the postpartum period is lacking in the data sources that we reviewed. Enhanced data collection may improve opportunities to conduct surveillance of hypertension among WRA.

Effectiveness of practices for improving the diagnostic accuracy of Non ST Elevation Myocardial Infarction in the Emergency Department: A Laboratory Medicine Best Practices™ systematic review.

OBJECTIVES: This article is a systematic review of the effectiveness of four practices (assay selection, decision point cardiac troponin (cTn) threshold selection, serial testing, and point of care testing) for improving the diagnostic accuracy Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) in the Emergency Department. DESIGN AND METHODS: The CDC-funded Laboratory Medicine Best Practices (LMBP) Initiative systematic review method for quality improvement practices was used. RESULTS: The current ACC/AHA guidelines recommend using cardiac troponin assays with a 99th percentile upper reference limit (URL) diagnostic threshold to diagnose NSTEMI. The evidence in this systematic review indicates that contemporary sensitive cTn assays meet the assay profile requirements (sensitivity, specificity, PPV, and NPV) to more accurately diagnose NSTEMI than alternate tests. Additional biomarkers did not increase diagnostic effectiveness of cTn assays. Sensitivity, specificity, and NPV were consistently high and low PPV improved with serial sampling. Evidence for use of point of care cTn testing was insufficient to make recommendation, though some evidence suggests that use may result in reduction to patient length of stay and costs. CONCLUSIONS: Based on the review of and the LMBP(TM) A-6 Method criteria, we recommend the use of cardiac troponin assays without additional biomarkers using the 99th percentile URL as the clinical diagnostic threshold for the diagnosis of NSTEMI. We recommend serial sampling with one sample at presentation and at least one additional second sample taken at least 6h later to identify a rise or fall in the troponin level. No recommendation is made either for or against the use of point of care tests. DISCLAIMER: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry (CDC/ATSDR).

Published norms underestimate the health-related quality of life among persons with type 2 diabetes.

OBJECTIVE: To assess health-related quality of life (HRQL) among adults with type 2 diabetes using the Short Form (SF)-36 and to obtain pooled estimates of HRQL for subpopulations defined by demographic characteristics, diabetes-related complications, and comorbidities. STUDY DESIGN AND METHODS: We conducted computerized searches of multiple electronic bibliographic databases, and studies in any language were selected in which HRQL was reported among adults with type 2 diabetes using the SF-36. Estimates were combined using a random-effects model. RESULTS: One hundred eighteen studies fulfilled the inclusion criteria. HRQL was lower in persons with type 2 diabetes, as measured by all the eight component scores of the SF-36 when compared with the existing U.S. population norms and with previously published type 2 diabetes norms. SF-36 component and summary scores were extremely heterogeneous, and subpopulation data were sparse; this precluded obtaining meaningful pooled scores for most populations of interest and made comparisons among subpopulations difficult. CONCLUSION: Our data suggest that previously published norms may underestimate the effect of diabetes on HRQL, and diabetes populations are extremely heterogeneous, making broad population "norms" for HRQL in type 2 diabetes of limited use. Additional research with important subpopulations and individual-level data are needed to further explore the effect of diabetes on HRQL.

Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review.

OBJECTIVE: To synthesize the cost-effectiveness (CE) of interventions to prevent and control diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS: We conducted a systematic review of literature on the CE of diabetes interventions recommended by the American Diabetes Association (ADA) and published between January 1985 and May 2008. We categorized the strength of evidence about the CE of an intervention as strong, supportive, or uncertain. CEs were classified as cost saving (more health benefit at a lower cost), very cost-effective ($100,000 per LYG or QALY). The CE classification of an intervention was reported separately by country setting (U.S. or other developed countries) if CE varied by where the intervention was implemented. Costs were measured in 2007 U.S. dollars. RESULTS: Fifty-six studies from 20 countries met the inclusion criteria. A large majority of the ADA recommended interventions are cost-effective. We found strong evidence to classify the following interventions as cost saving or very cost-effective: (I) Cost saving- 1) ACE inhibitor (ACEI) therapy for intensive hypertension control compared with standard hypertension control; 2) ACEI or angiotensin receptor blocker (ARB) therapy to prevent end-stage renal disease (ESRD) compared with no ACEI or ARB treatment; 3) early irbesartan therapy (at the microalbuminuria stage) to prevent ESRD compared with later treatment (at the macroalbuminuria stage); 4) comprehensive foot care to prevent ulcers compared with usual care; 5) multi-component interventions for diabetic risk factor control and early detection of complications compared with conventional insulin therapy for persons with type 1 diabetes; and 6) multi-component interventions for diabetic risk factor control and early detection of complications compared with standard glycemic control for persons with type 2 diabetes. (II) Very cost-effective- 1) intensive lifestyle interventions to prevent type 2 diabetes among persons with impaired glucose tolerance compared with standard lifestyle recommendations; 2) universal opportunistic screening for undiagnosed type 2 diabetes in African Americans between 45 and 54 years old; 3) intensive glycemic control as implemented in the UK Prospective Diabetes Study in persons with newly diagnosed type 2 diabetes compared with conventional glycemic control; 4) statin therapy for secondary prevention of cardiovascular disease compared with no statin therapy; 5) counseling and treatment for smoking cessation compared with no counseling and treatment; 6) annual screening for diabetic retinopathy and ensuing treatment in persons with type 1 diabetes compared with no screening; 7) annual screening for diabetic retinopathy and ensuing treatment in persons with type 2 diabetes compared with no screening; and 8) immediate vitrectomy to treat diabetic retinopathy compared with deferred vitrectomy. CONCLUSIONS: Many interventions intended to prevent/control diabetes are cost saving or very cost-effective and supported by strong evidence. Policy makers should consider giving these interventions a higher priority.

Surveillance of certain health behaviors and conditions among states and selected local areas - Behavioral Risk Factor Surveillance System, United States, 2007.

PROBLEM: Chronic diseases (e.g., heart disease, cancer, stroke, and diabetes) are the leading causes of death in the United States. Controlling health risk behaviors (e.g., smoking, physical inactivity, poor diet, and excessive drinking) and using preventive health-care services (e.g., cancer, hypertension, and cholesterol screenings) can reduce morbidity and mortality from chronic diseases. Monitoring health-risk behaviors, chronic health conditions, and preventive care practices is essential to develop health promotion activities, intervention programs, and health policies at the state, city, and county levels. REPORTING PERIOD COVERED: January 2007-December 2007. DESCRIPTION OF THE SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based, on-going, random--digit-dialed household telephone survey of noninstitutionalized adults aged >or=18 years residing in the United States. BRFSS collects data on health-risk behaviors and use of preventative health services related to the leading causes of death and disability in the United States. This report presents results for 2007 for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Virgin Islands, 184 metropolitan and micropolitan statistical areas (MMSAs), and 298 counties. RESULTS: In 2007, prevalence estimates of risk behaviors, chronic conditions, and the use of preventive services varied substantially by state and territory, MMSA, and county. The following is a summary of results listed by BRFSS question topic. Each set of proportions refers to the range of estimated prevalence for the disease, condition, or behavior, as reported by the survey subject. Adults who reported fair or poor health: 11% to 32% for states and territories and 6% to 31% for MMSAs and counties. Adults with health-care coverage: 71% to 94% for states and territories and 51% to 97% for MMSAs and counties. Annual influenza vaccination among adults aged >or=65 years: 32% to 80% for states and territories, 48% to 83% for MMSAs, and 44% to 88% for counties. Pneumococcal vaccination among adults aged >/=65 years: 26% to 74% for states and territories, 44% to 83% for MMSAs, and 39% to 87% for counties. Adults who had their cholesterol checked within the preceding 5 years: 66% to 85% for states and territories and 58% to 90% for MMSAs and counties. Adults who consumed at least 5 servings of fruits and vegetables per day: 14% to 33% for states and territories, 16% to 34% for MMSAs and 14% to 37% for counties. Adults who reported no leisure-time physical activity: 17% to 44% for states and territories and 9% to 38% for MMSAs and counties. Adults who engaged in moderate or vigorous physical activity: 31% to 61% for states and territories and 36% to 67% for MMSAs and counties. Adults who engaged in only vigorous physical activity: 19% to 40% for states and territories and 15% to 45% for MMSAs and counties. Cigarette smoking among adults: 9% to 31% for states and territories, 7% to 34% for MMSAs, and 7% to 30% for counties. Binge drinking among adults: 3% to 8% for states and territories. Adults classified as overweight: 33% to 40% for states and territories and 26% to 47% for MMSAs and counties. Adults aged >or=20 years who were obese: 20% to 34% for states and territories and 14% to 38% for MMSAs and counties. Adults who were told of a diabetes diagnosis: 5% to 13% for states and territories and 2% to 17% for MMSAs and counties. Adults with high blood pressure diagnosis: 21% to 35% for states and territories and 16% to 38% for MMSAs and counties. Adults who had high blood cholesterol: 28% to 43% for states and territories, 29% to 49% for MMSAs, and 26% to 51% for counties. Adults with a history of coronary heart disease: 2% to 14% for states and territories, MMSAs, and counties. Adults who were told of a stroke diagnosis: 1% to 7% for states and territories, MMSAs, and counties. Adults who were diagnosed with arthritis: 14% to 36% for states and territories and 16% to 40% for MMSAs and counties. Adults who had asthma: 5% to 10% for states and territories and 3% to 13% for MMSAs and counties. Adults with activity limitation associated with physical, mental, or emotional problems: 10% to 26% for states and territories. Adults who required special equipment because of health problems: 3% to 10% for states and territories and 3% to 14% for MMSAs and counties. INTERPRETATION: The findings in this report indicate substantial variation in self-reported health status, health-care coverage, use of preventive health-care services, health behaviors leading to chronic health conditions, and disability among U.S. adults at the state and territory, MMSA, and county levels. The findings underscore the continued need for surveillance of health-risk behaviors, chronic diseases and conditions, and the use of preventive services. PUBLIC HEALTH ACTIONS: Healthy People 2010 (HP 2010) objectives have been established to monitor health behaviors and the use of preventive health services. Local and state health departments and federal agencies use BRFSS data to identify populations at high risk for certain health behaviors, chronic diseases and conditions and to evaluate the use of preventive services. In addition, BRFSS data are used to direct, implement, monitor, and evaluate public health programs and policies that can lead to a reduction in morbidity and mortality.

Effectiveness of interventions to promote screening for diabetic retinopathy.

OBJECTIVE: To assess the effectiveness of interventions aimed to increase retinal screening among people with diabetes. METHODS: A systematic literature search was conducted of multiple electronic bibliographic databases up to May 2005. Studies were included if interventions were used to promote screening for diabetic retinopathy in any language and with any study design. RESULTS: Forty-eight studies (12 randomized controlled trials [RCTs], four nonrandomized studies, and 32 pre-post studies) with a total of 162,157 participants, examined a wide range of interventions, which focused on one or more of the following: (1) patients or populations, (2) providers or practices, and (3) healthcare system infrastructure and processes. Four of five RCTs focusing on patients demonstrated that interventions increased screening significantly, with relative risk ranging from 1.05 (95% confidence interval [CI]=1.01-1.08) to 2.01 (95% CI=1.48-2.73). Five RCTs with a focus on the system all demonstrated significant increases in screening with relative risk ranging from 1.12 (95% CI=1.03-1.22) to 5.56 (95% CI=2.19-14.10). Thirty-six non-RCTs, which included interventions with single or multiple foci, also generally demonstrated positive effects. CONCLUSIONS: Increasing patient awareness of diabetic retinopathy, improving provider and practice performance, and improving healthcare system infrastructure and processes, can significantly increase screening for diabetic retinopathy. Further research should explore strategies for increasing the rate of retinal screening among diverse or disadvantaged populations and the economic efficiency of effective interventions in large community populations.

The effects of interventions on health-related quality of life among persons with diabetes: a systematic review.

BACKGROUND: Health-related quality of life (HRQL) is increasingly used to measure the outcomes of interventions among people with chronic diseases. OBJECTIVES: To assess the effect of interventions for adults with diabetes on HRQL, as measured by the Short Form (SF)-36 questionnaire. RESEARCH DESIGN: The systematic review was conducted using the methods of the Cochrane Collaboration. Studies reporting SF-36 scores before and after an intervention focused on adults with diabetes were obtained from searches of multiple bibliographic databases. The mean changes and standardized mean differences between pre- and post-intervention were reported as outcome measures. Pooled estimates were obtained using random effects models. RESULTS: : We identified 33 studies examining a wide range of interventions, including diabetes education and behavioral modifications (15 studies), pharmacotherapy (11 studies), and surgery (7 studies). Interventions generally demonstrated improvement in HRQL. When all available profile scores were examined together, the ranges of mean changes in scores were as follows: surgery for treating diabetes comorbidities, 15.0 to 42.0 point improvement; surgery for treating diabetes complications, -13.0 to 37.9; pharmacotherapy using insulin to optimize glycemic control, -4.6 to 27.6; pharmacotherapy for treating comorbidities, 3.8 to 33.2; pharmacotherapy for treating complications, -2.6 to 14.6. Pooled effects from 5 randomized controlled trials of educational interventions demonstrated significantly improved physical function [3.4 (95% CI, 0.1-6.6)] and mental health [4.2 (95% CI, 1.8-6.6)], and a decrease in bodily pain [3.6 (95% CI, 0.6-6.7)]. CONCLUSIONS: A variety of interventions can improve HRQL among adults with diabetes, but the magnitude of effects varied with the interventions. The mechanism of these changes needs to be further examined in the future research.

Effectiveness of community health workers in the care of people with hypertension.

BACKGROUND: The contributions of community health workers (CHWs) in the delivery of culturally relevant programs for hypertension control have been studied since the 1970s. This systematic review examines the effectiveness of CHWs in supporting the care of people with hypertension. METHODS: Computerized searches were conducted of multiple bibliographic electronic databases from their inception until May 2006. No restrictions were applied for language or study design, and studies were restricted to those that reported at least one outcome among participants. RESULTS: Fourteen studies were identified, including eight randomized controlled trials (RCTs). Many of the studies focused on poor, urban African Americans. Significant improvements in controlling blood pressure were reported in seven of the eight RCTs. Several studies reported significant improvements in participants' self-management behaviors, including appointment keeping and adherence to antihypertensive medications. Four studies reported positive changes in healthcare utilization and in systems outcomes. Two of the RCTs showed significant improvements in other patient outcomes, such as changes in heart mass and risk of CVD. CONCLUSIONS: Community health workers may have an important impact on the self-management of hypertension. Programs involving CHWs as multidisciplinary team members hold promise, particularly for diverse racial/ethnic populations that are under-served.