Interventions to address global inequity in diabetes: international progress.

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.

A preoperative supervised exercise program potentially improves long-term survival after elective abdominal aortic aneurysm repair.

OBJECTIVE: A preoperative supervised exercise program (SEP) improves cardiorespiratory fitness and perioperative outcomes for patients undergoing elective abdominal aortic aneurysm (AAA) repair. The aim of this study was to assess the effect of a preoperative SEP on long-term survival of these patients. A secondary aim was to consider long-term changes in cardiorespiratory fitness and quality of life. METHODS: Patients scheduled for open or endovascular AAA repair were previously randomized to either a 6-week preoperative SEP or standard management, and a significant improvement in a composite outcome of cardiac, pulmonary, and renal complications was seen following SEP. For the current analysis, patients were followed up to 5 years post-surgery. The primary outcome for this analysis was all-cause mortality. Data were analyzed on an intention to treat (ITT) and per protocol (PP) basis, with the latter meaning that patients randomized to SEP who did not attend any sessions were excluded. The PP analysis was further interrogated using a complier average causal effect (CACE) analysis on an all or nothing scale, which adjusts for compliance. Additionally, patients who agreed to follow-up attended the research center for cardiopulmonary exercise testing and/or provided quality of life measures. RESULTS: ITT analysis demonstrated that the primary endpoint occurred in 24 of the 124 participants at 5 years, with eight in the SEP group and 16 in the control group (P = .08). The PP analysis demonstrated a significant survival benefit associated with SEP attendance (4 vs 16 deaths; P = .01). CACE analysis confirmed a significant intervention effect (hazard ratio, 0.36; 95% confidence interval, 0.16-0.90; P = .02). There was no difference between groups for cardiorespiratory fitness measures and most quality of life measures. CONCLUSIONS: These novel findings suggest a long-term mortality benefit for patients attending a SEP prior to elective AAA repair. The underlying mechanism remains unknown, and this merits further investigation.

High INtensity Interval Training in pATiEnts with Intermittent Claudication: A Qualitative Acceptability Study.

BACKGROUND: A novel high-intensity interval training (HIIT) program has demonstrated feasibility for patients with intermittent claudication (IC). The aim of this study was to explore patient perspectives of the HIIT program to inform refinement and future research. METHODS: All patients screened and eligible for the 'high intensity interval training in patients with intermittent claudication (INITIATE)' study were eligible to take part in a semistructured interview. A convenience subsample of patients was selected from 3 distinct groups: 1) those who completed the HIIT program, 2) those who prematurely discontinued the HIIT program, and 3) those who declined the HIIT program. Interviews considered patients views of the program and experiences of undertaking and/or being invited to undertake it. Interviews were audio recorded, transcribed verbatim, and analyzed via thematic analysis. RESULTS: Eleven out of 31 participants who completed the program and 12 out of 38 decliners were interviewed. No participants who withdrew from the program agreed to interview. The 3 key themes were; personal reflections of the program; program facilitators and barriers; and perceived benefits. Completers enjoyed taking part, reported symptomatic improvement and would complete it again. Practical and psychological barriers exist, such as transport and motivation. Changes to the program were suggested. CONCLUSIONS: Findings support the acceptability of this novel HIIT program, which in combination with the feasibility findings, suggest that a fully powered randomized controlled trial, comparing HIIT to usual-care supervised exercise programs is warranted.

High-intensity interval training in patients with intermittent claudication.

OBJECTIVE: Provision, uptake, adherence, and completion rates for supervised exercise programs (SEP) for intermittent claudication (IC) are low. A shorter, more time-efficient, 6-week, high-intensity interval training (HIIT) program may be an effective alternative that is more acceptable to patients and easier to deliver. The aim of this study was to determine the feasibility of HIIT for patients with IC. METHODS: A single arm proof-of-concept study, performed in secondary care, recruiting patients with IC referred to usual-care SEPs. Supervised HIIT was performed three times per week for 6 weeks. The primary outcome was feasibility and tolerability. Potential efficacy and potential safety were considered, and an integrated qualitative study was undertaken to consider acceptability. RESULTS: A total of 280 patients were screened: 165 (59%) were eligible, and 40 (25%) were recruited. The majority (n = 31; 78%) of participants completed the HIIT program. The remaining nine patients were withdrawn or chose to withdraw. Completers attended 99% of training sessions, completed 85% of sessions in full, and performed 84% of completed intervals at the required intensity. There were no related serious adverse events. Maximum walking distance (+94 m; 95% confidence interval, 66.6-120.8 m) and the SF-36 physical component summary (+2.2; 95% confidence interval, 0.3-4.1) were improved following completion of the program. CONCLUSIONS: Uptake to HIIT was comparable to SEPs in patients with IC, but completion rates were higher. HIIT appears feasible, tolerable, and potentially safe and beneficial for patients with IC. It may provide a more readily deliverable, acceptable form of SEP. Research comparing HIIT with usual-care SEPs appears warranted.

Digital Health and Community Health Worker Support for Diabetes Management: a Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of a digital health intervention plus community health worker (CHW) support on self-monitoring of blood glucose and glycosylated hemoglobin (HbA1c) among adult Medicaid beneficiaries with diabetes. DESIGN: Randomized controlled trial. SETTING: Urban outpatient clinic. PARTICIPANTS: Adult Medicaid beneficiaries living with diabetes and treated with insulin and who had a HbA1c ≥ 9%. INTERVENTION: Participants were randomly assigned to one of three arms. Participants in the usual-care arm received a wireless glucometer if needed. Those in the digital arm received a lottery incentive for daily glucose monitoring. Those in the hybrid arm received the lottery plus support from a CHW if they had low adherence or high blood glucose levels. MAIN MEASURES: The primary outcome was the difference in adherence to daily glucose self-monitoring at 3 months between the hybrid and usual-care arms. The secondary outcome was difference in HbA1c from baseline at 6 months. KEY RESULTS: A total of 150 participants were enrolled in the study. A total of 102 participants (68%) completed the study. At 3 months, glucose self-monitoring rates in the hybrid versus usual-care arms were 0.72 vs 0.65, p = 0.23. At 6 months, change in HbA1c in the hybrid versus usual-care arms was - 0.74% vs - 0.49%, p = 0.69. CONCLUSION: There were no statistically significant differences between the hybrid and usual care in glucose self-monitoring adherence or improvements in HbA1C. TRIAL REGISTRATION: This trial is registered with clinicaltrials.gov identifier: NCT03939793.

Pediatric Hospitalizations from Immigration Detention in Texas, 2015-2018.

Although there are concerns regarding children's health in immigration detention, there are little data regarding hospitalizations in this population. Using 2015-2018 Texas inpatient data, we identified 95 hospitalizations of children in detention and found that most (60%) were driven by infectious causes, and that 37% of these children were admitted to an intensive care unit (ICU) or intermediate ICU.

The Gears of Knowledge Translation: Process Evaluation of the Dissemination and Implementation of a Patient Engagement Toolkit.

BACKGROUND: Patient engagement is a key tenet of patient-centered care and is associated with many positive health outcomes. To improve resources for patient engagement, we created a web-based, interactive patient engagement toolkit to improve patient engagement in primary care across the Veterans Health Administration (VHA). OBJECTIVE: To use the knowledge translation (KT) framework to evaluate the dissemination and implementation of a patient engagement toolkit at facilities across one region in the VHA. DESIGN: Using a mixed-methods approach, this process evaluation involved phone monitoring via semi-structured interviews and group meetings, during which we explored barriers and facilitators to KT. Outcomes were assessed using a structured rubric and existing patient satisfaction measures. PARTICIPANTS: We enlisted implementers at 40 VHA facilities primarily serving Pennsylvania, New Jersey, and Delaware to implement patient engagement practices at their sites. Sites were randomly assigned into a high or low coaching group to assess whether external support influenced implementation. KEY RESULTS: Sites with high rubric scores employed and possessed several elements across the KT trajectory from identification of the problem to sustainment of knowledge use. Key factors for successful implementation and dissemination included implementer engagement, organizational support, and strong collaborators. The most frequently cited barriers included short staffing, time availability, lack of buy-in, and issues with leadership. Successful implementers experienced just as many barriers, but leveraged facilitators to overcome obstacles. While sites that received more coaching did not have different outcomes, they were more likely to revisit the toolkit and indicated that they felt more accountable to local personnel. CONCLUSIONS: Because leveraging available resources is a key component of successful implementation, future toolkits should highlight the type of facilitators necessary for successful implementation of toolkit content in healthcare settings. The ability to tailor interventions to local context is critical for overcoming barriers faced in most healthcare settings.

Impact of a Multidisciplinary, Endocrinologist-Led Shared Medical Appointment Model on Diabetes-Related Outcomes in an Underserved Population.

A multidisciplinary endocrinologist-led shared medical appointment (SMA) model showed statistically significant reductions in A1C from baseline over 3 years that were not significantly different from appointments with endocrinologists or primary care providers alone within a resource-poor population. Similarly, the SMA model achieved clinical outcomes on par with endocrinologist-only visits with the added benefit of improving endocrine provider productivity and specialty access for patients. Greater patient engagement with the SMA model was associated with significantly lower A1C.

Exploring feedback from research nurses in relation to the design and conduct of a randomised controlled trial of wound care treatments: A sequential, dependent, mixed-methods study.

BACKGROUND: Research nurse involvement in trials is crucial to successful conduct, however their feedback on trial design and conduct is not necessarily always collected and shared. This study was designed to explore research nurse feedback in relation to study and protocol design and implementation in the National Institute for Health Research Programme Grants for Applied Research funded Surgical Wounds Healing by Secondary Intention pilot and feasibility trial (SWHSI). The primary aim of this study was to inform the design and conduct of a proposed future, larger study in this area. Given the evidence gap, it was deemed prudent to share these findings for the benefit of others. METHODS: A sequential, dependent mixed methods study, comprising a Likert scale questionnaire and semi-structured interviews, explored the experiences, in relation to study design and conduct, of research nurses involved in the trial. Of the 10 research nurses involved in the trial, eight nurses completed a questionnaire and were interviewed. Questionnaire data was analysed using descriptive statistics and interview data using thematic analysis. RESULTS: A range of questionnaire responses were provided, however at least 50% (n = 4) of respondents indicated that they were happy with both the study design and conduct. Interview data identified key themes to consider when involving research nurses in the design, delivery and conduct of RCTs; removing barriers to recruitment, time management, engagement strategies and resource provision. CONCLUSION: Engagement of research nurses is important to enable effective trial conduct. Research teams should therefore consider how best to obtain and include input from all members of the research team from the outset. Furthermore, the sharing of feedback on research design and conduct, from the perspective of research nurses delivering trial recruitment and retention, remains crucial to effective and efficient trial conduct. TRIAL REGISTRATION: Clinical Trial Registry: ISRCTN12761776. Date of registration: 10th December 2015.

Why Effective Interventions Do Not Work for All Patients: Exploring Variation in Response to a Chronic Disease Management Intervention.

BACKGROUND: Half of all Americans have a chronic disease. Promoting healthy behaviors to decrease this burden is a national priority. A number of behavioral interventions have proven efficacy; yet even the most effective of these has high levels of nonresponse. OBJECTIVES: In this study, we explore variation in response to an evidence-based community health worker (CHW) intervention for chronic disease management. RESEARCH DESIGN: We used a convergent parallel design that combined a randomized controlled trial with a qualitative process evaluation that triangulated chart abstraction, in-depth interviews and participant observation. SUBJECTS: Eligible patients lived in a high-poverty region and were diagnosed with 2 or more of the following chronic diseases: diabetes, obesity, hypertension or tobacco dependence. There were 302 patients in the trial, 150 of whom were randomly assigned to the CHW intervention. Twenty patients and their CHWs were included in the qualitative evaluation. RESULTS: We found minimal differences between responders and nonresponders by sociodemographic or clinical characteristics. A qualitative process evaluation revealed that health behavior change was challenging for all patients and most experienced failure (ie, gaining weight or relapsing with cigarettes) along the way. Responders seemed to increase their resolve after failed attempts at health behavior change, while nonresponders became discouraged and "shut down." CONCLUSIONS: Failure is a common and consequential aspect of health behavior change; a deeper understanding of failure should inform chronic disease interventions.

Improving Patient-centered Care: How Clinical Staff Overcome Barriers to Patient Engagement at the VHA.

BACKGROUND: While patient engagement can be beneficial for patient care, there are barriers to engaging patients. These barriers exist for health care organizations, for health care personnel, and for the patients themselves. Solutions to barriers are not well documented. OBJECTIVES: Our objective was to explore barriers to patient engagement efforts and their corresponding solutions. RESEARCH DESIGN: Qualitative interviews and site visits from a national sample of primary care facilities within the Veterans Health Administration were analyzed to understand patient engagement barriers and solutions. SAMPLING: We conducted a total of 155 phone and in-person semistructured interviews with primary care providers, mental health staff, social workers, pharmacists, patient advocates, health behavior coaches, and administrative staff at 27 Veterans Health Administration sites. Participants were asked to describe the obstacles they had to overcome in their efforts to improve patient engagement at their site. RESULTS: Barriers to patient engagement are overcome by strategically updating data analytics; enhancing organization-wide processes and procedures; being creative with space design, staff hiring, and time commitments; cultivating staff collaborations; and addressing patient care issues such as access, customer service, and patient education. A key component of successful implementation is to create a culture, supported by leadership that promotes patient engagement. CONCLUSIONS: Participants understood the patient centered approach, despite experiencing a lack of resources and training and could push through solutions to patient engagement barriers while working within the limits of their settings.

Physician Experiences With High Value Care in Internal Medicine Residency: Mixed-Methods Study of 2003-2013 Residency Graduates.

Phenomenon: High healthcare costs and relatively poor health outcomes in the United States have led to calls to improve the teaching of high value care (defined as care that balances potential benefits of interventions with their harms including costs) to physicians-in-training. Numerous interventions to increase high value care in graduate medical education were implemented at the national and local levels over the past decade. However, there has been little evaluation of their impact on physician experiences during training and perceived preparedness for practice. We aimed to assess trends in U.S. physician experiences with high value care during residency over the past decade. APPROACH: This mixed-methods study used a cross-sectional survey mailed July 2014 to January 2015 to 902 internists who completed residency in 2003-2013, randomly selected from the American Medical Association Masterfile. Quantitative analyses of survey responses and content analysis of free-text comments submitted by respondents were performed. FINDINGS: A total of 456 physicians (50.6%) responded. Fewer than one fourth reported being exposed to teaching about high value care at least frequently (23.6%, 106/450). Only 43.8% of respondents (193/446) felt prepared to use overtreatment guidelines in conversations with patients, whereas 85.8% (379/447) felt prepared to participate in shared decision making with patients at the conclusion of their training, and 84.4% (380/450) reported practicing generic prescribing. Physicians who completed residency more recently were more likely to report practicing generic prescribing and feeling well prepared to use overtreatment guidelines in conversations with patients (p < .01 for both). Insights: In a national survey, recent U.S. internal medicine residency graduates were more likely to experience high value care during training, which may reflect increased national and local efforts in this area. However, being exposed to high value care as a trainee may not translate into specific tools for practice. In fact, many U.S. internists reported inadequate exposure to prepare them for patient discussions about costs and the use of overtreatment guidelines in practice.

Creating a Toolkit to Reduce Disparities in Patient Engagement.

BACKGROUND: Patient engagement has become a major focus of health care improvement efforts nationally. Although evidence suggests patient engagement can be beneficial to patients, it has not been consistently defined, operationalized, or translated into practice. OBJECTIVES: Our objective was to develop a toolkit to help providers increase patient engagement and reduce disparities in patient engagement. RESEARCH DESIGN: We used qualitative interviews and observations with staff at primary care sites nationally to identify patient engagement practices and resources used to engage patients. We then used a modified Delphi process, that included a series of conference calls and surveys, where stakeholders reduced lists of engagement practices based on perceived feasibility and importance to develop a toolkit for patient engagement. SAMPLING: Sites were selected for interviews and site visits based on the concentration of minority patients served and performance on a measure of patient engagement, with the goal of highlighting practices at sites that successfully serve minority patients. RESULTS: We created a toolkit consisting of patient engagement practices and resources. No identified practice or resource specifically targeted patient engagement of minorities or addressed disparities. However, high-performing, high-minority-serving sites tended to describe more staff training opportunities and staff feedback mechanisms. In addition, low-performing and high-minority-serving sites more often reported barriers to implementation of patient engagement practices. CONCLUSIONS: Stakeholders agreed on feasible and important engagement practices. Implementation of this toolkit will be tracked to better understand patient engagement and its effect on patient-centered care and related disparities in care.

African American Veterans Storytelling: A Multisite Randomized Trial to Improve Hypertension.

BACKGROUND: Disparities in hypertension control persist for African American Veterans. OBJECTIVE: To enhance cultural relevance of hypertension control self-management education, in a multisite, stratified randomized trial, we tested an interactive Veteran-to-Veteran storytelling digital video disk (DVD) intervention created with Veteran partners, versus an education-only DVD comparison. METHODS: At 3 VA facilities, African American Veterans with uncontrolled hypertension were randomized to storytelling DVD intervention or didactic comparison DVD and followed for 6 months. We hypothesized that follow-up blood pressure (BP) would be lower among Veterans in the intervention group. RESULTS: African American Veterans (N=619) were 92% male, 39% over age 65, most had a high-school education, over 50% of both the intervention and comparison group reported a household income of <$20,000, and 40% had less than adequate health literacy. At baseline, mean intervention and comparison group BPs were 138/80 and 139/81 mm Hg, respectively; at 6 months, mean systolic BP (SBP) increased by 0.1 in the intervention group and by 1.9 for the comparison group; diastolic BP fell by 0.1 in the intervention group and rose by 0.2 in the comparison group. No differences between the intervention and control groups were statistically significant (all P>0.3). Site differences were large; at one, the intervention group improved while the comparison groups deteriorated, resulting in 6.3 and 3.9 mm Hg more improvement for the intervention group in SBP and diastolic BP (P=0.06 and 0.04), respectively; at the other 2 sites, there were positive and negative changes, all small, in the 2 measures, with minimal differences-one site favored the comparison group and the other, the intervention (these comparisons did not approach statistical significance (all P>0.20). In a secondary analysis stratified by baseline BP, there was no intervention effect among those with uncontrolled BP, but intervention patients who were in control at baseline were more likely to stay in control, compared with comparison [SBP increase by 6.3 mm Hg (SD=14.4) among intervention, and by 10.9 mm Hg (SD=16.9) in comparison, P=0.02]. CONCLUSIONS: In this multisite trial, we did not find a significant overall storytelling intervention effect (Clinicaltrials.gov Reg. #NCT01276197).

Patient and Partner Feedback Reports to Improve Statin Medication Adherence: A Randomized Control Trial.

BACKGROUND: Simple nudges such as reminders and feedback reports to either a patient or a partner may facilitate improved medication adherence. OBJECTIVE: To test the impact of a pill bottle used to monitor adherence, deliver a daily alarm, and generate weekly medication adherence feedback reports on statin adherence. DESIGN: Three-month, three-arm randomized clinical trial (ClinicalTrials.gov identifier: NCT02480530). PARTICIPANTS: One hundred and twenty-six veterans with known coronary artery disease and poor adherence (medication possession ratio <80 %). INTERVENTION: Patients were randomized to one of three groups: (1) a control group (n = 36) that received a pill-monitoring device with no alarms or feedback; (2) an individual feedback group (n = 36) that received a daily alarm and a weekly medication adherence feedback report; and (3) a partner feedback group (n = 54) that received an alarm and a weekly feedback report that was shared with a friend, family member, or a peer. The intervention continued for 3 months, and participants were followed for an additional 3 months after the intervention period. MAIN MEASURES: Adherence as measured by pill bottle. Secondary outcomes included change in LDL (mg/dl), patient activation, and social support. KEY RESULTS: During the 3-month intervention period, medication adherence was higher in both feedback arms than in the control arm (individual feedback group 89 %, partner feedback group 86 %, control group 67 %; p < 0.001 and = 0.001). At 6 months, there was no difference in medication adherence between either of the feedback groups and the control (individual feedback 60 %, partner feedback 52 %, control group 54 %; p = 0.75 and 0.97). CONCLUSIONS: Daily alarms combined with individual or partner feedback reports improved statin medication adherence. While neither an individual feedback nor partner feedback strategy created a sustainable medication adherence habit, the intervention itself is relatively easy to implement and low cost.

Community Health Worker Support for Disadvantaged Patients With Multiple Chronic Diseases: A Randomized Clinical Trial.

OBJECTIVES: To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions. METHODS: We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013-2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences. RESULTS: Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: -0.4 vs 0.0; body mass index: -0.3 vs -0.1; cigarettes per day: -5.5 vs -1.3; systolic blood pressure: -1.8 vs -11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs -0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 28% (P = .11). There were no differences in patient activation or self-rated physical health. CONCLUSIONS: A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for health care systems. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01900470.

Penn Center for Community Health Workers: Step-by-Step Approach to Sustain an Evidence-Based Community Health Worker Intervention at an Academic Medical Center.

Community-engaged researchers who work with low-income communities can be reliant on grant funding. We use the illustrative case of the Penn Center for Community Health Workers (PCCHW) to describe a step-by-step framework for achieving financial sustainability for community-engaged research interventions. PCCHW began as a small grant-funded research project but followed an 8-step framework to engage both low-income patients and funders, determine outcomes, and calculate return on investment. PCCHW is now fully funded by Penn Medicine and delivers the Individualized Management for Patient-Centered Targets (IMPaCT) community health worker intervention to 2000 patients annually.

Food insecurity, coping strategies and glucose control in low-income patients with diabetes.

OBJECTIVE: To examine the relationship between food insecurity and coping strategies (actions taken to manage economic stress) hypothesized to worsen glucose control in patients with diabetes. DESIGN: Using a cross-sectional telephone survey and clinical data, we compared food-insecure and food-secure individuals in their use of coping strategies. Using logistic regression models, we then examined the association between poor glucose control (glycated Hb, HbA1c≥8·0 %), food insecurity and coping strategies. SETTING: An urban medical centre, between June and December 2013. SUBJECTS: Four hundred and seven adults likely to be low income (receiving Medicaid or uninsured and/or residing in a zip code with >30 % of the population below the federal poverty level) with type 2 diabetes. RESULTS: Of respondents, 40·5 % were food insecure. A significantly higher percentage of the food-insecure group reported use of most examined coping strategies, including foregone medical care, participation in the Supplemental Nutrition Assistance Program (SNAP)) and use of emergency food programmes. Food insecurity was associated with poor glucose control (OR=2·23; 95 % CI 1·22, 4·10); coping strategies that were more common among the food insecure were not associated with poor glucose control. Among the food insecure, receipt of SNAP was associated with lower risk of poor glucose control (OR=0·27; 95 % CI 0·09, 0·80). CONCLUSIONS: While food insecurity was associated with poor glucose control, most examined coping strategies did not explain this relationship. However, receipt of SNAP among food-insecure individuals was associated with better diabetes control, suggesting that such programmes may play a role in improving health.

A Brief, Multifaceted, Generic Intervention to Improve Blood Pressure Control and Reduce Disparities Had Little Effect.

BACKGROUND: Poor blood pressure (BP) control and racial disparities therein may be a function of clinical inertia and ineffective communication about BP care. METHODS: We compared two different interventions (electronic medical record reminder for BP care (Reminder only, [RO]), and clinician training on BP care-related communication skills plus the reminder (Reminder + Training, [R+T]) with usual care in three primary care clinics, examining BP outcomes among 8,866 patients, and provider-patient communication and medication adherence among a subsample of 793. RESULTS: Clinician counseling improved most at R+T. BP improved overall; R+T had a small but significantly greater reduction in diastolic BP (DBP; -1.7 mm Hg). White patients at RO experienced greater overall improvements in BP control. Site and race disparities trends suggested that disparities decreased at R+T, either stayed the same or decreased at Control; and stayed the same or increased at RO. CONCLUSIONS: More substantial or racial/ethnically tailored interventions are needed.

Determining Chronic Disease Prevalence in Local Populations Using Emergency Department Surveillance.

OBJECTIVES: We sought to improve public health surveillance by using a geographic analysis of emergency department (ED) visits to determine local chronic disease prevalence. METHODS: Using an all-payer administrative database, we determined the proportion of unique ED patients with diabetes, hypertension, or asthma. We compared these rates to those determined by the New York City Community Health Survey. For diabetes prevalence, we also analyzed the fidelity of longitudinal estimates using logistic regression and determined disease burden within census tracts using geocoded addresses. RESULTS: We identified 4.4 million unique New York City adults visiting an ED between 2009 and 2012. When we compared our emergency sample to survey data, rates of neighborhood diabetes, hypertension, and asthma prevalence were similar (correlation coefficient = 0.86, 0.88, and 0.77, respectively). In addition, our method demonstrated less year-to-year scatter and identified significant variation of disease burden within neighborhoods among census tracts. CONCLUSIONS: Our method for determining chronic disease prevalence correlates with a validated health survey and may have higher reliability over time and greater granularity at a local level. Our findings can improve public health surveillance by identifying local variation of disease prevalence.