BACKGROUND: Gender differences in health system usage can lead to differences in the incidence of morbidity and mortality. We conducted a pilot screening targeted towards men to evaluate gender differences in cardiovascular disease risk factor detection and time since last clinic visit.

METHODS: Three evening sessions in two communities screened 148 people, mean age 47.7 years. Height, weight, body mass index, blood pressure, blood glucose, and total cholesterol were measured. A questionnaire on past medical history was administered. Participants with elevated measurements were referred to appropriate care.

RESULTS: Men accounted for 60.1% of those screened; 65.5% of the group was overweight, and 22.3% was obese with 42.6% hypertension, 39.2% hypercholesterolemia, and 2.7% high blood glucose. Among men aged 35 to 65, 65.2% were overweight, 20.3% obese, 46.4% hypertensive, 42.0% hypercholesterolemic, and 1.5% with high blood glucose. Within the last 2 years, 53.3% of men and 9.1% of women aged 35 to 65 had not visited a doctor (P = 0.004).

CONCLUSIONS: A significant portion of those screened had elevated cardiovascular disease risk factors. Given that men visited doctors significantly less frequently, efforts to involve men in prevention of cardiovascular disease within these communities are warranted.

Quality assurance (QA) processes for new technologies are used to ensure safety. Clinical decision support systems (DSS), identified by the Institute of Medicine (IOM) as an important tool in preventing patient errors, should undergo similar predeployment testing to prevent introduction of new errors. Post-fielding surveillance, akin to post-marketing surveillance for adverse events, may detect rarely occurring problems that appear only in widespread use. To assess the quality of a guideline-based DSS for hypertension, ATHENA DSS, researchers monitored real-time clinician feedback during point-of-care use of the system. Comments (n = 835) were submitted by 44 of the 91 (48.4 percent) study clinicians (median 8.5 comments/ clinician). Twenty-three (2.8 percent) comments identified important, rarely occurring problems. Timely analysis of such feedback revealed omissions of medications, diagnoses, and adverse drug reactions due to rare events in data extraction and conversion from the electronic health record. Analysis of clinician-user feedback facilitated rapid detection and correction of such errors. Based on this experience, new technologies for improving patient safety should include mechanisms for post-fielding quality assurance testing.

Background:

Among the 60 million Americans with hypertension, only approximately 31% have their blood pressure (BP) under control (140/90 mm Hg). Despite the damaging impact of hypertension and the availability of evidence-based target values for BP, interventions to improve BP control have had limited success.

Objectives:

A randomized controlled health services intervention trial with a split-plot design is being conducted to improve BP control. This 4-year trial evaluates both a patient and a provider intervention in a primary care setting among diagnosed hypertensive veterans.

Methods:

In a cluster-randomization, 30 primary care providers in the Durham VAMC Primary Care Clinic were randomly assigned to receive the provider intervention or control. The provider intervention is a patient-specific electronically generated hypertension decision support system (DSS) delivering guideline-based recommendations to the provider at each patient's visit, designed to improve guideline-concordant therapy. For these providers, a sample of their hypertensive patients (n=588) was randomly assigned to receive a telephone-administered patient intervention or usual care. The patient intervention incorporates patients' need assessments and involves tailored behavioral and education modules to promote medication adherence and improve specific health behaviors. All modules are delivered over the telephone bi-monthly for 24 months. In this trial, the primary outcome is the proportion of patients who achieve a BP or =140/90 mm Hg at each outpatient clinic visit over 24 months.

Conclusion:

Despite the known risk of poor BP control, a majority of adults still do not have their BP controlled. This study is an important step in testing the effectiveness of a patient and provider intervention to improve BP control among veterans in the primary care setting.

Objective:

Hypertension affects more than 50 million people in the United States alone. Despite clear evidence regarding the beneficial effects of quality treatment for high blood pressure, many millions of diagnosed and undiagnosed hypertensives are not receiving the optimal standard of care. The difference in patient outcomes achieved with present hypertension treatment methods and those thought to be possible using best practice treatment methods is known as a quality gap, and such gaps are at least partly responsible for the loss of thousands of lives each year. This review was organized to bring a systematic assessment of different quality improvement (QI) strategies and their effects to the process of identifying and managing hypertension.

Search Strategy and Inclusion Criteria:

Investigators searched the MEDLINE® database, the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) registry, article bibliographies, and relevant journals for experimental evaluations of QI interventions aimed at improving hypertension screening and management of non-pregnant adults with primary hypertension. The reviewers included randomized or quasi-randomized controlled trials, controlled before/after studies, and interrupted time series in which at least one reported outcome measure included changes in blood pressure, or provider or patient adherence to a recommended process of care.

Data Collection and Analysis:

Relevant data were abstracted independently by two reviewers. Each QI intervention was classified into one or more of the following components: provider education, provider reminders, facilitated relay of clinical information, patient education, promotion of self-management, patient reminders, audit and feedback, organizational change, or financial incentives. Certain categories were further subdivided into major subtypes (e.g., professional meetings for provider education and disease management for organizational change). The researchers also evaluated the impact of clinical information systems as a mediator for interventions of all types. They compared the different QI strategies in terms of the median effects achieved for blood pressure control and for a generalized measure of provider or patient adherence.

Main Results:

Sixty-three articles reporting a total of 82 comparisons met the inclusion criteria. Studies of hypertension identification were found to be too heterogeneous for quantitative analysis. The majority of screening studies were clinic-based (with a few offered at work sites), and the most common strategies involved patient and/or provider reminders. These generally showed positive results; several studies found that patients were more likely to know their blood pressure or attend clinic visits after receiving reminders. Across all studies with a variety of strategies, the median reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 4.5 mmHg (interquartile range: 1.5, 11.0) and 2.1 mmHg (interquartile range: -0.2, 5.0), respectively. The median increase in the proportion of patients in the target SBP range and target DBP range was 16.2 percent (interquartile range: 10.3, 32.2), and 6.0 percent (interquartile range: 1.5, 17.5), respectively. Studies that focused on improving provider adherence showed a range of median reduction of 1.3 percent to a median improvement of 3.3 percent across all QI strategies. Overall, patient adherence showed a median improvement of 2.8 percent (interquartile

range: 1.9, 3.0).

Conclusion:

The findings of this review suggest that QI strategies appear, in general, to be associated with the improved identification and control of hypertension.

Measurement of provider adherence to a guideline-based decision support system (DSS) presents a number of important challenges. Establishing a causal relationship between the DSS and change in concordance requires consideration of both the primary intention of the guideline and different ways providers attempt to satisfy the guideline. During our work with a guideline-based decision support system for hypertension, ATHENA DSS, we document a number of subtle deviations from the strict hypertension guideline recommendations that ultimately demonstrate provider adherence. We believe that understanding these complexities is crucial to any valid evaluation of provider adherence. We also describe the development of an advisory evaluation engine that automates the interpretation of clinician adherence with the DSS on multiple levels, facilitating the high volume of complex data analysis that is created in a clinical trial of a guideline-based DSS.

STUDY OBJECTIVES: Patients with pulmonary arterial hypertension (PAH) often present with dyspnea and severe functional limitations, but their health-related quality of life (HRQOL) has not been studied extensively. This study describes HRQOL in a cohort of patients with PAH.

DESIGN: Cross-sectional study.

SETTING: A tertiary care, university hospital-based, pulmonary hypertension (PH) clinic.

PARTICIPANTS: We studied HRQOL in 53 patients with PAH (mean age, 47 years; median duration of disease, 559 days). Eighty-three percent were women, 53% received epoprostenol, and 72% reported moderate-to-severe functional limitations with a New York Heart Association class 3 or 4 at enrollment.

MEASUREMENTS AND RESULTS: We examined HRQOL by administering the Nottingham Health Profile, Congestive Heart Failure Questionnaire, and Hospital Anxiety and Depression Scale. We used the Visual Analog Scale and standard gamble (SG) techniques to measure preferences for current health (utilities). Compared with population norms, participants reported moderate-to-severe impairment in multiple domains of HRQOL, including physical mobility, emotional reaction, pain, energy, sleep, and social isolation. Mean SG utilities were 0.71, suggesting that, on average, participants were willing to accept a 29% risk of death in order to be cured of PH.

CONCLUSIONS: PAH is a devastating condition that affects predominately young women in the prime of their life. Understanding HRQOL and preferences are important in the care and management of these patients. Compared with population norms, patients with PAH have substantial functional and emotional limitations that adversely affect their HRQOL.

STUDY OBJECTIVES: Patients with pulmonary arterial hypertension (PAH) often present with dyspnea and severe functional limitations, but their health-related quality of life (HRQOL) has not been studied extensively. This study describes HRQOL in a cohort of patients with PAH.

DESIGN: Cross-sectional study.

SETTING: A tertiary care, university hospital-based, pulmonary hypertension (PH) clinic.

PARTICIPANTS: We studied HRQOL in 53 patients with PAH (mean age, 47 years; median duration of disease, 559 days). Eighty-three percent were women, 53% received epoprostenol, and 72% reported moderate-to-severe functional limitations with a New York Heart Association class 3 or 4 at enrollment.

MEASUREMENTS AND RESULTS: We examined HRQOL by administering the Nottingham Health Profile, Congestive Heart Failure Questionnaire, and Hospital Anxiety and Depression Scale. We used the Visual Analog Scale and standard gamble (SG) techniques to measure preferences for current health (utilities). Compared with population norms, participants reported moderate-to-severe impairment in multiple domains of HRQOL, including physical mobility, emotional reaction, pain, energy, sleep, and social isolation. Mean SG utilities were 0.71, suggesting that, on average, participants were willing to accept a 29% risk of death in order to be cured of PH.

CONCLUSIONS: PAH is a devastating condition that affects predominately young women in the prime of their life. Understanding HRQOL and preferences are important in the care and management of these patients. Compared with population norms, patients with PAH have substantial functional and emotional limitations that adversely affect their HRQOL.

Purpose:

Little is known about how well clinicians are aware of their own adherence to clinical guidelines, an important indicator of quality. We compared clinicians' beliefs about their adherence to hypertension guidelines with data on their actual performance.

Methods:

We surveyed 139 primary care clinicians at three Veterans Affairs medical centers, asking them to assess their own adherence to hypertension guidelines. We then extracted data from the centers' clinical databases on guideline-concordant medication use and blood pressure control for patients cared for by these providers during a 6-month period. Data were collected for patients with hypertension and diabetes, hypertension and coronary disease, or hypertension with neither of these comorbid conditions.

Results:

Eighty-six clinicians (62%) completed the survey. Each clinician saw a median of 94 patients with hypertension (mean age, 65 years). Patients were treated with an average of 1.6 antihypertensive medications. Overall, clinicians overestimated the proportion of their patients who were prescribed guideline-concordant medications (75% perceived vs. 67% actual, P 0.001) and who had blood pressure levels 140/90 mm Hg on their last visit (68% perceived vs. 43% actual, P 0.001). Among individual clinicians, there were no significant correlations between perceived and actual guideline adherence (r = 0.18 for medications, r = 0.14 for blood pressure control; P 0.10 for both). Clinicians with relatively low actual guideline performance were most likely to overestimate their adherence to medication recommendations and blood pressure targets.

Conclusion:

Clinicians appear to overestimate their adherence to hypertension guidelines, particularly with regards to the proportion of their patients with controlled blood pressure. This limited awareness may represent a barrier to successful implementation of guidelines, and could be addressed through the use of provider profiles and point-of-service feedback to clinicians.

BACKGROUND: Research is limited regarding national patterns of behavioral counseling during ambulatory care. We examined time trends and independent correlates of diet and physical activity counseling for American adults with an elevated cardiovascular risk during their outpatient visits.

METHODS: The National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) provided 1992-2000 national estimates of counseling practices in private physician offices and hospital outpatient departments.

RESULTS: Rates of diet and physical activity counseling among visits by at-risk adults exhibited a modest ascending trend from 1992 to 2000, with the biggest growth found between 1996 and 1997. Throughout the 1990s, however, diet counseling was provided in 45% and physical activity counseling in or = 30% of visits by adults with hyperlipidemia, hypertension, obesity, or diabetes mellitus. Lower likelihood of either counseling was significantly associated with patients who were > or = 75 years of age, seen by generalists, and those with fewer risk factors. Also, diet counseling was less frequently provided during visits by whites vs. ethnic minorities and by men vs. women.

CONCLUSIONS: Despite available national guidelines, diet and physical activity counseling remain below expectations during outpatient visits by adults with an elevated cardiovascular risk. Given recent trends, immediate, satisfactory improvement is unlikely without future innovative interventions.