The Connecticut high blood pressure program: a program of public education and high blood pressure screening

Impact of Socioeconomic Factors and Gender on Refill Adherence and Persistence to Lipid-Lowering Therapy in Type 1 Diabetes

INTRODUCTION

Lipid-lowering therapy (LLT) reduces the risk of cardiovascular disease (CVD) in patients with type 1 diabetes (T1D). However, socioeconomic factors and gender may have an impact on the adherence to and non-persistence with LLT.

METHODS

This was a nationwide register-based cohort study that included 6192 individuals with T1D aged ≥ 18 years who were registered in the Swedish National Diabetes Register and had initiated novel use of LLT. Information on socioeconomic parameters (source: Statistics Sweden) and comorbidity (source: National Patient Register) was collected. The individuals were followed for 36 months, and adherence to LLT was analyzed according to age, socioeconomics and gender. The medication possession ratio (MPR; categorized into ≤ 80% and > 80%) and non-persistence (discontinuation) with medication was calculated after 18 and 36 months.

RESULTS

Individuals older than 53 years were more adherent to LLT (MPR > 80%) than those younger than 36 years (odds ratio [(OR] 1.30, p < 0.0001) at 36 months. Women were more adherent and less prone to discontinue LLT at 18 months (OR 1.05, p = 0.0005 and OR 0.95, p = 0.0004, respectively), but not at 36 months. Divorced individuals were less adherent than married ones (OR 0.93, p = 0.0005) and discontinued LLT more often than the latter (OR 1.06, p = 0.003). Education had no impact on adherence, but individuals with higher incomes discontinued LLT less frequently than those with lower incomes. Individuals with a country of origin other than Sweden discontinued LLT more often.

CONCLUSION

Lower adherence to LLT in individuals with T1D was associated with male gender, younger age, marital status and country of birth. These factors should be considered when evaluating adherence to LLT in clinical practice, with the aim to help patients achieve full cardioprotective treatment.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Salt reduction in a population for the prevention of hypertension

Hypertension is one of the major risk factors for cardiovascular disease, the prevention of which is acknowledged to be critically important. Human beings are the only animal species which consume large quantities of salt, and their consumption has increased with the advancement of civilization. Many observational and interventional epidemiologic studies have demonstrated that a high intake of salt results in elevation of blood pressure, and that a salt-reduced diet induces blood pressure reduction in patients with hypertension as well as in individuals with normal blood pressure. Reduced salt intake, blood pressure reduction, and a remarkable decrease in mortality due to stroke in Japan are important examples of this effect. A decrease in the mean blood pressure in an entire population can contribute significantly to decreased incidence of cardiovascular diseases. A population-based strategy for preventing hypertension, including a salt-reduced diet, is therefore desirable. Proposed measures include public health education by the mass media, reduced salt content in processed foods, salt reduction in foods served by schools or organizations and at restaurants, and labeling of salt content. Further studies are needed of population-wide salt reduction methods, and the effectiveness of such methods.

Linking community-based blood pressure measurement to clinical care: a randomized controlled trial of outreach and tracking by community health workers

OBJECTIVES

This study assessed the effectiveness of enhanced tracking and follow-up services provided by community health workers in promoting medical follow-up of persons whose elevated blood pressures were detected during blood pressure measurement at urban community sites.

METHODS

In a randomized controlled trial, 421 participants received either enhanced or usual referrals to care. Participants were 18 years or older, were either Black or White, and had blood pressure greater than or equal to 140/90 mm Hg and income equal to or less than 200% of poverty. The primary outcome measure was completion of a medical follow-up visit within 90 days of referral.

RESULTS

The enhanced intervention increased follow-up by 39.4% (95% confidence interval [CI] = 14%, 71%; P = .001) relative to usual care. Follow-up visits were completed by 65.1% of participants in the intervention group, compared with 46.7% of those in the usual-care group. The number needed to treat was 5 clients (95% CI = 3, 13) per additional follow-up visit realized.

CONCLUSIONS

Enhanced tracking and outreach increased the proportion of persons with elevated blood pressure detected during community measurement who followed up with medical care.

Changes in the prevalence distribution of hypertension: Connecticut adults 1978-79 to 1982

In the Spring and Summer of 1982 the Second Connecticut Blood Pressure Survey (CBPS-II) was completed. This survey is independent of, but essentially identical in design and implementation to the First Connecticut Blood Pressure Survey reported on by Freeman et al. [1]. This paper compares the results of the two surveys using the same analytic techniques as reported previously [2]. In addition, a model for analyzing the components of hypertension control is utilized in the analysis. Finally, the implications of the survey comparison are discussed in the context of the Connecticut High Blood Pressure Program (CHBP) [3].

The prevalence distribution of hypertension: Connecticut adults 1978-1979

The results of the first Connecticut Blood Pressure Survey are reported. It was found that sharp differences exist in the prevalence of hypertension by age and sex but that race differences are much less than previously reported for United States populations. Differences were also found between men and women with respect to the patterns of treatment and control. Age differences in treatment and control are noted. The findings reported are based on a statewide probability sample for which the target population exceeded 2 million persons. Because of the complexity of sampling such a population an extensive discussion of the survey method is given.