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Zhu J, Chen W. Use of aspirin in cardiovascular disease prevention-the role of online information search. Chronic Illn 2024:17423953241241761. [PMID: 38584373 DOI: 10.1177/17423953241241761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
OBJECTIVES This study intends to examine influences of online information search on the use of aspirin in cardiovascular diseases (CVDs) prevention among the applicable adult population in the United States. METHODS We used data of 2018 National Health Interview Survey (NHIS). Our study sample is limited to adults age 40 or older to be consistent with the American Heart Association/American College of Cardiology Foundation (AHA/ACCF) guidelines for aspirin use. Linear probability models were used to test the association between patient's aspirin use behaviors and the variables of interest in four separate models. RESULTS Our results show that the use of aspirin for CVD prevention was associated with online health information seeking in different ways. When patients received doctors' advice to use aspirin, online information seeking has a negative influence, depending on whether the individual has CVD risk factors. However, for patients without recommendations from providers, the effects of online information seeking on self-initiated aspirin use depend on the different types of preventions (primary vs. secondary) and CVD risk factors. CONCLUSION Overall, online health information might lead to both overuse and underuse of aspirin in CVD preventions. Findings in this study may lead to decision-making that is not consistent with advice from healthcare professionals and/or established clinical guidelines.
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Affiliation(s)
- Jingrong Zhu
- School of Economics and Management, Communication University of China, Beijing, China
| | - Wenjia Chen
- School of Economics and Management, Beijing Information Science and Technology University, Beijing, China
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2
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Blecker S, Gannon M, De Leon S, Shelley D, Wu WY, Tabaei B, Magno J, Pham-Singer H. Practice facilitation for scale up of clinical decision support for hypertension management: study protocol for a cluster randomized control trial. Contemp Clin Trials 2023; 129:107177. [PMID: 37037392 PMCID: PMC10871131 DOI: 10.1016/j.cct.2023.107177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/09/2023] [Accepted: 04/04/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Only half of patients with hypertension have adequately controlled blood pressure. Clinical decision support (CDS) has the potential to overcome barriers to delivering guideline-recommended care and improve hypertension management. However, optimal strategies for scaling CDS have not been well established, particularly in small, independent primary care practices which often lack the resources to effectively change practice routines. Practice facilitation is an implementation strategy that has been shown to support process changes. Our objective is to evaluate whether practice facilitation provided with hypertension-focused CDS can lead to improvements in blood pressure control for patients seen in small primary care practices. METHODS/DESIGN We will conduct a cluster randomized control trial to compare the effect of hypertension-focused CDS plus practice facilitation on BP control, as compared to CDS alone. The practice facilitation intervention will include an initial training in the CDS and a review of current guidelines along with follow-up for coaching and integration support. We will randomize 46 small primary care practices in New York City who use the same electronic health record vendor to intervention or control. All patients with hypertension seen at these practices will be included in the evaluation. We will also assess implementation of CDS in all practices and practice facilitation in the intervention group. DISCUSSION The results of this study will inform optimal implementation of CDS into small primary care practices, where much of care delivery occurs in the U.S. Additionally, our assessment of barriers and facilitators to implementation will support future scaling of the intervention. CLINICALTRIALS gov Identifier: NCT05588466.
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Affiliation(s)
- Saul Blecker
- NYU Grossman School of Medicine, New York, NY, United States of America.
| | - Matthew Gannon
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Samantha De Leon
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Donna Shelley
- NYU School of Global Public Health, New York, NY, United States of America
| | - Winfred Y Wu
- University of Miami - Miller School of Medicine, Miami, FL, United States of America
| | - Bahman Tabaei
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Janice Magno
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, United States of America
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3
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Shelley DR, Brown D, Cleland CM, Pham-Singer H, Zein D, Chang JE, Wu WY. Facilitation of team-based care to improve HTN management and outcomes: a protocol for a randomized stepped wedge trial. BMC Health Serv Res 2023; 23:560. [PMID: 37259081 DOI: 10.1186/s12913-023-09533-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/10/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND There are well-established guidelines for treating hypertension (HTN), yet only half of patients with HTN meet the defined target of < 140/90. Team-based care (TBC) is an evidence-based strategy for improving blood pressure (BP) management and control. TBC is defined as the provision of health services by at least two health professionals "who work collaboratively with patients and their caregivers to accomplish shared goals to achieve coordinated, high-quality care". However, primary care practices experience challenges to implementing TBC principles and care processes; these are more pronounced in small independent practice settings (SIPs). Practice facilitation (PF) is an implementation strategy that may overcome barriers to adopting evidence-based TBC to improve HTN management in SIPs. METHODS Using a stepped wedge randomized controlled trial design, we will test the effect of PF on the adoption of TBC to improve HTN management in small practices (< 5 FTE clinicians) in New York City, and the impact on BP control compared with usual care. We will enroll 90 SIPs and randomize them into one of three 12-month intervention waves. Practice facilitators will support SIPs to adopt TBC principles to improve implementation of five HTN management strategies (i.e., panel management, population health, measuring BP, supporting medication adherence, self-management). The primary outcome is the adoption of TBC for HTN management measured at baseline and 12 months. Secondary outcomes include the rate of BP control and sustainability of TBC and BP outcomes at 18 months. Aggregated data on BP measures are collected every 6 months in all clusters so that each cluster provides data points in both the control and intervention conditions. Using a mixed methods approach, we will also explore factors that influence the effectiveness of PF at the organization and team level. DISCUSSION This study will provide much-needed guidance on how to optimize adoption and sustainability of TBC in independent primary care settings to reduce the burden of disease related to suboptimal BP control and advance understanding of how facilitation works to improve implementation of evidence-based interventions. TRIAL REGISTRATION ClinicalTrials.gov; NCT05413252 .
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Affiliation(s)
- Donna R Shelley
- New York University School of Global Public Health, New York, NY, USA.
| | - Dominique Brown
- New York University School of Global Public Health, New York, NY, USA
| | | | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, Long Island City, NY, USA
| | - Dina Zein
- New York University School of Global Public Health, New York, NY, USA
| | - Ji Eun Chang
- New York University School of Global Public Health, New York, NY, USA
| | - Winfred Y Wu
- University of Miami Miller School of Medicine, Miami, FL, USA
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4
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Kowitt SD, Goldstein AO, Cykert S. A Heart Healthy Intervention Improved Tobacco Screening Rates and Cessation Support in Primary Care Practices. JOURNAL OF PREVENTION (2022) 2022; 43:375-386. [PMID: 35301643 PMCID: PMC9536240 DOI: 10.1007/s10935-022-00672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 06/03/2023]
Abstract
We examined whether an evidence-based cardiovascular disease risk reduction intervention (Heart Health Now) would improve rates for tobacco cessation screening and counseling in small primary care practices in North Carolina. Heart Health Now was a stepped wedge, stratified, cluster randomized trial for primary care practices that were staffed by 10 or fewer clinicians and had an electronic health record. The Heart Health Now intervention consisted of education tools, onsite practice facilitation for one year, and a practice-specific cardiovascular population management dashboard that included monthly, measure-specific run charts to help guide quality improvement. Our primary outcomes were practice-level rates of tobacco screening and tobacco cessation support-extracted from practices' electronic health records-and measured at pre-intervention and 6 months post-intervention. The 28 practices included in our analyses represented 78,120 patients and 17,687 smokers. Significant change occurred in practices' tobacco screening rates and cessation support rates over time. From pre- to post-intervention, screening rates significantly increased from 82.7 to 96.2% (p < 0.001). Similarly, cessation support rates significantly increased from 44.3 to 50.1% (p = 0.03). Several practice-level factors were associated with improvement including being in an academic health center or faculty practice, having more clinicians, and having a lower percentage of White patients. In conclusion, a multi-component intervention focused on multiple cardiovascular disease risk reduction in multiple small primary care practices successfully improved rates of tobacco screening and cessation support.
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Affiliation(s)
- Sarah D Kowitt
- The Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, 590 Manning Dr, 27599, Chapel Hill, NC, United States.
| | - Adam O Goldstein
- The Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, 590 Manning Dr, 27599, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Samuel Cykert
- The Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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5
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Ballengee LA, Rushton S, Lewinski AA, Hwang S, Zullig LL, Ricks KAB, Ramos K, Brahmajothi MV, Moore TS, Blalock DV, Cantrell S, Kosinski AS, Gordon A, Ear B, Williams JW, Gierisch JM, Goldstein KM. Effectiveness of Quality Improvement Coaching on Process Outcomes in Health Care Settings: A Systematic Review. J Gen Intern Med 2022; 37:885-899. [PMID: 34981354 PMCID: PMC8904663 DOI: 10.1007/s11606-021-07217-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND A culture of improvement is an important feature of high-quality health care systems. However, health care teams often need support to translate quality improvement (QI) activities into practice. One method of support is consultation from a QI coach. The literature suggests that coaching interventions have a positive impact on clinical outcomes. However, the impact of coaching on specific process outcomes, like adoption of clinical care activities, is unknown. Identifying the process outcomes for which QI coaching is most effective could provide specific guidance on when to employ this strategy. METHODS We searched multiple databases from inception through July 2021. Studies that addressed the effects of QI coaching on process of care outcomes were included. Two reviewers independently extracted study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE. RESULTS We identified 1983 articles, of which 23 cluster-randomized trials met eligibility criteria. All but two took place in a primary care setting. Overall, interventions typically targeted multiple simultaneous processes of care activities. We found that coaching probably has a beneficial effect on composite process of care outcomes (n = 9) and ordering of labs and vital signs (n = 6), and possibly has a beneficial effect on changes in organizational process of care (n = 5), appropriate documentation (n = 5), and delivery of appropriate counseling (n = 3). We did not perform meta-analyses because of conceptual heterogeneity around intervention design and outcomes; rather, we synthesized the data narratively. Due to imprecision, inconsistency, and high risk of bias of the included studies, we judged the certainty of these results as low or very low. CONCLUSION QI coaching interventions may affect certain processes of care activities such as ordering of labs and vital signs. Future research that advances the identification of when QI coaching is most beneficial for health care teams seeking to implement improvement processes in pursuit of high-quality care will support efficient use of QI resources. PROTOCOL REGISTRATION This study was registered and followed a published protocol (PROSPERO: CRD42020165069).
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Affiliation(s)
- Lindsay A Ballengee
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA.
- Department of Orthopaedic Surgery, Duke University School of Medicine, Division of Physical Therapy, Duke University, Durham, NC, USA.
| | | | - Allison A Lewinski
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Soohyun Hwang
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Leah L Zullig
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Katharine A Ball Ricks
- Cecil G. Sheps Center for Health Service Research, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine Ramos
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Medicine Geriatrics, Duke University, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, NC, USA
| | - Mulugu V Brahmajothi
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, USA
| | - Thomasena S Moore
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Dan V Blalock
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Adelaide Gordon
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Belinda Ear
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - John W Williams
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer M Gierisch
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Karen M Goldstein
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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Brunström M, Ng N, Dahlström J, Lindholm LH, Norberg M, Nyström L, Weinehall L, Carlberg B. Association of education and feedback on hypertension management with risk for stroke and cardiovascular disease. Blood Press 2022; 31:31-39. [PMID: 35179089 DOI: 10.1080/08037051.2022.2041393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PURPOSE Education and feedback on hypertension management has been associated with improved hypertension control. This study aimed to assess the effectiveness of such interventions to reduce the risk of stroke and cardiovascular events. MATERIALS AND METHODS Individuals ≥18 years with a blood pressure (BP) recording in Västerbotten or Södermanland County during the study period 2001 to 2009 were included in 108 serial cohort studies, each with 24 months follow-up. The primary outcome was risk of first-ever stroke in Västerbotten County (intervention) compared with Södermanland County (control). Secondary outcomes were first-ever major adverse cardiovascular event (MACE), myocardial infarction, and heart failure, as well as all-cause and cardiovascular mortality. All outcomes were analysed using time-to-event data included in a Cox proportional hazards model adjusted for age, sex, hypertension, diabetes, coronary artery disease, atrial fibrillation, systolic BP at inclusion, marital status, and disposable income. RESULTS A total of 121 365 individuals (mean [SD] age at inclusion 61.7 [16.3] years; 59.9% female; mean inclusion BP 142.3/82.6 mmHg) in the intervention county were compared to 131 924 individuals (63.6 [16.2] years; 61.2% female; 144.1/81.1 mmHg) in the control county. A first-ever stroke occurred in 2 823 (2.3%) individuals in the intervention county, and 3 584 (2.7%) individuals in the control county (adjusted hazard ratio 0.96, 95% CI 0.90 to 1.03). No differences were observed for MACE, myocardial infarction or heart failure, whereas all-cause mortality (HR 0.91, 95% CI 0.87 to 0.95) and cardiovascular mortality (HR 0.91, 95% CI 0.85 to 0.98) were lower in the intervention county. CONCLUSIONS This study does not support an association between education and feedback on hypertension management to primary care physicians and the risk for stroke or cardiovascular outcomes. The observed differences for mortality outcomes should be interpreted with caution.
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Affiliation(s)
- Mattias Brunström
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Nawi Ng
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,School of Public Health and Community Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - John Dahlström
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Lars H Lindholm
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Margareta Norberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Lennarth Nyström
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Lars Weinehall
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Bo Carlberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Gold HT, McDermott C, Hoomans T, Wagner TH. Cost data in implementation science: categories and approaches to costing. Implement Sci 2022; 17:11. [PMID: 35090508 PMCID: PMC8796347 DOI: 10.1186/s13012-021-01172-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 11/03/2021] [Indexed: 12/14/2022] Open
Abstract
A lack of cost information has been cited as a barrier to implementation and a limitation of implementation research. This paper explains how implementation researchers might optimize their measurement and inclusion of costs, building on traditional economic evaluations comparing costs and effectiveness of health interventions. The objective of all economic evaluation is to inform decision-making for resource allocation and to measure costs that reflect opportunity costs—the value of resource inputs in their next best alternative use, which generally vary by decision-maker perspective(s) and time horizon(s). Analyses that examine different perspectives or time horizons must consider cost estimation accuracy, because over longer time horizons, all costs are variable; however, with shorter time horizons and narrower perspectives, one must differentiate the fixed and variable costs, with fixed costs generally excluded from the evaluation. This paper defines relevant costs, identifies sources of cost data, and discusses cost relevance to potential decision-makers contemplating or implementing evidence-based interventions. Costs may come from the healthcare sector, informal healthcare sector, patient, participant or caregiver, and other sectors such as housing, criminal justice, social services, and education. Finally, we define and consider the relevance of costs by phase of implementation and time horizon, including pre-implementation and planning, implementation, intervention, downstream, and adaptation, and through replication, sustainment, de-implementation, or spread.
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The Potential Benefits and Costs of an Intensified Approach to Low Density Lipoprotein Cholesterol Lowering in People with Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2021; 62:643-650. [PMID: 34507892 DOI: 10.1016/j.ejvs.2021.06.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/07/2021] [Accepted: 06/20/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The aims of this study were to assess the incidence of major vascular events (MVE) and peripheral vascular events (PVE) in people with a small asymptomatic abdominal aortic aneurysm (AAA) and model the theoretical benefits and costs of an intensified low density lipoprotein cholesterol (LDL-C) lowering programme. METHODS A total of 583 participants with AAAs measuring 30 - 54 mm were included in this study. The control of LDL-C and prescription of lipid lowering drugs were assessed by dividing participants into approximately equal tertiles depending on their year of recruitment into the study. The occurrence of MVE (myocardial infarction, stroke, cardiovascular death, and coronary or non-coronary revascularisation) and PVE (non-coronary revascularisation, AAA repair, and major amputation) were recorded prospectively, and the incidence of these events was calculated using Kaplan-Meier analysis. The relative risk reduction reported for these events in a previous randomised control trial (RCT) was then applied to these figures to model the absolute risk reduction and numbers needed to treat (NTT) that could theoretically be achieved with a mean LDL-C lowering of 1 mmol/L. The maximum allowable expense for a cost effective intensive LDL-C lowering programme was estimated using a cost utility analysis. RESULTS At entry, only 28.5% of participants had an LDL-C of < 1.8 mmol/L and only 18.5% were prescribed a high potency statin (atorvastatin 80 mg or rosuvastatin 40 mg). The five year incidences of MVE and PVE were 38.1% and 44.7%, respectively. It was estimated that if the mean LDL-C of the cohort had been reduced by 1 mmol/L, this could have reduced the absolute risk of MVE and PVE by 6.5% (95% CI 4.4 - 8.7; NNT 15) and 5.3% (95% CI 1.4 - 7.5; NNT 19), respectively. It was estimated that the maximum allowable expense for a cost effective LDL-C lowering programme would be between $1 239 AUD (€768) and $1 582 AUD (€981) per person per annum over a five year period. CONCLUSION People with a small asymptomatic AAA are at high risk of MVE and PVE. This study provides evidence of the possible benefits and allowable expense for a cost effective intensive LDL-C lowering programme in this population.
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9
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Golledge J, Drovandi A. Evidence-Based Recommendations for Medical Management of Peripheral Artery Disease. J Atheroscler Thromb 2021; 28:573-583. [PMID: 33746159 PMCID: PMC8219542 DOI: 10.5551/jat.62778] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Patients with lower limb artery stenosis or occlusion (peripheral artery disease; PAD) have been determined to be at very high risk of both major adverse cardiovascular events, such as myocardial infarction and stroke, and major adverse limb events, such as amputation and requirement for artery surgery. Effective medical management has been identified as key in reducing this risk; however, this is often poorly implemented in clinical practice. Thus, the aim of this narrative review was to summarize the current evidence on the medical management of PAD in order to inform clinicians and highlight recommendations for clinical practice. International guidelines, randomized controlled trials, and relevant systematic reviews and meta-analyses have been included in this study. The focus was the management of the key modifiable risk factors to mitigate possible adverse events through prescription of anti-platelet and anticoagulation drugs and medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes and aid smoking cessation. The available evidence from randomized clinical trials provide a strong rationale for the need for holistic medical management programs that are effective in achieving uptake of these medical therapies in patients with PAD. In conclusion, people with PAD have some of the highest adverse event rates among those with cardiovascular diseases. Secondary preventive measures have been proven effective in reducing these adverse events; however, they remain to be adequately implemented. Thus, the need for an effective implementation program has emerged to reduce adverse events in this patient group.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University.,The Australian Institute of Tropical Health and Medicine, James Cook University.,The Department of Vascular and Endovascular Surgery, The Townsville University Hospital
| | - Aaron Drovandi
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University.,The Australian Institute of Tropical Health and Medicine, James Cook University
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10
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Gold HT, Siman N, Cuthel AM, Nguyen AM, Pham-Singer H, Berry CA, Shelley DR. A practice facilitation-guided intervention in primary care settings to reduce cardiovascular disease risk: a cost analysis. Implement Sci Commun 2021; 2:15. [PMID: 33549152 PMCID: PMC7868016 DOI: 10.1186/s43058-021-00116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background A stepped-wedge, cluster randomized controlled trial assessed the effectiveness of practice facilitation (PF) for adoption of guidelines for prevention and treatment of cardiovascular disease risk factors. This study estimated the associated cost of PF for guideline adoption in small, private primary care practices. Methods The cost analysis included categories for start-up costs, intervention costs, and practice staff costs for the implemented PF-guided intervention. We estimated the total 1-year costs to operate the program and calculated the mean and range of the cost-per-practice by quarter of the intervention. We estimated the lower and upper bounds for all salary expenses, rounding to the nearest $100. Results Total 1-year intervention costs for all 261 practices ranged from $7,900,000 to $10,200,000, with program and practice salaries comprising $6,600,000–$8,400,000 of the total. Start-up costs were a small proportion (3%) of the total 1-year costs. Excluding start-up costs, quarter 1 cost-per-practice was the most expensive at $20,400–$26,700, and quarter 4 was the least expensive at about $10,000. Practice staff time (compared with program staff time) was the majority of the staffing costs at 75–84%. Conclusions The PF strategy costs approximately $10,000 per practice per quarter for program and practice costs, once implemented and running at highest efficiency. Whether this program is “worth it” to the decision-maker depends on the relative costs and effectiveness of their other options for improving cardiovascular risk reduction. Trial registration This study is retrospectively registered on January 5, 2016, at www.clinicaltrials.gov as NCT02646488.
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Affiliation(s)
- Heather T Gold
- Department of Population Health, NYU Langone Health, New York, NY, USA.
| | - Nina Siman
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, NY, USA
| | - Ann M Nguyen
- Rutgers Center for State Health Policy, Rutgers University, New Brunswick, NJ, USA
| | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Carolyn A Berry
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Donna R Shelley
- Department of Policy and Public Health Management, School of Global Public Health, New York University, New York, NY, USA
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Anstey KJ, Cherbuin N, Kim S, McMaster M, D'Este C, Lautenschlager N, Rebok G, McRae I, Torres SJ, Cox KL, Pond CD. An Internet-Based Intervention Augmented With a Diet and Physical Activity Consultation to Decrease the Risk of Dementia in At-Risk Adults in a Primary Care Setting: Pragmatic Randomized Controlled Trial. J Med Internet Res 2020; 22:e19431. [PMID: 32969833 PMCID: PMC7545332 DOI: 10.2196/19431] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/28/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is a need to develop interventions to reduce the risk of dementia in the community by addressing lifestyle factors and chronic diseases over the adult life course. OBJECTIVE This study aims to evaluate a multidomain dementia risk reduction intervention, Body Brain Life in General Practice (BBL-GP), targeting at-risk adults in primary care. METHODS A pragmatic, parallel, three-arm randomized trial involving 125 adults aged 18 years or older (86/125, 68.8% female) with a BMI of ≥25 kg/m2 or a chronic health condition recruited from general practices was conducted. The arms included (1) BBL-GP, a web-based intervention augmented with an in-person diet and physical activity consultation; (2) a single clinician-led group, Lifestyle Modification Program (LMP); and (3) a web-based control. The primary outcome was the Australian National University Alzheimer Disease Risk Index Short Form (ANU-ADRI-SF). RESULTS Baseline assessments were conducted on 128 participants. A total of 125 participants were randomized to 3 groups (BBL-GP=42, LMP=41, and control=42). At immediate, week 18, week 36, and week 62 follow-ups, the completion rates were 43% (18/42), 57% (24/42), 48% (20/42), and 48% (20/42), respectively, for the BBL-GP group; 71% (29/41), 68% (28/41), 68% (28/41), and 51% (21/41), respectively, for the LMP group; and 62% (26/42), 69% (29/42), 60% (25/42), and 60% (25/42), respectively, for the control group. The primary outcome of the ANU-ADRI-SF score was lower for the BBL-GP group than the control group at all follow-ups. These comparisons were all significant at the 5% level for estimates adjusted for baseline differences (immediate: difference in means -3.86, 95% CI -6.81 to -0.90, P=.01; week 18: difference in means -4.05, 95% CI -6.81 to -1.28, P<.001; week 36: difference in means -4.99, 95% CI -8.04 to -1.94, P<.001; and week 62: difference in means -4.62, 95% CI -7.62 to -1.62, P<.001). CONCLUSIONS A web-based multidomain dementia risk reduction program augmented with allied health consultations administered within the general practice context can reduce dementia risk exposure for at least 15 months. This study was limited by a small sample size, and replication on a larger sample with longer follow-up will strengthen the results. TRIAL REGISTRATION Australian clinical trials registration number (ACTRN): 12616000868482; https://anzctr.org.au/ACTRN12616000868482.aspx.
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Affiliation(s)
- Kaarin J Anstey
- School of Psychology, University of New South Wales, Sydney, Australia.,Neuroscience Research Australia, Sydney, Australia.,Centre for Research on Ageing, Health and Wellbeing, Australian National University, Canberra, Australia
| | - Nicolas Cherbuin
- Centre for Research on Ageing, Health and Wellbeing, Australian National University, Canberra, Australia
| | - Sarang Kim
- Wicking Dementia Resaerch & Education Centre, University of Tasmania, Hobart, Australia
| | - Mitchell McMaster
- Centre for Research on Ageing, Health and Wellbeing, Australian National University, Canberra, Australia
| | - Catherine D'Este
- National Centre for Epidemiology and Public Health, Australian National University, Canberra, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Nicola Lautenschlager
- Academic Unit for Psychiatry of Old Age, University of Melbourne, Melbourne, Australia
| | - George Rebok
- Johns Hopkins Centre on Aging and Health, Johns Hopkins University, Baltimore, MD, United States
| | - Ian McRae
- Centre for Research on Ageing, Health and Wellbeing, Australian National University, Canberra, Australia
| | - Susan J Torres
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Australia
| | - Kay L Cox
- Medical School, University of Western Australia, Perth, Australia
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Berry CA, Nguyen AM, Cuthel AM, Cleland CM, Siman N, Pham-Singer H, Shelley DR. Measuring Implementation Strategy Fidelity in HealthyHearts NYC: A Complex Intervention Using Practice Facilitation in Primary Care. Am J Med Qual 2020; 36:270-276. [PMID: 32964719 DOI: 10.1177/1062860620959450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Few studies have assessed the fidelity of practice facilitation (PF) as an implementation strategy, and none have used an a priori definition or conceptual framework of fidelity to guide fidelity assessment. The authors adapted the Conceptual Framework for Implementation Fidelity to guide fidelity assessment in HealthyHearts NYC, an intervention that used PF to improve adoption of cardiovascular disease evidence-based guidelines in primary care practices. Data from a web-based tracking system of 257 practices measured fidelity using 4 categories: frequency, duration, content, and coverage. Almost all (94.2%) practices received at least the required 13 PF visits. Facilitators spent on average 26.3 hours at each site. Most practices (95.7%) completed all Task List items, and 71.2% were educated on all Chronic Care Model strategies. The majority (65.8%) received full coverage. This study provides a model that practice managers and implementers can use to evaluate fidelity of PF, and potentially other implementation strategies.
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Affiliation(s)
- Carolyn A Berry
- NYU Langone Health, New York, NY New York City Department of Health and Mental Hygiene, New York, NY New York University, New York, NY
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Pham-Singer H, Onakomaiya M, Cuthel A, De Leon S, Shih S, Chow S, Shelley D. Using a Customer Relationship Management System to Manage a Quality Improvement Intervention. Am J Med Qual 2020; 36:247-254. [PMID: 32924529 DOI: 10.1177/1062860620953214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
HealthyHearts New York City (HHNYC), one of 7 cooperatives funded through the Agency for Healthcare Research and Quality's EvidenceNOW initiative, evaluated the impact of practice facilitation on implementation of the Million Hearts guidelines for cardiovascular disease prevention and treatment. Tracking the intervention required a system to facilitate process data collection that was also user-friendly and flexible. Coupled with protocols and training, a strategically planned and customizable customer relationship management system (CRMS) was implemented to support the quality improvement intervention with 257 small independent practices. Features of the CRMS and implementation protocols were customized to optimize program management, practice facilitation tracking and supervision, and data collection for performance feedback to practices and research. The CRMS was a valuable tool for tracking and managing the intervention systematically. Successful implementation of the HHNYC protocol also required an articulated implementation plan and adoption process.
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Affiliation(s)
- Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, Queens, NY New York University School of Medicine, New York, NY
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