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Berlowitz DR. Should Primary Care Physicians Be Managing Hypertension? Am J Hypertens 2024; 37:266-267. [PMID: 38195163 DOI: 10.1093/ajh/hpad119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/11/2024] Open
Affiliation(s)
- Dan R Berlowitz
- Department of Public Health, University of Massachusetts Lowell, Lowell, Massachusetts, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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Davila H, Mills WL, Clark V, Hartmann CW, Sullivan JL, Mohr DC, Baughman AW, Berlowitz DR, Pimentel CB. Quality Improvement Efforts in VA Community Living Centers Following Public Reporting of Performance. J Aging Soc Policy 2024; 36:118-140. [PMID: 37014929 DOI: 10.1080/08959420.2023.2196913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 01/12/2023] [Indexed: 04/06/2023]
Abstract
For two decades, the U.S. government has publicly reported performance measures for most nursing homes, spurring some improvements in quality. Public reporting is new, however, to Department of Veterans Affairs nursing homes (Community Living Centers [CLCs]). As part of a large, public integrated healthcare system, CLCs operate with unique financial and market incentives. Thus, their responses to public reporting may differ from private sector nursing homes. In three CLCs with varied public ratings, we used an exploratory, qualitative case study approach involving semi-structured interviews to compare how CLC leaders (n = 12) perceived public reporting and its influence on quality improvement. Across CLCs, respondents said public reporting was helpful for transparency and to provide an "outside perspective" on CLC performance. Respondents described employing similar strategies to improve their public ratings: using data, engaging staff, and clearly defining staff roles vis-à-vis quality improvement, although more effort was required to implement change in lower performing CLCs. Our findings augment those from prior studies and offer new insights into the potential for public reporting to spur quality improvement in public nursing homes and those that are part of integrated healthcare systems.
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Affiliation(s)
- Heather Davila
- Center for Access and Delivery Research & Evaluation, Iowa City Department of Veterans Affairs (VA) Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Whitney L Mills
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Valerie Clark
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Jennifer L Sullivan
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, MA, USA
| | - Amy W Baughman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School,Boston, MA, USA
| | - Dan R Berlowitz
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Camilla B Pimentel
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
- New England Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, Bedford, MA, USA
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Zheutlin AR, Addo DK, Jacobs JA, Derington CG, Herrick JS, Greene T, Stulberg EL, Berlowitz DR, Williamson JD, Pajewski NM, Supiano MA, Bress AP. Evidence for Age Bias Contributing to Therapeutic Inertia in Blood Pressure Management: A Secondary Analysis of SPRINT. Hypertension 2023; 80:1484-1493. [PMID: 37165900 PMCID: PMC10438422 DOI: 10.1161/hypertensionaha.123.21323] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/25/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Despite evidence supporting the cardiovascular and cognitive benefits of intensive blood pressure management, older adults have the lowest rates of blood pressure control. We determined the association between age and therapeutic inertia (TI) in SPRINT (Systolic Blood Pressure Intervention Trial), and whether frailty, cognitive function, or gait speed moderate or mediate these associations. METHODS We performed a secondary analysis of SPRINT of participant visits with blood pressure above randomized treatment goal. We categorized baseline age as <60, 60 to <70, 70 to <80, and ≥80 years and TI as no antihypertensive medication intensification per participant visit. Generalized estimating equations generated odds ratios for TI associated with age, stratified by treatment group based on nested models adjusted for baseline frailty index score (fit [frailty index, ≤0.10], less fit [0.10 RESULTS Participants 60 to <70, 70 to <80, and ≥80 years of age had a higher prevalence of TI in both treatment groups versus participants <60 years of age (standard: 59.7%, 60.5%, and 60.1% versus 56.0%; 29 527 participant visits; intensive: 55.1%, 57.2%, and 57.8% versus 53.8%; 47 129 participant visits). The adjusted odds ratios for TI comparing participants ≥80 versus <60 years of age were 1.32 (95% CI, 1.14-1.53) and 1.25 (95% CI, 1.11-1.41) in the standard and intensive treatment groups, respectively. Adjustment for frailty, cognitive function, or gait speed did not attenuate the association or demonstrate effect modification (all Pinteraction, >0.10). CONCLUSIONS Older age is associated with greater TI independent of physical or cognitive function, implying age bias in hypertension management.
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Affiliation(s)
- Alexander R Zheutlin
- Department of Internal Medicine (A.R.Z.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Daniel K Addo
- Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Joshua A Jacobs
- Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Catherine G Derington
- Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Jennifer S Herrick
- Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- Informatics, Decision-Enhancement, and Analytic Sciences Center, Veterans Affairs, Salt Lake City Health Care System, Utah (J.S.H., A.P.B.)
| | - Tom Greene
- Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Eric L Stulberg
- Department of Neurology (E.L.S.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Dan R Berlowitz
- Department of Public Health, University of Massachusetts-Lowell (D.R.B.)
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine (J.D.W.), Wake Forest University School of Medicine, Winston-Salem, NC
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Division of Public Health Sciences (N.M.P.), Wake Forest University School of Medicine, Winston-Salem, NC
| | - Mark A Supiano
- Geriatrics Division, Spencer Fox Eccles School of Medicine, University of Utah Center on Aging, Salt Lake City (M.A.S.)
| | - Adam P Bress
- Intermountain Healthcare Department of Population Health Sciences (D.K.A., J.A.J., C.G.D., J.S.H., T.G., A.P.B.), Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- Informatics, Decision-Enhancement, and Analytic Sciences Center, Veterans Affairs, Salt Lake City Health Care System, Utah (J.S.H., A.P.B.)
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4
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Zheutlin AR, Mondesir FL, Derington CG, King JB, Zhang C, Cohen JB, Berlowitz DR, Anstey DE, Cushman WC, Greene TH, Ogedegbe O, Bress AP. Analysis of Therapeutic Inertia and Race and Ethnicity in the Systolic Blood Pressure Intervention Trial: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2143001. [PMID: 35006243 PMCID: PMC8749480 DOI: 10.1001/jamanetworkopen.2021.43001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022] Open
Abstract
Importance Therapeutic inertia may contribute to racial and ethnic differences in blood pressure (BP) control. Objective To determine the association between race and ethnicity and therapeutic inertia in the Systolic Blood Pressure Intervention Trial (SPRINT). Design, Setting, and Participants This cross-sectional study was a secondary analysis of data from SPRINT, a randomized clinical trial comparing intensive (<120 mm Hg) vs standard (<140 mm Hg) systolic BP treatment goals. Participants were enrolled between November 8, 2010, and March 15, 2013, with a median follow-up 3.26 years. Participants included adults aged 50 years or older at high risk for cardiovascular disease but without diabetes, previous stroke, or heart failure. The present analysis was restricted to participant visits with measured BP above the target goal. Analyses for the present study were performed in from October 2020 through March 2021. Exposures Self-reported race and ethnicity, mutually exclusively categorized into groups of Hispanic, non-Hispanic Black, or non-Hispanic White participants. Main Outcomes and Measures Therapeutic inertia, defined as no antihypertensive medication intensification at each study visit where the BP was above target goal. The association between self-reported race and ethnicity and therapeutic inertia was estimated using generalized estimating equations and stratified by treatment group. Antihypertensive medication use was assessed with pill bottle inventories at each visit. Blood pressure was measured using an automated device. Results A total of 8556 participants, including 4141 in the standard group (22 844 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1467 women [35.4%]) and 4415 in the intensive group (35 453 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1584 women [35.9%]) with at least 1 eligible study visit were included in the present analysis. Among non-Hispanic White, non-Hispanic Black, and Hispanic participants, the overall prevalence of therapeutic inertia in the standard vs intensive groups was 59.8% (95% CI, 58.9%-60.7%) vs 56.0% (95% CI, 55.2%-56.7%), 56.8% (95% CI, 54.4%-59.2%) vs 54.5% (95% CI, 52.4%-56.6%), and 59.7% (95% CI, 56.5%-63.0%) vs 51.0% (95% CI, 47.4%-54.5%), respectively. The adjusted odds ratios in the standard and intensive groups for therapeutic inertia associated with non-Hispanic Black vs non-Hispanic White participants were 0.85 (95% CI, 0.79-0.92) and 0.94 (95% CI, 0.88-1.01), respectively. The adjusted odds ratios for therapeutic inertia comparing Hispanic vs non-Hispanic White participants were 1.00 (95% CI, 0.90-1.13) and 0.89 (95% CI, 0.79-1.00) in the standard and intensive groups, respectively. Conclusions and Relevance Among SPRINT participants above BP target goal, this cross-sectional study found that therapeutic inertia prevalence was similar or lower for non-Hispanic Black and Hispanic participants compared with non-Hispanic White participants. These findings suggest that a standardized approach to BP management, as used in SPRINT, may help ensure equitable care and could reduce the contribution of therapeutic inertia to disparities in hypertension. Trial Registration ClinicalTrials.gov identifier: NCT01206062.
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Affiliation(s)
- Alexander R. Zheutlin
- Department of Internal Medicine, University of Utah, School of Medicine, Salt Lake City
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
| | - Favel L. Mondesir
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
| | - Catherine G. Derington
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
| | - Jordan B. King
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Chong Zhang
- Department of Internal Medicine, University of Utah, School of Medicine, Salt Lake City
| | - Jordana B. Cohen
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Dan R. Berlowitz
- Department of Public Health, University of Massachusetts-Lowell, Lowell
| | - D. Edmund Anstey
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - William C. Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
- Medical Service, Memphis VA Medical Center, Memphis, Tennessee
| | - Tom H. Greene
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
| | - Olugbenga Ogedegbe
- Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, New York University School of Medicine, New York, New York
| | - Adam P. Bress
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
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Rose AJ, Lee JS, Berlowitz DR, Liu W, Mitra A, Yu H. Guideline-discordant dosing of direct-acting oral anticoagulants in the veterans health administration. BMC Health Serv Res 2021; 21:1351. [PMID: 34922546 PMCID: PMC8684634 DOI: 10.1186/s12913-021-07397-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background Clear guidelines exist to guide the dosing of direct-acting oral anticoagulants (DOACs). It is not known how consistently these guidelines are followed in practice. Methods We studied patients from the Veterans Health Administration (VA) with non-valvular atrial fibrillation who received DOACs (dabigatran, rivaroxaban, apixaban) between 2010 and 2016. We used patient characteristics (age, creatinine, body mass) to identify which patients met guideline recommendations for low-dose therapy and which for full-dose therapy. We examined how often patient dosing was concordant with these recommendations. We examined variation in guideline-concordant dosing by site of care and over time. We examined patient-level predictors of guideline-concordant dosing using multivariable logistic models. Results A total of 73,672 patients who were prescribed DOACS were included. Of 5837 patients who were recommended to receive low-dose therapy, 1331 (23%) received full-dose therapy instead. Of 67,935 patients recommended to receive full-dose therapy, 4079 (6%) received low-dose therapy instead. Sites varied widely on guideline discordant dosing; on inappropriate low-dose therapy, sites varied from 0 to 15%, while on inappropriate high-dose therapy, from 0 to 41%. Guideline discordant therapy decreased by about 20% in a relative sense over time, but its absolute numbers grew as DOAC therapy became more common. The most important patient-level predictors of receiving guideline-discordant therapy were older age and creatinine function being near the cutoff value. Conclusions A substantial portion of DOAC prescriptions in the VA system are dosed contrary to clinical guidelines. This phenomenon varies widely across sites of care and has persisted over time. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07397-x.
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Affiliation(s)
- Adam J Rose
- Hebrew University School of Public Health, Ein Kerem Campus, Jerusalem, Israel.
| | - Jong Soo Lee
- School of Public Health, University of Massachusetts, Lowell, MA, USA
| | - Dan R Berlowitz
- School of Public Health, University of Massachusetts, Lowell, MA, USA.,Edith Nourse Rogers VA Medical Center, Bedford, MA, USA
| | - Weisong Liu
- School of Public Health, University of Massachusetts, Lowell, MA, USA
| | - Avijit Mitra
- College of Information and Computer Science, University of Massachusetts, Amherst, MA, USA
| | - Hong Yu
- School of Public Health, University of Massachusetts, Lowell, MA, USA.,Edith Nourse Rogers VA Medical Center, Bedford, MA, USA
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6
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Pimentel CB, Clark V, Baughman AW, Berlowitz DR, Davila H, Mills WL, Mohr DC, Sullivan JL, Hartmann CW. Health Care Providers and the Public Reporting of Nursing Home Quality in the United States Department of Veterans Affairs: Protocol for a Mixed Methods Pilot Study. JMIR Res Protoc 2021; 10:e23516. [PMID: 34287218 PMCID: PMC8339985 DOI: 10.2196/23516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 11/25/2022] Open
Abstract
Background In June 2018, the United States Department of Veterans Affairs (VA) began the public reporting of its 134 Community Living Centers’ (CLCs) overall quality by using a 5-star rating system based on data from the national quality measures captured in CLC Compare. Given the private sector’s positive experience with report cards, this is a seminal moment for stimulating measurable quality improvements in CLCs. However, the public reporting of CLC Compare data raises substantial and immediate implications for CLCs. The report cards, for example, facilitate comparisons between CLCs and community nursing homes in which CLCs generally fare worse. This may lead to staff anxiety and potentially unintended consequences. Additionally, CLC Compare is designed to spur improvement, yet the motivating aspects of the report cards are unknown. Understanding staff attitudes and early responses is a critical first step in building the capacity for public reporting to spur quality. Objective We will adapt an existing community nursing home public reporting survey to reveal important leverage points and support CLCs’ quality improvement efforts. Our work will be grounded in a conceptual framework of strategic orientation. We have 2 aims. First, we will qualitatively examine CLC staff reactions to CLC Compare. Second, we will adapt and expand upon an extant community nursing home survey to capture a broad range of responses and then pilot the adapted survey in CLCs. Methods We will conduct interviews with staff at 3 CLCs (1 1-star CLC, 1 3-star CLC, and 1 5-star CLC) to identify staff actions taken in response to their CLCs’ public data; staff’s commitment to or difficulties with using CLC Compare; and factors that motivate staff to improve CLC quality. We will integrate these findings with our conceptual framework to adapt and expand a community nursing home survey to the current CLC environment. We will conduct cognitive interviews with staff in 1 CLC to refine survey items. We will then pilot the survey in 6 CLCs (2 1-star CLCs, 2 3-star CLCs, and 2 5-star CLCs) to assess the survey’s feasibility, acceptability, and preliminary psychometric properties. Results We will develop a brief survey for use in a future national administration to identify system-wide responses to CLC Compare; evaluate the impact of CLC Compare on veterans’ clinical outcomes and satisfaction; and develop, test, and disseminate interventions to support the meaningful use of CLC Compare for quality improvement. Conclusions The knowledge gained from this pilot study and from future work will help VA refine how CLC Compare is used, ensure that CLC staff understand and are motivated to use its quality data, and implement concrete actions to improve clinical quality. The products from this pilot study will also facilitate studies on the effects of public reporting in other critical VA clinical areas. International Registered Report Identifier (IRRID) DERR1-10.2196/23516
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Affiliation(s)
- Camilla B Pimentel
- Center for Healthcare Organization and Implementation Research, United States Department of Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,New England Geriatric Research Education and Clinical Center, United States Department of Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Valerie Clark
- Center for Healthcare Organization and Implementation Research, United States Department of Veterans Affairs Bedford Healthcare System, Bedford, MA, United States
| | - Amy W Baughman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Dan R Berlowitz
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, United States
| | - Heather Davila
- Center for Healthcare Organization and Implementation Research, United States Department of Veterans Affairs Boston Healthcare System, Boston, MA, United States
| | - Whitney L Mills
- Center of Innovation in Long Term Services and Supports, United States Department of Veterans Affairs Providence Healthcare System, Providence, RI, United States.,Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, United States
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research, United States Department of Veterans Affairs Boston Healthcare System, Boston, MA, United States.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, MA, United States
| | - Jennifer L Sullivan
- Center for Healthcare Organization and Implementation Research, United States Department of Veterans Affairs Boston Healthcare System, Boston, MA, United States.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, MA, United States
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research, United States Department of Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, United States
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Derington CG, Cohen JB, Mohanty AF, Greene TH, Cook J, Ying J, Wei G, Herrick JS, Stevens VW, Jones BE, Wang L, Zheutlin AR, South AM, Hanff TC, Smith SM, Cooper-DeHoff RM, King JB, Alexander GC, Berlowitz DR, Ahmad FS, Penrod MJ, Hess R, Conroy MB, Fang JC, Rubin MA, Beddhu S, Cheung AK, Xian W, Weintraub WS, Bress AP. Angiotensin II receptor blocker or angiotensin-converting enzyme inhibitor use and COVID-19-related outcomes among US Veterans. PLoS One 2021; 16:e0248080. [PMID: 33891615 PMCID: PMC8064574 DOI: 10.1371/journal.pone.0248080] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/19/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) may positively or negatively impact outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We investigated the association of ARB or ACEI use with coronavirus disease 2019 (COVID-19)-related outcomes in US Veterans with treated hypertension using an active comparator design, appropriate covariate adjustment, and negative control analyses. METHODS AND FINDINGS In this retrospective cohort study of Veterans with treated hypertension in the Veterans Health Administration (01/19/2020-08/28/2020), we compared users of (A) ARB/ACEI vs. non-ARB/ACEI (excluding Veterans with compelling indications to reduce confounding by indication) and (B) ARB vs. ACEI among (1) SARS-CoV-2+ outpatients and (2) COVID-19 hospitalized inpatients. The primary outcome was all-cause hospitalization or mortality (outpatients) and all-cause mortality (inpatients). We estimated hazard ratios (HR) using propensity score-weighted Cox regression. Baseline characteristics were well-balanced between exposure groups after weighting. Among outpatients, there were 5.0 and 6.0 primary outcomes per 100 person-months for ARB/ACEI (n = 2,482) vs. non-ARB/ACEI (n = 2,487) users (HR 0.85, 95% confidence interval [CI] 0.73-0.99, median follow-up 87 days). Among outpatients who were ARB (n = 4,877) vs. ACEI (n = 8,704) users, there were 13.2 and 14.8 primary outcomes per 100 person-months (HR 0.91, 95%CI 0.86-0.97, median follow-up 85 days). Among inpatients who were ARB/ACEI (n = 210) vs. non-ARB/ACEI (n = 275) users, there were 3.4 and 2.0 all-cause deaths per 100 person months (HR 1.25, 95%CI 0.30-5.13, median follow-up 30 days). Among inpatients, ARB (n = 1,164) and ACEI (n = 2,014) users had 21.0 vs. 17.7 all-cause deaths, per 100 person-months (HR 1.13, 95%CI 0.93-1.38, median follow-up 30 days). CONCLUSIONS This observational analysis supports continued ARB or ACEI use for patients already using these medications before SARS-CoV-2 infection. The novel beneficial association observed among outpatients between users of ARBs vs. ACEIs on hospitalization or mortality should be confirmed with randomized trials.
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Affiliation(s)
- Catherine G. Derington
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Jordana B. Cohen
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - April F. Mohanty
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Tom H. Greene
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - James Cook
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Jian Ying
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
| | - Guo Wei
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
| | - Jennifer S. Herrick
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
| | - Vanessa W. Stevens
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
| | - Barbara E. Jones
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Libo Wang
- Department of Medicine, Division of Cardiology, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Alexander R. Zheutlin
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Andrew M. South
- Department of Pediatrics, Section of Nephrology, Brenner Children’s Hospital, Wake Forest School of Medicine, Winston Salem, NC, United States of America
- Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, NC, United States of America
| | - Thomas C. Hanff
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Steven M. Smith
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, United States of America
| | - Rhonda M. Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, United States of America
- Department of Medicine, University of Florida, College of Medicine, Gainesville, FL, United States of America
| | - Jordan B. King
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States of America
| | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dan R. Berlowitz
- Department of Public Health; University of Massachusetts Lowell, Lowell, MA, United States of America
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States of America
| | - Faraz S. Ahmad
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - M. Jason Penrod
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Rachel Hess
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Molly B. Conroy
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - James C. Fang
- Department of Medicine, Division of Cardiology, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Michael A. Rubin
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Srinivasan Beddhu
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Alfred K. Cheung
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Weiming Xian
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States of America
- Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, Boston, MA, United States of America
| | | | - Adam P. Bress
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
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8
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Jasuja GK, Bettano A, Smelson D, Bernson D, Rose AJ, Byrne T, Berlowitz DR, McCullough MB, Miller DR. Homelessness and Veteran Status in Relation to Nonfatal and Fatal Opioid Overdose in Massachusetts. Med Care 2021; 59:S165-S169. [PMID: 33710090 DOI: 10.1097/mlr.0000000000001437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Compared with non-Veterans, Veterans are at higher risk of experiencing homelessness, which is associated with opioid overdose. OBJECTIVE To understand how homelessness and Veteran status are related to risks of nonfatal and fatal opioid overdose in Massachusetts. DESIGN A cross-sectional study. PARTICIPANTS All residents aged 18 years and older during 2011-2015 in the Massachusetts Department of Public Health's Data Warehouse (Veterans: n=144,263; non-Veterans: n=6,112,340). A total of 40,036 individuals had a record of homelessness, including 1307 Veterans and 38,729 non-Veterans. MAIN MEASURES The main independent variables were homelessness and Veteran status. Outcomes included nonfatal and fatal opioid overdose. RESULTS A higher proportion of Veterans with a record of homelessness were older than 45 years (77% vs. 48%), male (80% vs. 62%), or receiving high-dose opioid therapy (23% vs. 15%) compared with non-Veterans. The rates of nonfatal and fatal opioid overdose in Massachusetts were 85 and 16 per 100,000 residents, respectively. Among individuals with a record of homelessness, these rates increased 31-fold to 2609 and 19-fold to 300 per 100,000 residents. Homelessness and Veteran status were independently associated with higher odds of nonfatal and fatal opioid overdose. There was a significant interaction between homelessness and Veteran status in their effects on risk of fatal overdose. CONCLUSIONS Both homelessness and Veteran status were associated with a higher risk of fatal opioid overdoses. An understanding of health care utilization patterns can help identify treatment access points to improve patient safety among vulnerable individuals both in the Veteran population and among those experiencing homelessness.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Health Law, Policy and Management, Boston University School of Public Health
| | - Amy Bettano
- Office of Population Health, Department of Public Health, The Commonwealth of Massachusetts, Boston
| | - David Smelson
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Psychiatry, University of Massachusetts Medical School, Worcester
| | - Dana Bernson
- Office of Population Health, Department of Public Health, The Commonwealth of Massachusetts, Boston
| | - Adam J Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine
| | - Thomas Byrne
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Boston University School of Social Work, Boston
| | - Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Public Health
| | - Megan B McCullough
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Public Health
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Center for Population Health, University of Massachusetts, Lowell, MA
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Tschanz CMP, Cushman WC, Harrell CTE, Berlowitz DR, Sall JL. Synopsis of the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: The Diagnosis and Management of Hypertension in the Primary Care Setting. Ann Intern Med 2020; 173:904-913. [PMID: 32866417 DOI: 10.7326/m20-3798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION In January 2020, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the diagnosis and management of hypertension in the primary care setting. METHODS The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature from 15 December 2013 to 25 March 2019 and developed and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. RECOMMENDATIONS This synopsis summarizes key features of the guideline in several key areas: the measurement of blood pressure, the definition of hypertension, target treatment goals, and nonpharmacologic and pharmacologic treatment of essential and resistant hypertension.
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Affiliation(s)
| | - William C Cushman
- University of Tennessee Health Science Center, Memphis, Tennessee (W.C.C.)
| | | | - Dan R Berlowitz
- University of Massachusetts Lowell, Lowell, Massachusetts (D.R.B.)
| | - James L Sall
- U.S. Department of Veterans Affairs, Washington, DC (J.L.S.)
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10
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Pajewski NM, Berlowitz DR, Bress AP, Callahan KE, Cheung AK, Fine LJ, Gaussoin SA, Johnson KC, King J, Kitzman DW, Kostis JB, Lerner AJ, Lewis CE, Oparil S, Rahman M, Reboussin DM, Rocco MV, Snyder JK, Still C, Supiano MA, Wadley VG, Whelton PK, Wright JT, Williamson JD. Intensive vs Standard Blood Pressure Control in Adults 80 Years or Older: A Secondary Analysis of the Systolic Blood Pressure Intervention Trial. J Am Geriatr Soc 2020; 68:496-504. [PMID: 31840813 PMCID: PMC7056569 DOI: 10.1111/jgs.16272] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/29/2019] [Accepted: 11/01/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To evaluate the effect of intensive systolic blood pressure (SBP) control in older adults with hypertension, considering cognitive and physical function. DESIGN Secondary analysis. SETTING Systolic Blood Pressure Intervention Trial (SPRINT) PARTICIPANTS: Adults 80 years or older. INTERVENTION Participants with hypertension but without diabetes (N = 1167) were randomized to an SBP target below 120 mm Hg (intensive treatment) vs a target below 140 mm Hg (standard treatment). MEASUREMENTS We measured the incidence of cardiovascular disease (CVD), mortality, changes in renal function, mild cognitive impairment (MCI), probable dementia, and serious adverse events. Gait speed was assessed via a 4-m walk test, and the Montreal Cognitive Assessment (MoCA) was used to quantify baseline cognitive function. RESULTS Intensive treatment led to significant reductions in cardiovascular events (hazard ratio [HR] = .66; 95% confidence interval [CI] = .49-.90), mortality (HR = .67; 95% CI = .48-.93), and MCI (HR = .70; 95% CI = .51-.96). There was a significant interaction (P < .001) whereby participants with higher baseline scores on the MoCA derived strong benefit from intensive treatment for a composite of CVD and mortality (HR = .40; 95% CI = .28-.57), with no appreciable benefit in participants with lower scores on the MoCA (HR = 1.33 = 95% CI = .87-2.03). There was no evidence of heterogeneity of treatment effects with respect to gait speed. Rates of acute kidney injury and declines of at least 30% in estimated glomerular filtration rate were increased in the intensive treatment group with no between-group differences in the rate of injurious falls. CONCLUSION In adults aged 80 years or older, intensive SBP control lowers the risk of major cardiovascular events, MCI, and death, with increased risk of changes to kidney function. The cardiovascular and mortality benefits of intensive SBP control may not extend to older adults with lower baseline cognitive function. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT01206062. J Am Geriatr Soc 68:496-504, 2020.
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Affiliation(s)
- Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Dan R. Berlowitz
- Bedford Veterans Affairs Hospital, Bedford, Massachusetts;,Department of Public Health, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Adam P. Bress
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Kathryn E. Callahan
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Alfred K. Cheung
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, Utah
| | - Larry J. Fine
- Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Sarah A. Gaussoin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Karen C. Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jordan King
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah;,Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Dalane W. Kitzman
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John B. Kostis
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Alan J. Lerner
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Cora E. Lewis
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mahboob Rahman
- Department of Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - David M. Reboussin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael V. Rocco
- Section of Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Joni K. Snyder
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Carolyn Still
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Mark A. Supiano
- Division of Geriatrics, University of Utah School of Medicine, Salt Lake City, Utah;,Geriatric Research, Education, and Clinical Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Virginia G. Wadley
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul K. Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Jackson T. Wright
- Division of Nephrology and Hypertension, Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Jeff D. Williamson
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
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11
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Berlowitz DR, Foy C, Conroy M, Evans GW, Olney CM, Pisoni R, Powell JR, Gure TR, Shorr RI. Impact of Intensive Blood Pressure Therapy on Concern about Falling: Longitudinal Results from the Systolic Blood Pressure Intervention Trial (SPRINT). J Am Geriatr Soc 2020; 68:614-618. [PMID: 31778222 PMCID: PMC7824027 DOI: 10.1111/jgs.16264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/12/2019] [Accepted: 10/17/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Concern about falling is common among older hypertension patients and could impact decisions to intensify blood pressure therapy. Our aim was to determine whether intensive therapy targeting a systolic blood pressure (SBP) of 120 mm Hg is associated with greater changes in concern about falling when compared with standard therapy targeting an SBP of 140 mm Hg. DESIGN Subsample analysis of participants randomized to either intensive or standard therapy in the Systolic Blood Pressure Intervention Trial (SPRINT). SETTING Approximately 100 outpatient sites. PARTICIPANTS A total of 2313 enrollees in SPRINT; participants were all age 50 or older (mean = 69 y) and diagnosed with hypertension. MEASUREMENTS Concern about falling was described by the shortened version of the Falls Efficacy Scale International as measured at baseline, 6 months, 1 year, and annually thereafter. RESULTS Concern about falling showed a small but significant increase over time among all hypertension patients. No differences were noted, however, among those randomized to intensive vs standard therapy (P = .95). Among participants younger than 75 years, no increase in concern about falling over time was noted, but among participants aged 75 years and older, the mean falls self-efficacy score increased by .3 points per year (P < .0001). No differences were observed between the intensive and standard treatment groups when stratified by age (P = .55). CONCLUSION Intensive blood pressure therapy is not associated with increased concern about falling among older hypertension patients healthy enough to participate in SPRINT. J Am Geriatr Soc 68:614-618, 2020.
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Affiliation(s)
- Dan R. Berlowitz
- Bedford VA Hospital, Bedford, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Capri Foy
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Molly Conroy
- Department of Medicine, Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Gregory W. Evans
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Christine M. Olney
- Research Service, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Roberto Pisoni
- Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | - James R. Powell
- Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Tanya R. Gure
- Department of Medicine, Division of General Internal Medicine, Ohio State Wexner Medical Center, Columbus, Ohio
| | - Ronald I. Shorr
- Malcom Randall VA Medical Center, University of Florida, Gainesville, Florida
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12
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Foy CG, Newman JC, Russell GB, Berlowitz DR, Bates JT, Burgner AM, Carson TY, Chertow GM, Doumas MN, Hughes RY, Kostis JB, Buren PV, Wadley VG. Effect of Intensive vs Standard Blood Pressure Treatment Upon Erectile Function in Hypertensive Men: Findings From the Systolic Blood Pressure Intervention Trial. J Sex Med 2019; 17:238-248. [PMID: 31862174 DOI: 10.1016/j.jsxm.2019.11.256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The effect of intensive blood pressure control upon erectile function in men with hypertension, but without diabetes, is largely unknown. AIM To examine the effects of intensive systolic blood pressure (SBP) lowering on erectile function in a multiethnic clinical trial of men with hypertension. METHODS We performed subgroup analyses from the Systolic Blood Pressure Intervention Trial ([SPRINT]; ClinicalTrials.gov: NCT120602, in a sample of 1255 men aged 50 years or older with hypertension and increased cardiovascular disease risk. Participants were randomly assigned to an intensive treatment group (SBP goal of <120 mmHg) or a standard treatment group (SBP goal of <140 mmHg). MAIN OUTCOME MEASURE The main outcome measure was change in erectile function from baseline, using the 5-item International Index of Erectile Function (IIEF-5) total score, and erectile dysfunction ([ED]; defined as IIEF-5 score ≤21) after a median follow-up of 3 years. RESULTS At baseline, roughly two-thirds (66.1%) of the sample had self-reported ED. At 48 months after randomization, we determined that the effects of more intensive blood pressure lowering were significantly moderated by race-ethnicity (p for interaction = 0.0016), prompting separate analyses stratified by race-ethnicity. In non-Hispanic whites, participants in the intensive treatment group reported slightly, but significantly better change in the IIEF-5 score than those in the standard treatment group (mean difference = 0.67; 95% CI = 0.03, 1.32; P = 0.041). In non-Hispanic blacks, participants in the intensive group reported slightly worse change in the IIEF-5 score than those in the standard group (mean difference = -1.17; 95% CI = -1.92, -0.41; P = 0.0025). However, in non-Hispanic whites and non-Hispanic blacks, further adjustment for the baseline IIEF-5 score resulted in nonsignificant differences (P > 0.05) according to the treatment group. In Hispanic/other participants, there were no significant differences in change in the IIEF-5 score between the two treatment groups (P = 0.40). In a subgroup of 280 participants who did not report ED at baseline, the incidence of ED did not differ in the two treatment groups (P = 0.53) and was without interaction by race-ethnicity. CLINICAL IMPLICATIONS The effect of intensive treatment of blood pressure on erectile function was very small overall and likely not of great clinical magnitude. STRENGTH & LIMITATIONS Although this study included a validated measure of erectile function, testosterone, other androgen, and estrogen levels were not assessed. CONCLUSION In a sample of male patients at high risk for cardiovascular events but without diabetes, targeting a SBP of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in statistically significant effects on erectile function that differed in accordance with race-ethnicity, although the clinical importance of the differences may be of small magnitude. Foy CG, Newman JC, Russell GB, et al. Effect of Intensive vs Standard Blood Pressure Treatment Upon Erectile Function in Hypertensive Men: Findings From the Systolic Blood Pressure Intervention Trial. J Sex Med 2020;17:238-248.
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Affiliation(s)
- Capri G Foy
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Jill C Newman
- Division of Public Health Sciences, Department of Biostatistic and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Greg B Russell
- Division of Public Health Sciences, Department of Biostatistic and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Dan R Berlowitz
- Bedford VA Hospital, Bedford, MA, and Boston University School of Medicine and Boston University School of Public Health, Boston, MA, USA
| | - Jeffrey T Bates
- Michael E. DeBakey Veterans' Administration Medical Center, Houston, TX, USA
| | - Anna M Burgner
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Thaddeus Y Carson
- Division of Internal Medicine, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Michael N Doumas
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Robin Y Hughes
- University Hospitals Case Medical Center, Cleveland, OH, USA
| | - John B Kostis
- Robert Wood Johnson Medical School, Rutgers University, University of Medicine and Dentistry of New Jersey, New Brunswick, NJ, USA
| | - Peter van Buren
- Department of Internal Medicine, Dallas Veterans' Administration Medical Center and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Virginia G Wadley
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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13
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Jasuja GK, Ameli O, Reisman JI, Rose AJ, Miller DR, Berlowitz DR, Bhasin S. Health Outcomes Among Long-term Opioid Users With Testosterone Prescription in the Veterans Health Administration. JAMA Netw Open 2019; 2:e1917141. [PMID: 31825502 PMCID: PMC6991198 DOI: 10.1001/jamanetworkopen.2019.17141] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Androgen deficiency is common among male opioid users, and opioid use has emerged as a common antecedent of testosterone treatment. The long-term health outcomes associated with testosterone therapy remain unknown, however. OBJECTIVE To compare health outcomes between long-term opioid users with testosterone deficiency who filled testosterone prescriptions and those with the same condition but who did not receive testosterone treatment. DESIGN, SETTING, AND PARTICIPANTS This cohort study focused on men in the care of the Veterans Health Administration (VHA) facilities throughout the United States from October 1, 2008, to September 30, 2014. It included male veterans who were long-term opioid users, had low testosterone levels (<300 ng/dL), and received either a testosterone prescription or any other prescription. It excluded male patients with HIV infection, gender dysphoria, or prostate cancer and those who received testosterone in fiscal year 2008. Data were analyzed from April 1, 2017, to April 30, 2019. EXPOSURE Prescription for testosterone. MAIN OUTCOMES AND MEASURES All-cause mortality and incidence of major adverse cardiovascular events (MACE), vertebral or femoral fractures, and anemia during the 6-year follow-up through September 30, 2015. RESULTS After exclusions, 21 272 long-term opioid users (mean [SD] age, 53 [10] years; n = 16 689 [78.5%] white) with low total or free testosterone levels were included for analysis, of whom 14 121 (66.4%) received testosterone and 7151 (33.6%) did not. At baseline, compared with opioid users who did not receive testosterone, long-term opioid users who received testosterone treatment were more likely to have obesity (43.7% vs 49.0%; P < .001), hyperlipidemia (43.0% vs 48.8%; P < .001), and hypertension (53.9% vs 55.2%; P = .07) but had lower prevalence of coronary artery disease (15.9% vs 12.9%; P < .001) and stroke (2.4% vs 1.3%; P < .001). After adjusting for covariates, opioid users who received testosterone had significantly lower all-cause mortality (hazard ratio [HR] = 0.51; 95% CI, 0.42-0.61) and lower incidence of MACE (HR = 0.58; 95% CI, 0.51-0.67), femoral or hip fractures (HR = 0.68; 95% CI, 0.48-0.96), and anemia (HR = 0.73; 95% CI, 0.68-0.79) during the follow-up period of up to 6 years, compared with their counterparts without a testosterone prescription. In covariate-adjusted models, men who received opioids plus testosterone were more likely to have resolved anemia compared with those who received opioids only during the 6-year follow-up (HR = 1.16; 95% CI, 1.02-1.31). Similar results were obtained in propensity score-matched models and when analyses were restricted to opioid users with noncancer pain or those who did not receive glucocorticoids. CONCLUSIONS AND RELEVANCE This study found that, in the VHA system, male long-term opioid users with testosterone deficiency who were treated with opioid and testosterone medications had significantly lower all-cause mortality and significantly lower incidence of MACE, femoral or hip fractures, and anemia after a multiyear follow-up. These results warrant confirmation through a randomized clinical trial to ascertain the efficacy of testosterone in improving health outcomes for opioid users with androgen deficiency.
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Affiliation(s)
- Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Administration Medical Center, Bedford, Massachusetts
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Omid Ameli
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- OptumLabs, Cambridge, Massachusetts
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Administration Medical Center, Bedford, Massachusetts
| | - Adam J. Rose
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Administration Medical Center, Bedford, Massachusetts
| | - Dan R. Berlowitz
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Administration Medical Center, Bedford, Massachusetts
| | - Shalender Bhasin
- Research Program in Men’s Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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14
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Derington CG, Gums TH, Bress AP, Herrick JS, Greene TH, Moran AE, Weintraub WS, Kronish IM, Morisky DE, Trinkley KE, Saseen JJ, Reynolds K, Bates JT, Berlowitz DR, Chang TI, Chonchol M, Cushman WC, Foy CG, Herring CT, Katz LA, Krousel-Wood M, Pajewski NM, Tamariz L, King JB. Association of Total Medication Burden With Intensive and Standard Blood Pressure Control and Clinical Outcomes: A Secondary Analysis of SPRINT. Hypertension 2019; 74:267-275. [PMID: 31256717 PMCID: PMC6938559 DOI: 10.1161/hypertensionaha.119.12907] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Total medication burden (antihypertensive and nonantihypertensive medications) may be associated with poor systolic blood pressure (SBP) control. We investigated the association of baseline medication burden and clinical outcomes and whether the effect of the SBP intervention varied according to baseline medication burden in SPRINT (Systolic Blood Pressure Intervention Trial). Participants were randomized to intensive or standard SBP goal (below 120 or 140 mm Hg, respectively); n=3769 participants with high baseline medication burden (≥5 medications) and n=5592 with low burden (<5 medications). PRIMARY OUTCOME differences in SBP. SECONDARY OUTCOMES 8-item Morisky Medication Adherence Scale and modified Treatment Satisfaction Questionnaire for Medications measured at baseline and 12 months and incident cardiovascular disease events and serious adverse events throughout the trial. Participants in the intensive group with high versus low medication burden were less likely to achieve their SBP goal at 12 months (risk ratio, 0.91; 95% CI, 0.85-0.97) but not in the standard group (risk ratio, 0.98; 95% CI, 0.93-1.03; Pinteraction<0.001). High medication burden was associated with increased cardiovascular disease events (hazard ratio, 1.39; 95% CI, 1.14-1.70) and serious adverse events (hazard ratio, 1.34; 95% CI, 1.24-1.45), but the effect of intensive versus standard treatment did not vary between medication burden groups (Pinteraction>0.5). Medication burden had minimal association with adherence or satisfaction. High baseline medication burden was associated with worse intensive SBP control and higher rates of cardiovascular disease events and serious adverse events. The relative benefits and risks of intensive SBP goals were similar regardless of medication burden. CLINICAL TRIAL REGISTRATION- URL http://www. CLINICALTRIALS gov. Unique identifier: NCT01206062.
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Affiliation(s)
- Catherine G Derington
- From Kaiser Permanente Colorado, Aurora (C.G.D., J.B.K.).,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO (C.G.D., K.E.T., J.J.S.)
| | - Tyler H Gums
- University of Texas at Austin, Austin, TX (T.H.G.)
| | - Adam P Bress
- University of Utah, School of Medicine, Salt Lake City, UT (A.P.B., J.S.H., T.H.G., J.B.K.)
| | - Jennifer S Herrick
- University of Utah, School of Medicine, Salt Lake City, UT (A.P.B., J.S.H., T.H.G., J.B.K.)
| | - Tom H Greene
- University of Utah, School of Medicine, Salt Lake City, UT (A.P.B., J.S.H., T.H.G., J.B.K.)
| | - Andrew E Moran
- Columbia University Medical Center, New York, NY (A.E.M., I.M.K.)
| | | | - Ian M Kronish
- Columbia University Medical Center, New York, NY (A.E.M., I.M.K.)
| | - Donald E Morisky
- Fielding School of Public Health, University of California Los Angeles, CA (D.E.M.)
| | - Katy E Trinkley
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO (C.G.D., K.E.T., J.J.S.).,School of Medicine, University of Colorado, Aurora, CO (K.E.T., J.J.S., M.C.)
| | - Joseph J Saseen
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO (C.G.D., K.E.T., J.J.S.).,School of Medicine, University of Colorado, Aurora, CO (K.E.T., J.J.S., M.C.)
| | | | - Jeffrey T Bates
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (J.T.B.).,Baylor College of Medicine, Houston, TX (J.T.B.)
| | | | - Tara I Chang
- Stanford University School of Medicine, CA (T.I.C.)
| | - Michel Chonchol
- School of Medicine, University of Colorado, Aurora, CO (K.E.T., J.J.S., M.C.)
| | - William C Cushman
- Memphis Veteran's Affairs Medical Center, Memphis, TN (W.C.C.).,University of Tennessee Health Science Center, Memphis, TN (W.C.C.)
| | - Capri G Foy
- Wake Forest School of Medicine, Winston-Salem, NC (C.G.F., N.M.P.)
| | - Charles T Herring
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC (C.T.H.)
| | - Lois Anne Katz
- New York University Langone School of Medicine, New York, NY (L.A.K.)
| | - Marie Krousel-Wood
- Tulane University School of Medicine and Public Health and Tropical Medicine, New Orleans, LA (M.K.-W.).,Ochsner Health System, New Orleans, LA (M.K.-W.)
| | | | | | - Jordan B King
- From Kaiser Permanente Colorado, Aurora (C.G.D., J.B.K.).,University of Utah, School of Medicine, Salt Lake City, UT (A.P.B., J.S.H., T.H.G., J.B.K.)
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15
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Foy CG, Newman JC, Berlowitz DR, Russell LP, Kimmel PL, Wadley VG, Thomas HN, Lerner AJ, Riley WT. Blood Pressure, Sexual Activity, and Erectile Function in Hypertensive Men: Baseline Findings from the Systolic Blood Pressure Intervention Trial (SPRINT). J Sex Med 2019; 16:235-247. [PMID: 30655182 PMCID: PMC6444897 DOI: 10.1016/j.jsxm.2018.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/29/2018] [Accepted: 12/06/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Erectile function, an important aspect of quality of life, is gaining increased research and clinical attention in older men with hypertension. AIM To assess the cross-sectional association between blood pressure measures (systolic blood pressure [SBP]; diastolic blood pressure [DBP]; and pulse pressure [PP]) and (i) sexual activity and (ii) erectile function in hypertensive men. METHODS We performed analyses of 1,255 male participants in a larger randomized clinical trial of 9,361 men and women with hypertension aged ≥50 years. MAIN OUTCOME MEASURES The main outcome measures were self-reported sexual activity (yes/no) and erectile function using the 5-item International Index of Erectile Function (IIEF-5). RESULTS 857 participants (68.3%) reported being sexually active during the previous 4 weeks. The mean (SD) IIEF-5 score for sexually active participants was 18.0 (5.8), and 59.9% of the sample reported an IIEF-5 score <21, suggesting erectile dysfunction (ED). In adjusted logistic regression models, neither SBP (adjusted odds ratio = 0.998; P = .707) nor DBP (adjusted odds ratio = 1.001; P = .929) was significantly associated with sexual activity. In multivariable linear regression analyses in sexually active participants, lower SBP (β = -0.04; P = .025) and higher DBP (β = 0.05; P = .029) were associated with better erectile function. In additional multivariable analyses, lower PP pressure was associated with better erectile function (β = -0.04; P = .02). CLINICAL IMPLICATIONS Blood pressure is an important consideration in the assessment of erectile function in men with hypertension. STRENGTHS & LIMITATIONS Assessments of blood pressure and clinical and psychosocial variables were performed using rigorous methods in this multi-ethnic and geographically diverse sample. However, these cross-sectional analyses did not include assessment of androgen or testosterone levels. CONCLUSIONS Erectile dysfunction was highly prevalent in this sample of men with hypertension, and SBP, DBP, and PP were associated with erectile function in this sample. Foy CG, Newman JC, Berlowitz DR, et al. Blood Pressure, Sexual Activity, and Erectile Function in Hypertensive Men: Baseline Findings from the Systolic Blood Pressure Intervention Trial (SPRINT). J Sex Med 2019;16:235-247.
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Affiliation(s)
- Capri G Foy
- Wake Forest School of Medicine, Division of Public Health Sciences, Department of Social Sciences and Health Policy, Winston-Salem, NC, USA.
| | - Jill C Newman
- Wake Forest School of Medicine, Division of Public Health Sciences, Department of Biostatistical Sciences, Winston-Salem, NC, USA
| | - Dan R Berlowitz
- Bedford VA Hospital, Bedford, MA, and Boston University School of Medicine and Boston University School of Public Health, Boston, MA, USA
| | - Laurie P Russell
- Wake Forest School of Medicine, Division of Public Health Sciences, Department of Biostatistical Sciences, Winston-Salem, NC, USA
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, USA
| | - Virginia G Wadley
- University of Alabama at Birmingham School of Medicine, Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, Birmingham, AL, USA
| | - Holly N Thomas
- University of Pittsburgh, Division of General Internal Medicine, Section of Women's Health, Pittsburgh, PA, USA
| | - Alan J Lerner
- Case Western Reserve University School of Medicine, Department of Neurology and Brain Health and Memory Center, Cleveland, OH, USA
| | - William T Riley
- National Institutes of Health, Office of Behavioral and Social Sciences Research, Bethesda, MD, USA
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16
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Hartmann CW, Mills WL, Pimentel CB, Palmer JA, Allen RS, Zhao S, Wewiorski NJ, Sullivan JL, Dillon K, Clark V, Berlowitz DR, Snow AL. Impact of Intervention to Improve Nursing Home Resident-Staff Interactions and Engagement. Gerontologist 2018; 58:e291-e301. [PMID: 29718195 DOI: 10.1093/geront/gny039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Indexed: 12/26/2022] Open
Abstract
Background and Objectives For nursing home residents, positive interactions with staff and engagement in daily life contribute meaningfully to quality of life. We sought to improve these aspects of person-centered care in an opportunistic snowball sample of six Veterans Health Administration nursing homes (e.g., Community Living Centers-CLCs) using an intervention that targeted staff behavior change, focusing on improving interactions between residents and staff and thereby ultimately aiming to improve resident engagement. Research Design and Methods We grounded this mixed-methods study in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change. We implemented the intervention by (a) using a set of evidence-based practices for implementing quality improvement and (b) combining primarily CLC-based staff facilitation with some researcher-led facilitation. Validated resident and staff surveys and structured observations collected pre and post intervention, as well as semi-structured staff interviews conducted post intervention, helped assess intervention success. Results Sixty-two CLC residents and 308 staff members responded to the surveys. Researchers conducted 1,490 discrete observations. Intervention implementation was associated with increased staff communication with residents during the provision of direct care and decreased negative staff interactions with residents. In the 66 interviews, staff consistently credited the intervention with helping them (a) develop awareness of the importance of identifying opportunities for engagement and (b) act to improve the quality of interactions between residents and staff. Discussion and Implications The intervention proved feasible and influenced staff to make simple enhancements to their behaviors that improved resident-staff interactions and staff-assessed resident engagement.
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Affiliation(s)
- Christine W Hartmann
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Massachusetts
| | - Whitney L Mills
- Center for Innovation in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Department of Medicine - Section of Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Camilla B Pimentel
- New England Geriatric Research Education and Clinical Center, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Jennifer A Palmer
- Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts
| | - Rebecca S Allen
- Tuscaloosa Veterans Affairs Medical Center, Tuscaloosa, Alabama.,Alabama Research Institute on Aging and the Department of Psychology, University of Alabama, Tuscaloosa
| | - Shibei Zhao
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Nancy J Wewiorski
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Jennifer L Sullivan
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Massachusetts.,Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Massachusetts
| | - Kristen Dillon
- Hospice and Palliative Care, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Valerie Clark
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Massachusetts
| | - Andrea Lynn Snow
- Tuscaloosa Veterans Affairs Medical Center, Tuscaloosa, Alabama.,Alabama Research Institute on Aging and the Department of Psychology, University of Alabama, Tuscaloosa
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17
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Jasuja GK, Ameli O, Miller DR, Land T, Bernson D, Rose AJ, Berlowitz DR, Smelson DA. Overdose risk for veterans receiving opioids from multiple sources. Am J Manag Care 2018; 24:536-540. [PMID: 30452210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate whether veterans in Massachusetts receiving opioids and/or benzodiazepines from both Veterans Health Administration (VHA) and non-VHA pharmacies are at higher risk of adverse events compared with those receiving opioids at VHA pharmacies only. STUDY DESIGN A cohort study of veterans who filled a prescription for any Schedule II through V substance at a Massachusetts VHA pharmacy. Prescriptions were recorded in the Massachusetts Department of Public Health Chapter 55 data set. METHODS The study sample included 16,866 veterans residing in Massachusetts, of whom 9238 (54.8%) received controlled substances from VHA pharmacies only and 7628 (45.2%) had filled prescriptions at both VHA and non-VHA pharmacies ("dual care users") between October 1, 2013, and December 31, 2015. Our primary outcomes were nonfatal opioid overdose, fatal opioid overdose, and all-cause mortality. RESULTS Compared with VHA-only users, more dual care users resided in rural areas (12.6% vs 10.6%), received high-dose opioid therapy (26.3% vs 7.3%), had concurrent prescriptions of opioids and benzodiazepines (34.8% vs 8.2%), and had opioid use disorder (6.8% vs 1.6%) (P <.0001 for all). In adjusted models, dual care users had higher odds of nonfatal opioid overdose (odds ratio [OR], 1.29; 95% CI, 0.98-1.71) and all-cause mortality (OR, 1.66; 95% CI, 1.43-1.93) compared with VHA-only users. Dual care use was not associated with fatal opioid overdoses. CONCLUSIONS Among veterans in Massachusetts, receipt of opioids from multiple sources was associated with worse outcomes, specifically nonfatal opioid overdose and mortality. Better information sharing between VHA and non-VHA pharmacies and prescribers has the potential to improve patient safety.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, 200 Springs Rd, Bedford, MA 01730.
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18
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Affiliation(s)
- Dan R. Berlowitz
- The Center for Healthcare Organization and Implementation ResearchBedford VA HospitalBedfordMassachusetts
- The Boston UniversitySchools of Public Health and MedicineBostonMassachusetts
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19
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Oparil S, Acelajado MC, Bakris GL, Berlowitz DR, Cífková R, Dominiczak AF, Grassi G, Jordan J, Poulter NR, Rodgers A, Whelton PK. Hypertension. Nat Rev Dis Primers 2018; 4:18014. [PMID: 29565029 PMCID: PMC6477925 DOI: 10.1038/nrdp.2018.14] [Citation(s) in RCA: 513] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Systemic arterial hypertension is the most important modifiable risk factor for all-cause morbidity and mortality worldwide and is associated with an increased risk of cardiovascular disease (CVD). Fewer than half of those with hypertension are aware of their condition, and many others are aware but not treated or inadequately treated, although successful treatment of hypertension reduces the global burden of disease and mortality. The aetiology of hypertension involves the complex interplay of environmental and pathophysiological factors that affect multiple systems, as well as genetic predisposition. The evaluation of patients with hypertension includes accurate standardized blood pressure (BP) measurement, assessment of the patients' predicted risk of atherosclerotic CVD and evidence of target-organ damage, and detection of secondary causes of hypertension and presence of comorbidities (such as CVD and kidney disease). Lifestyle changes, including dietary modifications and increased physical activity, are effective in lowering BP and preventing hypertension and its CVD sequelae. Pharmacological therapy is very effective in lowering BP and in preventing CVD outcomes in most patients; first-line antihypertensive medications include angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, dihydropyridine calcium-channel blockers and thiazide diuretics.
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Affiliation(s)
- Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, School of Medicine, The University of Alabama at Birmingham (UAB), 1720 2nd Avenue South, Birmingham, Alabama, USA 35294-0007
| | | | - George L. Bakris
- University of Chicago Medicine, Chicago, Illinois, United States of America (U.S.A.)
| | - Dan R. Berlowitz
- Center for Healthcare Organization and Implementation Research, Bedford Veteran Affairs Medical Center, Bedford, Massachusetts,Schools of Medicine and Public Health, Boston University, Boston, Massachusetts, United States of America (U.S.A.)
| | - Renata Cífková
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer Hospital, Prague, Czech Republic
| | - Anna F. Dominiczak
- Institute of Cardiovascular and Medical Science, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (U.K.)
| | - Guido Grassi
- Clinica Medica, University of Milano-Bicocca, Milan, Italy,IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center (DLR), University of Cologne, Cologne, Germany
| | - Neil R. Poulter
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, United Kingdom (U.K.)
| | - Anthony Rodgers
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Paul K. Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America (U.S.A.)
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20
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Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Skolnik A, Berlowitz DR, Gifford AL. Use of testosterone in men infected with human immunodeficiency virus in the veterans healthcare system. AIDS Care 2018; 30:1207-1214. [PMID: 29557189 DOI: 10.1080/09540121.2018.1447080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Testosterone supplementation has been widely used in those infected with human immunodeficiency virus (HIV) for hypogonadism, and wasting. But with effective antiretroviral therapy and increasing recognition of atherosclerotic disease and adults infected with HIV, the risks of inappropriate testosterone use in HIV-infected patients are far better recognized than previously. Testosterone use has expanded among U.S. males, but few studies have examined prescribing in those infected with HIV. In a national cohort of males with at least one outpatient prescription in the Veterans Health Administration (VHA), we examined 9475 HIV-infected males, including 2484 who had received testosterone and a randomly selected 6991 who had not. For comparison, we identified 1,387,241 uninfected males (189,369 had received testosterone and a randomly selected 1,197,872 had not). We determined rates of new and prevalent testosterone use, and also examined the adequacy of the diagnostic evaluation that had preceded testosterone initiation among our HIV-infected and uninfected testosterone groups. Our main results were as follows. HIV-infected men had higher rates of initiation (0.8% vs. 0.4% in FY09; p < 0.001) and prevalence of testosterone use (2.2% vs. 0.8% in FY08; p < 0.001) compared to the uninfected men across the entire period. Trends of prescribing for both groups followed a similar pattern, rising from FY08, reaching a peak in FY13, and then dipping in FY 14. Only 1.1% of HIV-infected patients had a fully guideline-concordant workup before starting testosterone therapy, compared to 3.5% of uninfected patients (p < 0.001). In conclusion, testosterone use among HIV-infected patients in the VHA system rose to a peak in FY13 and has decreased somewhat since. Only a small minority of HIV-infected patients who receive testosterone therapy from VHA have undergone an appropriate workup before starting therapy, suggesting an opportunity for improvement.
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Affiliation(s)
- Guneet K Jasuja
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA
| | - Shalender Bhasin
- d Research Program in Men's Health, Aging and Metabolism; Boston Claude D. Pepper Older Americans Independence Center , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
| | - Adam J Rose
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,e Department of Medicine , Section of General Internal Medicine, Boston University School of Medicine , Boston , MA , USA
| | - Joel I Reisman
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA
| | - Avy Skolnik
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA
| | - Dan R Berlowitz
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA
| | - Allen L Gifford
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,b VA Boston Healthcare System , Boston , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA.,e Department of Medicine , Section of General Internal Medicine, Boston University School of Medicine , Boston , MA , USA
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21
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Snow AL, Jacobs ML, Palmer JA, Parmelee PA, Allen RS, Wewiorski NJ, Hilgeman MM, Vinson LD, Berlowitz DR, Halli-Tierney AD, Hartmann CW. Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship. Gerontologist 2018; 58:e15-e24. [PMID: 28499032 PMCID: PMC6281332 DOI: 10.1093/geront/gnw255] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 01/13/2017] [Indexed: 11/12/2022] Open
Abstract
Purpose of Study To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions. Design and Methods In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification. Results The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review. Implications The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.
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Affiliation(s)
- A Lynn Snow
- Research & Development, Tuscaloosa VA Medical Center, Alabama
- Alabama Research Institute on Aging and Psychology Department, The University of Alabama, Tuscaloosa
| | - M Lindsey Jacobs
- Mental Health Service, VA Boston Healthcare System Brockton Division, Massachusetts
| | - Jennifer A Palmer
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Patricia A Parmelee
- Alabama Research Institute on Aging and Psychology Department, The University of Alabama, Tuscaloosa
| | - Rebecca S Allen
- Alabama Research Institute on Aging and Psychology Department, The University of Alabama, Tuscaloosa
| | - Nancy J Wewiorski
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Michelle M Hilgeman
- Research & Development, Tuscaloosa VA Medical Center, Alabama
- Alabama Research Institute on Aging and Psychology Department, The University of Alabama, Tuscaloosa
| | - Latrice D Vinson
- Mental Illness Research, Education & Clinical Center, VA Maryland Health Care System, Baltimore
| | - Dan R Berlowitz
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
- Health Law, Policy, & Management, Boston University School of Public Health, Massachusetts
| | - Anne D Halli-Tierney
- Alabama Research Institute on Aging and College of Community Health Sciences, The University of Alabama, Tuscaloosa
| | - Christine W Hartmann
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
- Health Law, Policy, & Management, Boston University School of Public Health, Massachusetts
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22
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23
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Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Hanlon JT, Miller DR, Morreale AP, Pogach LM, Cunningham FE, Park A, Wiener RS, Gifford AL, Berlowitz DR. Provider and Site-Level Determinants of Testosterone Prescribing in the Veterans Healthcare System. J Clin Endocrinol Metab 2017; 102:3226-3233. [PMID: 28911150 PMCID: PMC5587071 DOI: 10.1210/jc.2017-00468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023]
Abstract
CONTEXT Testosterone prescribing rates have increased substantially in the past decade. However, little is known about the context within which such prescriptions occur. OBJECTIVE We evaluated provider- and site-level determinants of receipt of testosterone and of guideline-concordant testosterone prescribing. DESIGN This study was cross-sectional in design. SETTING This study was conducted at the Veterans Health Administration (VA). PARTICIPANTS Study participants were a national cohort of male patients who had received at least one outpatient prescription within the VA during fiscal year (FY) 2008 to FY 2012. A total of 38,648 providers and 130 stations were associated with these patients. MAIN OUTCOME MEASURE This study measured receipt of testosterone and guideline-concordant testosterone prescribing. RESULTS Providers ranging in age from 31 to 60 years, with less experience in the VA [all adjusted odds ratio (AOR), <2; P < 0.01] and credentialed as medical doctors in endocrinology (AOR, 3.88; P < 0.01) and urology (AOR, 1.48; P < 0.01) were more likely to prescribe testosterone compared with older providers, providers of longer VA tenure, and primary care providers, respectively. Sites located in the West compared with the Northeast [AOR, 1.75; 95% confidence interval (CI), 1.45-2.11] and care received at a community-based outpatient clinic compared with a medical center (AOR, 1.22; 95% CI, 1.20-1.24) also predicted testosterone use. Although they were more likely to prescribe testosterone, endocrinologists were also more likely to obtain an appropriate workup before prescribing compared with primary care providers (AOR, 2.14; 95% CI, 1.54-2.97). CONCLUSIONS Our results highlight the opportunity to intervene at both the provider and the site levels to improve testosterone prescribing. This study also provides a useful example of how to examine contributions to prescribing variation at different levels of the health care system.
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Affiliation(s)
- Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
| | - Shalender Bhasin
- Research Program in Men’s Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School Boston, Boston, Massachusetts 02115
| | - Adam J. Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Joseph T. Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15213
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Anthony P. Morreale
- Clinical Pharmacy Services and Healthcare Services Research, VA Pharmacy Benefits Management Services VACO, San Diego, California 92161
| | - Leonard M. Pogach
- Department of Veterans Affairs, New Jersey Healthcare System, East Orange, New Jersey 07018
| | | | - Angela Park
- New England Veterans Engineering Resource Center, Boston, Massachusetts 02130
| | - Renda S. Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Medicine, The Pulmonary Center, Boston University, Boston, Massachusetts 02118
| | - Allen L. Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Dan R. Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
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24
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Berlowitz DR, Foy CG, Kazis LE, Bolin LP, Conroy MB, Fitzpatrick P, Gure TR, Kimmel PL, Kirchner K, Morisky DE, Newman J, Olney C, Oparil S, Pajewski NM, Powell J, Ramsey T, Simmons DL, Snyder J, Supiano MA, Weiner DE, Whittle J. Effect of Intensive Blood-Pressure Treatment on Patient-Reported Outcomes. N Engl J Med 2017; 377:733-744. [PMID: 28834483 PMCID: PMC5706112 DOI: 10.1056/nejmoa1611179] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The previously published results of the Systolic Blood Pressure Intervention Trial showed that among participants with hypertension and an increased cardiovascular risk, but without diabetes, the rates of cardiovascular events were lower among those who were assigned to a target systolic blood pressure of less than 120 mm Hg (intensive treatment) than among those who were assigned to a target of less than 140 mm Hg (standard treatment). Whether such intensive treatment affected patient-reported outcomes was uncertain; those results from the trial are reported here. METHODS We randomly assigned 9361 participants with hypertension to a systolic blood-pressure target of less than 120 mm Hg or a target of less than 140 mm Hg. Patient-reported outcome measures included the scores on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Veterans RAND 12-Item Health Survey, the Patient Health Questionnaire 9-item depression scale (PHQ-9), patient-reported satisfaction with their blood-pressure care and blood-pressure medications, and adherence to blood-pressure medications. We compared the scores in the intensive-treatment group with those in the standard-treatment group among all participants and among participants stratified according to physical and cognitive function. RESULTS Participants who received intensive treatment received an average of one additional antihypertensive medication, and the systolic blood pressure was 14.8 mm Hg (95% confidence interval, 14.3 to 15.4) lower in the group that received intensive treatment than in the group that received standard treatment. Mean PCS, MCS, and PHQ-9 scores were relatively stable over a median of 3 years of follow-up, with no significant differences between the two treatment groups. No significant differences between the treatment groups were noted when participants were stratified according to baseline measures of physical or cognitive function. Satisfaction with blood-pressure care was high in both treatment groups, and we found no significant difference in adherence to blood-pressure medications. CONCLUSIONS Patient-reported outcomes among participants who received intensive treatment, which targeted a systolic blood pressure of less than 120 mm Hg, were similar to those among participants who received standard treatment, including among participants with decreased physical or cognitive function. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062 .).
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Affiliation(s)
- Dan R Berlowitz
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Capri G Foy
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Lewis E Kazis
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Linda P Bolin
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Molly B Conroy
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Peter Fitzpatrick
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Tanya R Gure
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Paul L Kimmel
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Kent Kirchner
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Donald E Morisky
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Jill Newman
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Christine Olney
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Suzanne Oparil
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Nicholas M Pajewski
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - James Powell
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Thomas Ramsey
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Debra L Simmons
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Joni Snyder
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Mark A Supiano
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Daniel E Weiner
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Jeff Whittle
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
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Bress AP, Bellows BK, King JB, Hess R, Beddhu S, Zhang Z, Berlowitz DR, Conroy MB, Fine L, Oparil S, Morisky DE, Kazis LE, Ruiz-Negrón N, Powell J, Tamariz L, Whittle J, Wright JT, Supiano MA, Cheung AK, Weintraub WS, Moran AE. Cost-Effectiveness of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2017; 377:745-755. [PMID: 28834469 PMCID: PMC5708850 DOI: 10.1056/nejmsa1616035] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In the Systolic Blood Pressure Intervention Trial (SPRINT), adults at high risk for cardiovascular disease who received intensive systolic blood-pressure control (target, <120 mm Hg) had significantly lower rates of death and cardiovascular disease events than did those who received standard control (target, <140 mm Hg). On the basis of these data, we wanted to determine the lifetime health benefits and health care costs associated with intensive control versus standard control. METHODS We used a microsimulation model to apply SPRINT treatment effects and health care costs from national sources to a hypothetical cohort of SPRINT-eligible adults. The model projected lifetime costs of treatment and monitoring in patients with hypertension, cardiovascular disease events and subsequent treatment costs, treatment-related risks of serious adverse events and subsequent costs, and quality-adjusted life-years (QALYs) for intensive control versus standard control of systolic blood pressure. RESULTS We determined that the mean number of QALYs would be 0.27 higher among patients who received intensive control than among those who received standard control and would cost approximately $47,000 more per QALY gained if there were a reduction in adherence and treatment effects after 5 years; the cost would be approximately $28,000 more per QALY gained if the treatment effects persisted for the remaining lifetime of the patient. Most simulation results indicated that intensive treatment would be cost-effective (51 to 79% below the willingness-to-pay threshold of $50,000 per QALY and 76 to 93% below the threshold of $100,000 per QALY), regardless of whether treatment effects were reduced after 5 years or persisted for the remaining lifetime. CONCLUSIONS In this simulation study, intensive systolic blood-pressure control prevented cardiovascular disease events and prolonged life and did so at levels below common willingness-to-pay thresholds per QALY, regardless of whether benefits were reduced after 5 years or persisted for the patient's remaining lifetime. (Funded by the National Heart, Lung, and Blood Institute and others; SPRINT ClinicalTrials.gov number, NCT01206062 .).
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Affiliation(s)
- Adam P Bress
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Brandon K Bellows
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Jordan B King
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Rachel Hess
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Srinivasan Beddhu
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Zugui Zhang
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Dan R Berlowitz
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Molly B Conroy
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Larry Fine
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Suzanne Oparil
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Donald E Morisky
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Lewis E Kazis
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Natalia Ruiz-Negrón
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Jamie Powell
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Leonardo Tamariz
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Jeff Whittle
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Jackson T Wright
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Mark A Supiano
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Alfred K Cheung
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - William S Weintraub
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
| | - Andrew E Moran
- From the Departments of Population Health Sciences (A.P.B., R.H., M.B.C.) and Pharmacotherapy (B.K.B., N.R.-N.) and the Divisions of General Internal Medicine (R.H., M.B.C.), Nephrology and Hypertension (S.B., A.K.C.), and Geriatrics (M.A.S.), Department of Internal Medicine, University of Utah School of Medicine, Medical Service, Veterans Affairs (VA) Salt Lake City Healthcare System (S.B., A.K.C.), and VA Salt Lake City Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City, and SelectHealth, Murray (B.K.B., N.R.-N.) - all in Utah; Pharmacy Department, Kaiser Permanente Colorado, Aurora (J.B.K.); Christiana Care Health System, Newark, DE (Z.Z., W.S.W.); Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, and the Department of Health Law, Policy, and Management, Boston University School of Public Health (D.R.B.), and the Department of Health Law, Policy and Management, Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston (L.E.K.) - all in Massachusetts; Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (L.F.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham (S.O.); Fielding School of Public Health, Department of Community Health Sciences, University of California, Los Angeles, Los Angeles (D.E.M.); the Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (J.P.); the Division of Population Health and Computational Medicine, University of Miami and Geriatric Research, Education and Clinical Center, Miami VA, Miami (L.T.); Clement J. Zablocki VA Medical Center, Milwaukee, and the Department of Medicine, Medical College of Wisconsin, Wauwatosa (J.W.) - both in Wisconsin; the Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland (J.T.W.); and the Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York (A.E.M.)
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Foy CG, Newman JC, Berlowitz DR, Russell LP, Kimmel PL, Wadley VG, Thomas HN, Lerner AJ, Riley WT. Blood Pressure, Sexual Activity, and Dysfunction in Women With Hypertension: Baseline Findings From the Systolic Blood Pressure Intervention Trial (SPRINT). J Sex Med 2017; 13:1333-1346. [PMID: 27555505 DOI: 10.1016/j.jsxm.2016.06.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 06/21/2016] [Accepted: 06/26/2016] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Sexual function, an important component of quality of life, is gaining increased research and clinical attention in older women with hypertension. AIM To assess the association between systolic blood pressure (SBP) and other variables, and sexual activity and sexual dysfunction in hypertensive women. METHODS Baseline analysis of 635 women participants of a larger randomized clinical trial of 9361 men and women. MAIN OUTCOME MEASURES Self-reported sexual activity (yes/no), and sexual function using the Female Sexual Function Inventory (FSFI). RESULTS 452 participants (71.2%) reported having no sexual activity during the previous 4 weeks. The mean (SD) FSFI score for sexually active participants was 25.3 (6.0), and 52.6% of the sample reported a FSFI score ≤26.55 designating sexual dysfunction. In logistic regression models, SBP was not significantly associated with sexual activity (AOR = 1.002; P > .05). Older age (AOR = 0.95, P < .05), and lower education (AOR for < high school vs college degree = 0.29, P < .05) were associated with lower odds of being sexually active, as was living alone versus living with others (AOR = 0.56, P < .05). Higher weekly alcohol consumption was associated with increased odds of being sexually active (AOR = 1.39; P < .05). In logistic regression models among sexually active participants, SBP was not associated with sexual dysfunction (AOR = 1.01; P > .05). Higher depressive symptoms from the Patient Health Questionnaire-9 (PHQ-9) was associated with higher odds of sexual dysfunction (AOR = 1.24, P < .05), as was increased number of physical comorbidities (AOR = 1.25, P < .05). Diuretic use was associated with lower odds of being sexually active in participants with chronic kidney disease (AOR = 0.33, P < .05). CONCLUSION Younger age, higher education, living with others, and higher weekly alcohol consumption were significantly associated with higher odds of being sexually active in a sample of middle-aged and older women with hypertension. Increased depressive symptoms and increased physical comorbidities were significantly associated with increased odds of sexual dysfunction. SBP was not significantly associated with sexual activity or sexual dysfunction.
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Affiliation(s)
- Capri G Foy
- Wake Forest School of Medicine, Division of Public Health Sciences, Department of Social Sciences and Health Policy, Winston-Salem, NC, USA.
| | - Jill C Newman
- Wake Forest School of Medicine, Division of Public Health Sciences, Department of Biostatistical Sciences, Winston-Salem, NC, USA
| | - Dan R Berlowitz
- Bedford VA Hospital, Bedford, MA and Boston University School of Public Health, Boston, MA, USA
| | - Laurie P Russell
- Wake Forest School of Medicine, Division of Public Health Sciences, Department of Biostatistical Sciences, Winston-Salem, NC, USA
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, USA
| | - Virginia G Wadley
- University of Alabama at Birmingham School of Medicine, Department of Psychiatry, Birmingham, AL, USA
| | - Holly N Thomas
- University of Pittsburgh, Division of General Internal Medicine, Section of Women's Health, Pittsburgh, PA, USA
| | - Alan J Lerner
- Case Western Reserve University School of Medicine, Department of Neurology and Brain Health and Memory Center, Cleveland, OH, USA
| | - William T Riley
- National Institutes of Health, Office of Behavioral and Social Sciences Research, Bethesda, MD, USA
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Odden MC, Peralta CA, Berlowitz DR, Johnson KC, Whittle J, Kitzman DW, Beddhu S, Nord JW, Papademetriou V, Williamson JD, Pajewski NM. Effect of Intensive Blood Pressure Control on Gait Speed and Mobility Limitation in Adults 75 Years or Older: A Randomized Clinical Trial. JAMA Intern Med 2017; 177:500-507. [PMID: 28166324 PMCID: PMC5699455 DOI: 10.1001/jamainternmed.2016.9104] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Intensive blood pressure (BP) control confers a benefit on cardiovascular morbidity and mortality; whether it affects physical function outcomes is unknown. OBJECTIVE To examine the effect of intensive BP control on changes in gait speed and mobility status. DESIGN, SETTING, AND PARTICIPANTS This randomized, clinical trial included 2636 individuals 75 years or older with hypertension and no history of type 2 diabetes or stroke who participated in the Systolic Blood Pressure Intervention Trial (SPRINT). Data were collected from November 8, 2010, to December 1, 2015. Analysis was based on intention to treat. INTERVENTIONS Participants were randomized to intensive treatment with a systolic BP target of less than 120 mm Hg (n = 1317) vs standard treatment with a BP target of less than 140 mm Hg (n = 1319). MAIN OUTCOMES AND MEASURES Gait speed was measured using a 4-m walk test. Self-reported information concerning mobility was obtained from items on the Veterans RAND 12-Item Health Survey and the EQ-5D. Mobility limitation was defined as a gait speed less than 0.6 meters per second (m/s) or self-reported limitations in walking and climbing stairs. RESULTS Among the 2629 participants in whom mobility status could be defined (996 women [37.9%]; 1633 men [62.1%]; mean [SD] age, 79.9 [4.0] years), median (interquartile range) follow-up was 3 (2-3) years. No difference in mean gait speed decline was noted between the intensive- and standard-treatment groups (mean difference, 0.0004 m/s per year; 95% CI, -0.005 to 0.005; P = .88). No evidence of any treatment group differences in subgroups defined by age, sex, race or ethnicity, baseline systolic BP, chronic kidney disease, or a history of cardiovascular disease were found. A modest interaction was found for the Veterans RAND 12-Item Health Survey Physical Component Summary score, although the effect did not reach statistical significance in either subgroup, with mean differences of 0.004 (95% CI, -0.002 to 0.010) m/s per year among those with scores of at least 40 and -0.008 (95% CI, -0.016 to 0.001) m/s per year among those with scores less than 40 (P = .03 for interaction). Multistate models allowing for the competing risk of death demonstrated no effect of intensive treatment on transitions to mobility limitation (hazard ratio, 1.06; 95% CI, 0.92-1.22). CONCLUSIONS AND RELEVANCE Among adults 75 years or older in SPRINT, treating to a systolic BP target of less than 120 mm Hg compared with a target of less than 140 mm Hg had no effect on changes in gait speed and was not associated with changes in mobility limitation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01206062.
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Affiliation(s)
- Michelle C Odden
- School of Biological and Population Health Sciences, Oregon State University, Corvallis
| | | | - Dan R Berlowitz
- Bedford Veterans Affairs Hospital, Bedford, Massachusetts4School of Public Health, Boston University, Boston, Massachusetts
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Jeffrey Whittle
- Department of Medicine, Medical College of Wisconsin, Milwaukee7Primary Care Division, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Dalane W Kitzman
- Section on Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Srinivasan Beddhu
- Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah10Department of Medicine, University of Utah School of Medicine, Salt Lake City
| | - John W Nord
- Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah10Department of Medicine, University of Utah School of Medicine, Salt Lake City
| | | | - Jeff D Williamson
- Section on Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M Pajewski
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Affiliation(s)
- Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research, Bedford VA Hospital, Bedford, MA. .,The Boston University School of Public Health, Boston, MA.
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Berlowitz DR, Breaux-Shropshire T, Foy CG, Gren LH, Kazis L, Lerner AJ, Newman JC, Powell JR, Riley WT, Rosman R, Wadley VG, Williams JA. Hypertension Treatment and Concern About Falling: Baseline Data from the Systolic Blood Pressure Intervention Trial. J Am Geriatr Soc 2016; 64:2302-2306. [PMID: 27640987 DOI: 10.1111/jgs.14441] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To determine the extent of concern about falling in older adults with hypertension, whether lower blood pressure (BP) and greater use of antihypertensive medications are associated with greater concern about falling, and whether lower BP has a greater effect on concern about falling in older and more functionally impaired individuals. DESIGN Secondary analysis involving cross-sectional study of baseline characteristics of participants enrolled in the Systolic Blood Pressure Intervention Trial (SPRINT). SETTING Approximately 100 outpatient sites. PARTICIPANTS SPRINT enrollees aged 50 and older (mean age 69) diagnosed with hypertension (N = 2,299). MEASUREMENTS Concern about falling was determined using the shortened version of the Falls Efficacy Scale International as measured at the baseline examination. RESULTS Mild concern about falling was present in 29.3% of participants and moderate to severe concern in 17.9%. Neither low BP (systolic BP<120 mmHg, diastolic BP <70 mmHg) nor orthostatic hypotension was associated with concern about falling (P > .10). Participants with moderate to severe concern about falling were taking significantly more antihypertensive medications than those with mild or no concern. After adjusting for baseline characteristics, no associations were evident between BP, medications, and concern about falling. Results were similar in older and younger participants; interactions between BP and age and functional status were not significantly associated with concern about falling. CONCLUSION Although concern about falling is common in older adults with hypertension, it was not found to be associated with low BP or use of more antihypertensive medications in baseline data from SPRINT.
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Affiliation(s)
- Dan R Berlowitz
- Bedford Veterans Affairs Hospital, Bedford, Massachusetts.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Tonya Breaux-Shropshire
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,University of Alabama at Birmingham, Birmingham, Alabama
| | - Capri G Foy
- Department Social Sciences and Health Policy, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Lisa H Gren
- Department of Family and Preventive Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Lewis Kazis
- Bedford Veterans Affairs Hospital, Bedford, Massachusetts.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Alan J Lerner
- Department of Neurology, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Jill C Newman
- Department Social Sciences and Health Policy, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - James R Powell
- Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - William T Riley
- Office of Behavioral and Social Sciences Research, National Institutes of Health, Bethesda, Maryland
| | - Robert Rosman
- Division of Academic Internal Medicine and Geriatrics, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | | | - Julie A Williams
- Section on Gerontology and Geriatric Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
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Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, Fine LJ, Haley WE, Hawfield AT, Ix JH, Kitzman DW, Kostis JB, Krousel-Wood MA, Launer LJ, Oparil S, Rodriguez CJ, Roumie CL, Shorr RI, Sink KM, Wadley VG, Whelton PK, Whittle J, Woolard NF, Wright JT, Pajewski NM. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. JAMA 2016; 315:2673-82. [PMID: 27195814 PMCID: PMC4988796 DOI: 10.1001/jama.2016.7050] [Citation(s) in RCA: 787] [Impact Index Per Article: 98.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE The appropriate treatment target for systolic blood pressure (SBP) in older patients with hypertension remains uncertain. OBJECTIVE To evaluate the effects of intensive (<120 mm Hg) compared with standard (<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension but without diabetes. DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial of patients aged 75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT). Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015. INTERVENTIONS Participants were randomized to an SBP target of less than 120 mm Hg (intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard treatment group, n = 1319). MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcome was a composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death from cardiovascular causes. All-cause mortality was a secondary outcome. RESULTS Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%) provided complete follow-up data. At a median follow-up of 3.14 years, there was a significantly lower rate of the primary composite outcome (102 events in the intensive treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66 [95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67 [95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI, 0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs 2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for injurious falls (HR, 0.91 [95% CI, 0.65-1.29]). CONCLUSIONS AND RELEVANCE Among ambulatory adults aged 75 years or older, treating to an SBP target of less than 120 mm Hg compared with an SBP target of less than 140 mm Hg resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01206062.
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Affiliation(s)
- Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Department of Internal Medicine, Winston-Salem, North Carolina
| | - Mark A Supiano
- Division of Geriatrics, School of Medicine, University of Utah, Salt Lake City3Veterans Affairs Salt Lake City, Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah
| | - William B Applegate
- Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Department of Internal Medicine, Winston-Salem, North Carolina
| | - Dan R Berlowitz
- Bedford Veterans Affairs Hospital, Bedford, Massachusetts5School of Public Health, Boston University, Boston, Massachusetts
| | - Ruth C Campbell
- Department of Medicine, Medical University of South Carolina, Charleston
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Larry J Fine
- Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - William E Haley
- Department of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Amret T Hawfield
- Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California, San Diego12Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California, San Diego13Department of Medicine, Nephrology
| | - Dalane W Kitzman
- Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John B Kostis
- Cardiovascular Institute at Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Marie A Krousel-Wood
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana17Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana18Center for Applied Health Research, Ochsner Clinic F
| | - Lenore J Launer
- Intramural Research Program, National Institute on Aging, Bethesda, Maryland
| | - Suzanne Oparil
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama, Birmingham
| | - Carlos J Rodriguez
- Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Christianne L Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center, HSR&D Center, Nashville23Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Ronald I Shorr
- Department of Epidemiology, University of Florida, Gainesville25Geriatric Research, Education, and Clinical Center, Malcom Randall Veterans Administration Medical Center, Gainesville, Florida
| | - Kaycee M Sink
- Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Department of Internal Medicine, Winston-Salem, North Carolina
| | | | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Jeffrey Whittle
- Department of Medicine, Medical College of Wisconsin, Milwaukee29Primary Care Division, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Nancy F Woolard
- Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Department of Internal Medicine, Winston-Salem, North Carolina
| | - Jackson T Wright
- Division of Nephrology and Hypertension, Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Nicholas M Pajewski
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Hartmann CW, Shwartz M, Zhao S, Palmer JA, Berlowitz DR. Longitudinal Pressure Ulcer Rates After Adoption of Culture Change in Veterans Health Administration Nursing Homes. J Am Geriatr Soc 2016; 64:151-5. [PMID: 26782865 DOI: 10.1111/jgs.13879] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To examine facility-level pressure ulcer (PrU) development rates and variations in these rates after a system-wide adoption of culture change in Veterans Health Administration (VHA) nursing homes. DESIGN Four-year retrospective longitudinal design. SETTING VHA facilities (N=109) representing 132 nursing homes known as community living centers (CLCs). PARTICIPANTS VHA nursing home residents. MEASUREMENTS PrUs were identified using fiscal year (FY) 2008-11 Minimum Data Set (MDS) data. PrU development was defined as a Stage 2 or larger PrU on an MDS assessment with no PrU on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of PrUs (c-statistic=0.72). A Bayesian hierarchical model that adjusted for differences in the precision of PrU rates from different-size facilities was used to calculate smoothed risk-adjusted (SRA) rates for each facility. The statistical significance of the trend over the 4 years was determined by examining the 95% interval estimate for the slope. RESULTS Over the 4-year period, the beginning of which coincided with the VHA's system-wide adoption of culture change as a performance measure, median SRA facility PrU development rates were fairly consistent at approximately 4%. The range in SRA rates declined over the years, from a 14.8-percentage point spread to 10.1-percentage point spread. Some facilities had significantly improving SRA rates (e.g., declined steadily from 5.5% to 3.9%) and some had significantly worsening SRA rates (e.g., increased steadily from 5.1% to 7.9%). Seven sites had significantly improving rates (P<.001) that were below the median across all 4 years. CONCLUSION A system-wide culture change implementation did not affect CLC PrU development rates, but there was significant variation in facility rates, and some facilities had sustained high performance.
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Affiliation(s)
- Christine W Hartmann
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts.,Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,School of Management, Boston University, Boston, Massachusetts
| | - Shibei Zhao
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Jennifer A Palmer
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts.,Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts
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Kapoor A, Chew PW, Reisman JI, Berlowitz DR. Low Self-Reported Function Predicts Adverse Postoperative Course in Veterans Affairs Beneficiaries Undergoing Total Hip and Total Knee Replacement. J Am Geriatr Soc 2016; 64:862-9. [PMID: 27100581 DOI: 10.1111/jgs.14020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To measure association between self-reported function and an adverse postoperative course and improvement in performance on the American College of Surgeons Universal Risk Calculator (ACS calculator) with inclusion of self-reported function available through the Veteran Rand-12 based Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. DESIGN Cohort analysis. SETTING Veteran Affairs health system. PARTICIPANTS Surgeries (n = 3,503) for older male veterans undergoing hip and knee replacement from 2002 to 2009. MEASUREMENTS Serious complication (per ACS definition), discharge to facility, readmission, and death within 30 days after surgery as a function of PCS and MCS; comparison of prediction of net reclassification index (NRI) for serious complication using a modified version of the ACS calculator with prediction using the ACS calculator with MCS and PCS added. RESULTS Being in the lowest PCS quartile (vs highest quartile) predicted more than twice the risk of a serious complication (odds ratio (OR) = 2.27, 95% confidence interval (CI) = 1.44-3.58), twice the risk of discharge to facility (OR = 1.97, 95% CI = 1.39-2.79), and almost twice the risk of readmission (OR = 1.80, 95% CI = 1.37-2.36). The lowest quartile of MCS predicted each outcome, although to a lesser extent than PCS. The enhanced model had a NRI of 29.4% (95% CI = 15.4-43.3%), reflecting that 20.8% of events were appropriately upgraded and 8.6% of nonevents appropriately downgraded. CONCLUSION Low PCS and MCS predicted an adverse postoperative course and enhanced the ACS calculator. Clinicians evaluating older adults undergoing orthopedic surgery could enhance the accuracy of their assessments by including self-reported functional status.
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Affiliation(s)
- Alok Kapoor
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
| | - Priscilla W Chew
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
| | - Joel I Reisman
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
| | - Dan R Berlowitz
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
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Kressin NR, Long JA, Glickman ME, Bokhour BG, Orner MB, Clark C, Rothendler JA, Berlowitz DR. A Brief, Multifaceted, Generic Intervention to Improve Blood Pressure Control and Reduce Disparities Had Little Effect. Ethn Dis 2016; 26:27-36. [PMID: 26843793 DOI: 10.18865/ed.26.1.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
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.
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Affiliation(s)
- Nancy R Kressin
- Boston VA Healthcare System; Center for Healthcare Organization and Implementation Research, Boston/Bedford VA Medical Centers; Section of General Internal Medicine, Boston University School of Medicine; Health/care Disparities Research Program
| | - Judith A Long
- Center for Health Equity Research and Promotion, Philadelphia VAMC; Department of Internal Medicine, University of Pennsylvania School of Medicine
| | - Mark E Glickman
- Center for Healthcare Organization and Implementation Research, Boston/Bedford VA Medical Centers; Health Policy and Management Department, Boston University School of Public Health
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, Boston/Bedford VA Medical Centers; Health Policy and Management Department, Boston University School of Public Health
| | - Michelle B Orner
- Center for Healthcare Organization and Implementation Research, Boston/Bedford VA Medical Centers
| | | | - James A Rothendler
- Center for Healthcare Organization and Implementation Research, Boston/Bedford VA Medical Centers; Health Policy and Management Department, Boston University School of Public Health
| | - Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research, Boston/Bedford VA Medical Centers; Health Policy and Management Department, Boston University School of Public Health
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Pajewski NM, Williamson JD, Applegate WB, Berlowitz DR, Bolin LP, Chertow GM, Krousel-Wood MA, Lopez-Barrera N, Powell JR, Roumie CL, Still C, Sink KM, Tang R, Wright CB, Supiano MA. Characterizing Frailty Status in the Systolic Blood Pressure Intervention Trial. J Gerontol A Biol Sci Med Sci 2016; 71:649-55. [PMID: 26755682 DOI: 10.1093/gerona/glv228] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/30/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The Systolic Blood Pressure Intervention Trial (SPRINT) is testing whether a lower systolic blood pressure (BP) target of 120 mm Hg leads to a reduction in cardiovascular morbidity and mortality among hypertensive, nondiabetic adults. Because there may be detrimental effects of intensive BP control, particularly in older, frail adults, we sought to characterize frailty within SPRINT to address ongoing questions about the ability of large-scale trials to enroll representative samples of noninstitutionalized, community-dwelling, older adults. METHODS We constructed a 36-item frailty index (FI) in 9,306 SPRINT participants, classifying participants as fit (FI ≤ 0.10), less fit (0.10 < FI ≤ 0.21), or frail (FI > 0.21). Recurrent event models were used to evaluate the association of the FI with the incidence of self-reported falls, injurious falls, and all-cause hospitalizations. RESULTS The distribution of the FI was comparable with what has been observed in population studies, with 2,570 (27.6%) participants classified as frail. The median FI was 0.18 (interquartile range = 0.14 to 0.24) in participants aged 80 years and older (N = 1,159), similar to the median FI of 0.17 reported for participants in the Hypertension in the Very Elderly Trial. In multivariable analyses, a 1% increase in the FI was associated with increased risk for self-reported falls (hazard ratio [HR] = 1.030), injurious falls (HR = 1.035), and all-cause hospitalizations (HR = 1.038) (all p values < .0001). CONCLUSIONS Large clinical trials assessing treatments to reduce cardiovascular disease risk, such as SPRINT, can enroll heterogeneous populations of older adults, including the frail elderly, comparable with general population cohorts.
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Affiliation(s)
- Nicholas M Pajewski
- Department of Biostatistical Sciences, Division of Public Health Sciences and
| | - Jeff D Williamson
- Department of Internal Medicine, Section on Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - William B Applegate
- Department of Internal Medicine, Section on Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Dan R Berlowitz
- Bedford Veterans Affairs Hospital, Massachusetts. School of Public Health, Boston University, Massachusetts
| | - Linda P Bolin
- College of Nursing, East Carolina University, Greenville, North Carolina
| | - Glenn M Chertow
- Department of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Marie A Krousel-Wood
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana. Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana. Research Division, Ochsner Clinic Foundation, New Orleans, Louisiana
| | | | - James R Powell
- Department of Internal Medicine, Division of General Internal Medicine, East Carolina University, Greenville, North Carolina
| | - Christianne L Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center (GRECC), HSR&D Center, Nashville. Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Carolyn Still
- Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Cleveland, Ohio. Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Kaycee M Sink
- Department of Internal Medicine, Section on Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Rocky Tang
- Department of Surgery, Columbia University, New York
| | - Clinton B Wright
- Evelyn F. McKnight Brain Institute, Departments of Neurology and Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, Florida
| | - Mark A Supiano
- Division of Geriatrics, School of Medicine, University of Utah, Salt Lake City. Veterans Affairs Salt Lake City, Geriatric Research, Education, and Clinical Center, Utah
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Kim EJ, Ozonoff A, Hylek EM, Berlowitz DR, Ash AS, Miller DR, Zhao S, Reisman JI, Jasuja GK, Rose AJ. Predicting outcomes among patients with atrial fibrillation and heart failure receiving anticoagulation with warfarin. Thromb Haemost 2015; 114:70-7. [PMID: 25948532 DOI: 10.1160/th14-09-0754] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 02/20/2015] [Indexed: 01/07/2023]
Abstract
Among patients receiving oral anticoagulation for atrial fibrillation (AF), heart failure (HF) is associated with poor anticoagulation control. However, it is not known which patients with heart failure are at greatest risk of adverse outcomes. We evaluated 62,156 Veterans Health Administration (VA) patients receiving warfarin for AF between 10/1/06-9/30/08 using merged VA-Medicare dataset. We predicted time in therapeutic range (TTR) and rates of adverse events by categorising patients into those with 0, 1, 2, or 3+ of five putative markers of HF severity such as aspartate aminotransferase (AST)> 80 U/l, alkaline phosphatase> 150 U/l, serum sodium< 130 mEq/l, any receipt of metolazone, and any inpatient admission for HF exacerbation. These risk categories predicted TTR: patients without HF (referent) had a mean TTR of 65.0 %, while HF patients with 0, 1, 2, 3 or more markers had mean TTRs of 62.2 %, 57.2 %, 53.5 %, and 50.7 %, respectively (p< 0.001). These categories also discriminated for major haemorrhage well; compared to patients without HF, HF patients with increasing severity had hazard ratios of 1.84, 3.06, 3.52 and 5.14 respectively (p< 0.001). However, although patients with HF had an elevated hazard for bleeding compared to those without HF, these categories did not effectively discriminate risk of ischaemic stroke across HF. In conclusion, we developed a HF severity model using easily available clinical characteristics that performed well to risk-stratify patients with HF who are receiving anticoagulation for AF with regard to major haemorrhage.
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Affiliation(s)
- Eun-Jeong Kim
- Eun-Jeong Kim, MD, Hospital Medicine Group, Division of General Internal Medicine, Massachusetts General Hospital, 55 Fruit Street Bulfinch 015, Boston, MA 02114, USA, Tel.: +1 617 724 3874, Fax: +1 617 643 1384, E-mail:
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Alvarez CA, Mortensen EM, Makris UE, Berlowitz DR, Copeland LA, Good CB, Amuan ME, Pugh MJV. Association of skeletal muscle relaxers and antihistamines on mortality, hospitalizations, and emergency department visits in elderly patients: a nationwide retrospective cohort study. BMC Geriatr 2015; 15:2. [PMID: 25623366 PMCID: PMC4322434 DOI: 10.1186/1471-2318-15-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 12/17/2014] [Indexed: 11/10/2022] Open
Abstract
Background High-risk medication exposure in the elderly is common and associated with increased mortality, hospitalizations, and emergency department (ED) visits. Skeletal muscle relaxants and antihistamines are high-risk medications commonly prescribed in elderly patients. The objective of this study was to determine the association between skeletal muscle relaxants or antihistamines and mortality, hospitalizations, and emergency department visits. Methods This study used a new-user, retrospective cohort design using national Veteran Affairs (VA) data from 128 hospitals. Veterans ≥65 years of age on October 1, 2005 who received VA inpatient/outpatient care at least once in each of fiscal year (FY) 2005 and FY 2006 were included. Exposure to skeletal muscle relaxants and antihistamines was defined by the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set measures for high-risk medications in the elderly. Primary outcomes identified within one year of exposure were death, ED visit, or hospitalization; ED visits or hospitalizations due to falls and fracture were also assessed. Propensity score matching (1 to 1 match) was used to balance covariates between exposed patients and non-exposed patients. Results In this cohort of 1,807,404 patients 55,566 patients were included in the propensity-matched cohort for skeletal muscle relaxants and 60,058 patients were included in the propensity-matched cohort for anti-histamines. Mortality was lower in skeletal muscle relaxants-exposed patients (adjusted odds ratio [AOR] 0.87, 95% CI 0.81-0.94), but risk of emergency care (AOR 2.25, 95% CI 2.16-2.33) and hospitalization (AOR 1.56, 95% CI 1.48-1.65) was higher for patients prescribed skeletal muscle relaxants. Similar findings were observed for emergency and hospital care for falls or fractures. Mortality (AOR 1.93, 95% CI 1.82-2.04), ED visits (AOR 2.35, 95% CI 2.27-2.43), and hospitalizations (AOR 2.21, 95% CI 2.11-2.32) were higher in the antihistamine-exposed group, with similar findings for falls and fractures outcomes. Conclusion Skeletal muscle relaxants and antihistamines are associated with an increased risk of ED visits and hospitalizations in elderly patients. Antihistamines were also associated with an increased risk of death, further validating the classification of these drug classes as “high risk”.
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Affiliation(s)
- Carlos A Alvarez
- Pharmacy Practice Department, Texas Tech University Health Sciences Center, Forest Park Rd, Dallas, TX, USA.
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Berlowitz DR. Remembering Gene Stollerman, MD. J Am Geriatr Soc 2014; 62:2426-7. [PMID: 25516037 DOI: 10.1111/jgs.13172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Hospital, Bedford, Massachuestts; Schools of Public Health and Medicine, Boston University, Boston, Massachusetts
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Frayne SM, Holmes TH, Berg E, Goldstein MK, Berlowitz DR, Miller DR, Pogach LM, Laungani KJ, Lee TT, Moos R. Mental illness and intensification of diabetes medications: an observational cohort study. BMC Health Serv Res 2014; 14:458. [PMID: 25339147 PMCID: PMC4282515 DOI: 10.1186/1472-6963-14-458] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 09/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians' decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type. METHODS In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003-2004, by MHC status. RESULTS Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0-14, 15-30 and 31-180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value. CONCLUSIONS For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.
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Affiliation(s)
- Susan M Frayne
- Department of Veterans Affairs HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
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Ambrosius WT, Sink KM, Foy CG, Berlowitz DR, Cheung AK, Cushman WC, Fine LJ, Goff DC, Johnson KC, Killeen AA, Lewis CE, Oparil S, Reboussin DM, Rocco MV, Snyder JK, Williamson JD, Wright JT, Whelton PK. The design and rationale of a multicenter clinical trial comparing two strategies for control of systolic blood pressure: the Systolic Blood Pressure Intervention Trial (SPRINT). Clin Trials 2014; 11:532-46. [PMID: 24902920 DOI: 10.1177/1740774514537404] [Citation(s) in RCA: 377] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND High blood pressure is an important public health concern because it is highly prevalent and a risk factor for adverse health outcomes, including coronary heart disease, stroke, decompensated heart failure, chronic kidney disease, and decline in cognitive function. Observational studies show a progressive increase in risk associated with blood pressure above 115/75 mm Hg. Prior research has shown that reducing elevated systolic blood pressure lowers the risk of subsequent clinical complications from cardiovascular disease. However, the optimal systolic blood pressure to reduce blood pressure-related adverse outcomes is unclear, and the benefit of treating to a level of systolic blood pressure well below 140 mm Hg has not been proven in a large, definitive clinical trial. PURPOSE To describe the design considerations of the Systolic Blood Pressure Intervention Trial (SPRINT) and the baseline characteristics of trial participants. METHODS The Systolic Blood Pressure Intervention Trial is a multicenter, randomized, controlled trial that compares two strategies for treating systolic blood pressure: one targets the standard target of <140 mm Hg, and the other targets a more intensive target of <120 mm Hg. Enrollment focused on volunteers of age ≥50 years (no upper limit) with an average baseline systolic blood pressure ≥130 mm Hg and evidence of cardiovascular disease, chronic kidney disease, 10-year Framingham cardiovascular disease risk score ≥15%, or age ≥75 years. The Systolic Blood Pressure Intervention Trial recruitment also targeted three pre-specified subgroups: participants with chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m(2)), participants with a history of cardiovascular disease, and participants 75 years of age or older. The primary outcome is first the occurrence of a myocardial infarction (MI), acute coronary syndrome, stroke, heart failure, or cardiovascular disease death. Secondary outcomes include all-cause mortality, decline in kidney function or development of end-stage renal disease, incident dementia, decline in cognitive function, and small-vessel cerebral ischemic disease. RESULTS Between 8 November 2010 and 15 March 2013, Systolic Blood Pressure Intervention Trial recruited and randomized 9361 people at 102 clinics, including 3331 women, 2648 with chronic kidney disease, 1877 with a history of cardiovascular disease, 3962 minorities, and 2636 ≥75 years of age. LIMITATIONS Although the overall recruitment target was met, the numbers recruited in the high-risk subgroups were lower than planned. CONCLUSIONS The Systolic Blood Pressure Intervention Trial will provide important information on the risks and benefits of intensive blood pressure treatment targets in a diverse sample of high-risk participants, including those with prior cardiovascular disease, chronic kidney disease, and those aged ≥75 years.
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Affiliation(s)
- Walter T Ambrosius
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kaycee M Sink
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Capri G Foy
- Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Hospital, Bedford, MA, USA
| | - Alfred K Cheung
- Department of Internal Medicine, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - William C Cushman
- Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN, USA
| | - Lawrence J Fine
- Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - David C Goff
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anthony A Killeen
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Cora E Lewis
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Suzanne Oparil
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David M Reboussin
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael V Rocco
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joni K Snyder
- Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jackson T Wright
- Division of Nephrology and Hypertension, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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Paradise HT, Berlowitz DR, Ozonoff A, Miller DR, Hylek EM, Ash AS, Jasuja GK, Zhao S, Reisman JI, Rose AJ. Outcomes of anticoagulation therapy in patients with mental health conditions. J Gen Intern Med 2014; 29:855-61. [PMID: 24549520 PMCID: PMC4026501 DOI: 10.1007/s11606-014-2784-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 12/03/2013] [Accepted: 01/12/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients with mental health conditions (MHCs) experience poor anticoagulation control when using warfarin, but we have limited knowledge of the association between specific mental illness and warfarin treatment outcomes. OBJECTIVE To examine the relationship between the severity of MHCs and outcomes of anticoagulation therapy. DESIGN Retrospective cohort analysis. PARTICIPANTS We studied 103,897 patients on warfarin for 6 or more months cared for by the Veterans Health Administration during fiscal years 2007-2008. We identified 28,216 patients with MHCs using ICD-9 codes: anxiety disorders, bipolar disorder, depression, post-traumatic stress disorder, schizophrenia, and other psychotic disorders. MAIN MEASURES Outcomes included anticoagulation control, as measured by percent time in the therapeutic range (TTR), as well as major hemorrhage. Predictors included different categories of MHC, Global Assessment of Functioning (GAF) scores, and psychiatric hospitalizations. KEY RESULTS Patients with bipolar disorder, depression, and other psychotic disorders experienced TTR decreases of 2.63 %, 2.26 %, and 2.92 %, respectively (p < 0.001), after controlling for covariates. Patients with psychotic disorders other than schizophrenia experienced increased hemorrhage after controlling for covariates [hazard ratio (HR) 1.24, p = 0.03]. Having any MHC was associated with a slightly increased hazard for hemorrhage (HR 1.19, p < 0.001) after controlling for covariates. CONCLUSION Patients with specific MHCs (bipolar disorder, depression, and other psychotic disorders) experienced slightly worse anticoagulation control. Patients with any MHC had a slightly increased hazard for major hemorrhage, but the magnitude of this difference is unlikely to be clinically significant. Overall, our results suggest that appropriately selected patients with MHCs can safely receive therapy with warfarin.
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Affiliation(s)
- Helen T Paradise
- Department of Community Based Clinics, University of Texas Medical Branch (UTMB), 6465 South Shore Blvd. Suite 500, League City, TX, 77573, USA,
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Efird LM, Mishkin DS, Berlowitz DR, Ash AS, Hylek EM, Ozonoff A, Reisman JI, Zhao S, Jasuja GK, Rose AJ. Stratifying the Risks of Oral Anticoagulation in Patients With Liver Disease. Circ Cardiovasc Qual Outcomes 2014; 7:461-7. [DOI: 10.1161/circoutcomes.113.000817] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Lydia M. Efird
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Daniel S. Mishkin
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Dan R. Berlowitz
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Arlene S. Ash
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Elaine M. Hylek
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Al Ozonoff
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Joel I. Reisman
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Shibei Zhao
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Guneet K. Jasuja
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Adam J. Rose
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
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Rao SR, Reisman JI, Kressin NR, Berlowitz DR, Ash AS, Ozonoff A, Miller DR, Hylek EM, Zhao S, Rose AJ. Explaining Racial Disparities in Anticoagulation Control. Am J Med Qual 2014; 30:214-22. [DOI: 10.1177/1062860614526282] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sowmya R. Rao
- Bedford VA Medical Center, Bedford, MA
- University of Massachusetts Medical School, Worcester, MA
| | | | - Nancy R. Kressin
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
| | - Dan R. Berlowitz
- Bedford VA Medical Center, Bedford, MA
- Boston University School of Medicine, Boston, MA
- Boston University School of Public Health, Boston, MA
| | - Arlene S. Ash
- Bedford VA Medical Center, Bedford, MA
- University of Massachusetts Medical School, Worcester, MA
| | - Al Ozonoff
- Bedford VA Medical Center, Bedford, MA
- Boston Children’s Hospital, Boston, MA
| | - Donald R. Miller
- Bedford VA Medical Center, Bedford, MA
- Boston University School of Public Health, Boston, MA
| | | | | | - Adam J. Rose
- Bedford VA Medical Center, Bedford, MA
- Boston University School of Medicine, Boston, MA
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Affiliation(s)
- Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research, Bedford VA Hospital, Bedford, MA; The Boston University School of Public Health, Boston, MA
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45
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Pugh MJV, Marcum ZA, Copeland LA, Mortensen EM, Zeber JE, Noël PH, Berlowitz DR, Downs JR, Good CB, Alvarez C, Amuan ME, Hanlon JT. The quality of quality measures: HEDIS® quality measures for medication management in the elderly and outcomes associated with new exposure. Drugs Aging 2013; 30:645-54. [PMID: 23645530 DOI: 10.1007/s40266-013-0086-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Clinical validation studies of the Healthcare Effectiveness Data and Information Set (HEDIS®) measures of inappropriate prescribing in the elderly are limited. OBJECTIVES The objective of this study was to examine associations of new exposure to high-risk medication in the elderly (HRME) and drug-disease interaction (Rx-DIS) with mortality, hospital admission, and emergency care. METHODS A retrospective database study was conducted examining new use of HRME and Rx-DIS in fiscal year 2006 (Oct 2005-Sep 2006; FY06), with index date being the date of first HRME/Rx-DIS exposure, or first day of FY07 if no HRME/Rx-DIS exposure. Outcomes were assessed 1 year after the index date. The participants were veterans who were ≥65 years old in FY06 and received Veterans Health Administration (VA) care in FY05-06. A history of falls/hip fracture, chronic renal failure, and/or dementia per diagnosis codes defined the Rx-DIS subsample. The variables included a number of new unique HRME drug exposures and new unique Rx-DIS drug exposure (0, 1, >1) in FY06, and outcomes (i.e., 1-year mortality, hospital admission, and emergency care) up to 1 year after exposure. Descriptive statistics summarized variables for the overall HRME cohort and the Rx-DIS subset. Multivariable statistical analyses using generalized estimating equations (GEE) models with a logit link accounted for nesting of patients within facilities. For these latter analyses, we controlled for demographic characteristics, chronic disease states, and indicators of disease burden the previous year (e.g., number of prescriptions, emergency/hospital care). RESULTS Among the 1,807,404 veterans who met inclusion criteria, 5.2 % had new HRME exposure. Of the 256,388 in the Rx-DIS cohort, 3.6 % had new Rx-DIS exposure. Multivariable analyses found that HRME was significantly associated with mortality [1: adjusted odds ratio (AOR) = 1.62, 95 % CI 1.56-1.68; >1: AOR = 1.80, 95 % CI 1.45-2.23], hospital admission (1: AOR = 2.31, 95 % CI 2.22-2.40; >1: AOR = 3.44, 95 % CI 3.06-3.87), and emergency care (1: AOR = 2.59, 95 % CI 2.49-2.70; >1: AOR = 4.18, 95 % CI 3.71-4.71). Rx-DIS exposure was significantly associated with mortality (1: AOR = 1.60, 95 % CI 1.51-1.71; >1: AOR = 2.00, 95 % CI 1.38-2.91), hospital admission for one exposure (1: AOR = 1.12, 95 % CI 1.03-1.27; >1: AOR = 1.18, 95 % CI 0.71-1.95), and emergency care for two or more exposures (1: AOR = 1.06, 95 % CI 0.97-1.15; >1: AOR = 2.0, 95 % CI 1.35-3.10). CONCLUSIONS Analyses support the link between HRME/Rx-DIS exposure and clinically significant outcomes in older veterans. Now is the time to begin incorporating input from both patients who receive these medications and providers who prescribe to develop approaches to reduce exposure to these agents.
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Affiliation(s)
- Mary Jo V Pugh
- South Texas Veterans Health Care System, Audie L. Murphy Division, Veterans Evidence-based Research Dissemination Implementation CenTer (VERDICT 11C6), San Antonio, TX 78229, USA.
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Efird LM, Miller DR, Ash AS, Berlowitz DR, Ozonoff A, Zhao S, Reisman JI, Jasuja GK, Rose AJ. Identifying the risks of anticoagulation in patients with substance abuse. J Gen Intern Med 2013; 28:1333-9. [PMID: 23620189 PMCID: PMC3785645 DOI: 10.1007/s11606-013-2453-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 02/25/2013] [Accepted: 04/03/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Warfarin is effective in preventing thromboembolic events, but concerns exist regarding its use in patients with substance abuse. OBJECTIVE Identify which patients with substance abuse who receive warfarin are at risk for poor outcomes. DESIGN Retrospective cohort study. Diagnostic codes, lab values, and other factors were examined to identify risk of adverse outcomes. PATIENTS Veterans AffaiRs Study to Improve Anticoagulation (VARIA) database of 103,897 patients receiving warfarin across 100 sites. MAIN MEASURES Outcomes included percent time in therapeutic range (TTR), a measure of anticoagulation control, and major hemorrhagic events by ICD-9 codes. RESULTS Nonusers had a higher mean TTR (62 %) than those abusing alcohol (53 %), drugs (50 %), or both (44 %, p < 0.001). Among alcohol abusers, an increasing ratio of the serum hepatic transaminases aspartate aminotransferase/alanine aminotransferase (AST:ALT) correlated with inferior anticoagulation control; normal AST:ALT ≤ 1.5 predicted relatively modest decline in TTR (54 %, p < 0.001), while elevated ratios (AST:ALT 1.50-2.0 and > 2.0) predicted progressively poorer anticoagulation control (49 % and 44 %, p < 0.001 compared to nonusers). Age-adjusted hazard ratio for major hemorrhage was 1.93 in drug and 1.37 in alcohol abuse (p < 0.001 compared to nonusers), and remained significant after also controlling for anticoagulation control and other bleeding risk factors (1.69 p < 0.001 and 1.22 p = 0.003). Among alcohol abusers, elevated AST:ALT >2.0 corresponded to more than three times the hemorrhages (HR 3.02, p < 0.001 compared to nonusers), while a normal ratio AST:ALT ≤ 1.5 predicted a rate similar to nonusers (HR 1.19, p < 0.05). CONCLUSIONS Anticoagulation control is particularly poor in patients with substance abuse. Major hemorrhages are more common in both alcohol and drug users. Among alcohol abusers, the ratio of AST/ALT holds promise for identifying those at highest risk for adverse events.
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Affiliation(s)
- Lydia M Efird
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, 72 East Concord Street, Evans 124, Boston, MA, 02118, USA,
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Rose AJ, Miller DR, Ozonoff A, Berlowitz DR, Ash AS, Zhao S, Reisman JI, Hylek EM. Gaps in monitoring during oral anticoagulation: insights into care transitions, monitoring barriers, and medication nonadherence. Chest 2013. [PMID: 23187457 DOI: 10.1378/chest.12-1119] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Among patients receiving oral anticoagulation, a gap of > 56 days between international normalized ratio tests suggests loss to follow-up that could lead to poor anticoagulation control and serious adverse events. METHODS We studied long-term oral anticoagulation care for 56,490 patients aged 65 years and older at 100 sites of care in the Veterans Health Administration. We used the rate of gaps in monitoring per patient-year to predict percentage time in therapeutic range (TTR) at the 100 sites. RESULTS Many patients (45%) had at least one gap in monitoring during an average of 1.6 years of observation; 5% had two or more gaps per year. The median gap duration was 74 days (interquartile range, 62-107). The average TTR for patients with two or more gaps per year was 10 percentage points lower than for patients without gaps (P < .001). Patient-level predictors of gaps included nonwhite race, area poverty, greater distance from care, dementia, and major depression. Site-level gaps per patient-year varied from 0.19 to 1.78; each one-unit increase was associated with a 9.2 percentage point decrease in site-level TTR (P < .001). CONCLUSIONS Site-level gap rates varied widely within an integrated care system. Sites with more gaps per patient-year had worse anticoagulation control. Strategies to address and reduce gaps in monitoring may improve anticoagulation control.
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Affiliation(s)
- Adam J Rose
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston.
| | - Donald R Miller
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Health Policy and Management, Boston University School of Public Health, Boston
| | - Al Ozonoff
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Biostatistics Section, Boston Children's Hospital, Boston
| | - Dan R Berlowitz
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston; Department of Health Policy and Management, Boston University School of Public Health, Boston
| | - Arlene S Ash
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston; Department of Quantitative Health Sciences (Dr Ash), Division of Biostatistics and Health Services Research, University of Massachusetts School of Medicine, Worcester, MA
| | - Shibei Zhao
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford
| | - Joel I Reisman
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford
| | - Elaine M Hylek
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston
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Avetisyan R, Cabral H, Montouris G, Jarrett K, Shapiro GD, Berlowitz DR, Kase CS, Kazis LE. Evaluating racial/ethnic variations in outpatient epilepsy care. Epilepsy Behav 2013; 27:95-101. [PMID: 23399943 DOI: 10.1016/j.yebeh.2012.12.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 12/07/2012] [Accepted: 12/08/2012] [Indexed: 11/28/2022]
Abstract
This study evaluated the quality of epilepsy care in an ambulatory population of a major medical center and determined if there were any racial/ethnic variations. The well-established 'Quality Indicators in Epilepsy Treatment (QUIET)' study dataset was used. Medical record, phone interview, and mail-out survey data of 311 patients with epilepsy were linked and analyzed. Evaluation of care from provider and patient perspectives was performed. Overall, the patients with epilepsy received 40.9% of QI recommended care. The black patients were more likely to receive 50% or more QI recommended care compared with non-Hispanic whites (odds ratio [OR]=2.16, 95% confidence interval [CI] 1.09-4.27). Black patients scored significantly worse than non-Hispanic whites for two patient-reported measures--perceived racial/ethnic disparities (OR=3.14, 95% CI 1.15-8.53) and difficulties getting follow-up appointments (OR=3.37, 95% CI 1.55-7.32). The results indicate the need to evaluate both provider- and patient-centered measures in quality-of-care studies in disparities research.
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Affiliation(s)
- Ruzan Avetisyan
- Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Jasuja GK, Reisman JI, Miller DR, Berlowitz DR, Hylek EM, Ash AS, Ozonoff A, Zhao S, Rose AJ. Identifying major hemorrhage with automated data: results of the Veterans Affairs study to improve anticoagulation (VARIA). Thromb Res 2012; 131:31-6. [PMID: 23158402 DOI: 10.1016/j.thromres.2012.10.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/29/2012] [Accepted: 10/22/2012] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Identifying major bleeding is fundamental to assessing the outcomes of anticoagulation therapy. This drives the need for a credible implementation in automated data for the International Society of Thrombosis and Haemostasis (ISTH) definition of major bleeding. MATERIALS AND METHODS We studied 102,395 patients who received 158,511 person-years of warfarin treatment from the Veterans Health Administration (VA) between 10/1/06-9/30/08. We constructed a list of ICD-9-CM codes of "candidate" bleeding events. Each candidate event was identified as a major hemorrhage if it fulfilled one of four criteria: 1) associated with death within 30days; 2) bleeding in a critical anatomic site; 3) associated with a transfusion; or 4) was coded as the event that precipitated or was responsible for the majority of an inpatient hospitalization. RESULTS This definition classified 11,240 (15.8%) of 71, 338 candidate events as major hemorrhage. Typically, events more likely to be severe were retained at higher rates than those less likely to be severe. For example, Diverticula of Colon with Hemorrhage (562.12) and Hematuria (599.7) were retained 46% and 4% of the time, respectively. Major, intracranial, and fatal hemorrhage were identified at rates comparable to those found in randomized clinical trials however, higher than those reported in observational studies: 4.73, 1.29, and 0.41 per 100 patient years, respectively. CONCLUSIONS We describe here a workable definition for identifying major hemorrhagic events from large automated datasets. This method of identifying major bleeding may have applications for quality measurement, quality improvement, and comparative effectiveness research.
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Affiliation(s)
- Guneet K Jasuja
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA, USA.
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Rothendler JA, Rose AJ, Reisman JI, Berlowitz DR, Kazis LE. Choices in the use of ICD-9 codes to identify stroke risk factors can affect the apparent population-level risk factor prevalence and distribution of CHADS2 scores. Am J Cardiovasc Dis 2012; 2:184-191. [PMID: 22937488 PMCID: PMC3427978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 06/10/2012] [Indexed: 06/01/2023]
Abstract
While developed for managing individuals with atrial fibrillation, risk stratification schemes for stroke, such as CHADS2, may be useful in population-based studies, including those assessing process of care. We investigated how certain decisions in identifying diagnoses from administrative data affect the apparent prevalence of CHADS2-associated diagnoses and distribution of scores. Two sets of ICD-9 codes (more restrictive/ more inclusive) were defined for each CHADS2-associated diagnosis. For stroke/transient ischemic attack (TIA), the more restrictive set was applied to only inpatient data. We varied the number of years (1-3) in searching for relevant codes, and, except for stroke/TIA, the number of instances (1 vs. 2) that diagnoses were required to appear. The impact of choices on apparent disease prevalence varied by type of choice and condition, but was often substantial. Choices resulting in substantial changes in prevalence also tended to be associated with more substantial effects on the distribution of CHADS2 scores.
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Affiliation(s)
- James A Rothendler
- Center for Health Quality, Outcomes and Economic Research, Health Services Research and Development, Bedford VA Medical CenterBedford, MA, USA
- Department of Health Policy and Management, Boston University School of Public HealthBoston, MA, USA
| | - Adam J Rose
- Center for Health Quality, Outcomes and Economic Research, Health Services Research and Development, Bedford VA Medical CenterBedford, MA, USA
- Department of Medicine, Section of General Internal Medicine, Boston University School of MedicineBoston, MA, USA
| | - Joel I Reisman
- Center for Health Quality, Outcomes and Economic Research, Health Services Research and Development, Bedford VA Medical CenterBedford, MA, USA
| | - Dan R Berlowitz
- Center for Health Quality, Outcomes and Economic Research, Health Services Research and Development, Bedford VA Medical CenterBedford, MA, USA
- Department of Health Policy and Management, Boston University School of Public HealthBoston, MA, USA
- Department of Medicine, Section of General Internal Medicine, Boston University School of MedicineBoston, MA, USA
| | - Lewis E Kazis
- Center for Health Quality, Outcomes and Economic Research, Health Services Research and Development, Bedford VA Medical CenterBedford, MA, USA
- Department of Health Policy and Management, Boston University School of Public HealthBoston, MA, USA
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