Research Objective
Cardiovascular disease (CVD) remains the leading cause of death in the United States and is particularly devastating in the southeastern United States. Despite evidence‐based ...approaches that can reduce CVD risk, adoption of effective therapies remains slow. TheAUTHOR: Please check the usage of the phrase ‘derived, population management dashboard’ throughout the article. Heart Health Now (HHN) study was designed to evaluate the effect of combining practice facilitation with an electronic health record derived, population management dashboard based on atherosclerotic cardiovascular disease (ASCVD) 10‐year risk scores on reducing risk for patients at high baseline risk.
Study Design
HHN was a step‐wedged, stratified, cluster‐randomized trial. Small primary care practices with 10 or fewer clinicians were enrolled. Practices were stratified by readiness and randomized to 6 cohorts according to start date. The 12‐month intervention began for Cohort 1 in January of 2016. The five subsequent cohorts started their intervention period every other month thereafter. The intervention consisted of onsite practice facilitation and a practice population dashboard stratified by ASCVD risk. Treatments to reduce risk included statin prescribing, blood pressure reduction, smoking cessation counseling, and aspirin use for high‐risk patients of appropriate age.
Population Studied
ASCVD risk scores were assessed on 437 556 patients in 219 small NC primary care practices. We report on 146 826 patients with a > = 10% baseline risk of experiencing a stroke, heart attack, or death within 10 years.
Principal Findings
Demographic characteristics of the high‐risk group included 66% of white race, 24% black, 3% Hispanic ethnicity, 54% male, and 52% residing in rural areas. The mean ASCVD 10‐year risk at baseline was 23.6% (SD ± 12.8%). After the intervention, the unadjusted mean score fell to 17.1% (SD ± 11.5%). After applying the stepped wedge and calendar time controls to the analysis, most (75%) of the 6.5% absolute risk reduction was attributable to the intervention. All demographic subgroups improved by at least 6% (range: 6.03%‐6.76%). In multivariate analysis, male gender, age > 65 years, low income (<$40 000), and black race (
P
<
0.001 for all variables) were each associated with greater relative risk reductions.
Conclusions
A one‐year intervention utilizing practice facilitation and an electronic health record derived, population management dashboard for small primary care practices resulted in significant risk reductions for patients at high risk for cardiovascular disease or death.
Implications for Policy or Practice
Implementation of practice facilitation and population management informatics support in small primary care practices can strongly drive the clinical use of new evidence and, in this case, dramatically reduce ASCVD risk.
Primary Funding Source
The study was funded by Agency for Healthcare Research and Quality.
Abstract Objective: To summarise the effect of primary prevention with lipid lowering drugs on coronary heart disease events, coronary heart disease mortality, and all cause mortality. Design: ...Meta-analysis. Identification: Systematic search of the Medline database from January 1994 to June 1999 for English language studies examining drug treatment for lipid disorders (use of the MeSH terms “hyperlipidemia” and “anticholesteremic agents,” keyword searches for individual drug names, and a search strategy for identifying randomised trials to capture relevant articles); identification of older studies through systematic reviews and hand search of bibliographies. Inclusion criteria: All randomised trials of at least one year's duration that examined drug treatment for patients with no known coronary heart disease, cerebrovascular disease, or peripheral vascular disease and that measured clinical end points, including all cause mortality, coronary heart disease mortality, and non-fatal myocardial infarctions. Data extraction: Review of the articles and extracted relevant data by two authors separately, with disagreements resolved by consensus. Results: Four studies met eligibility criteria. Drug treatment reduced the odds of a coronary heart disease event by 30% (summary odds ratio 0.70, 95% confidence interval 0.62 to 0.79) but not the odds of all cause mortality (0.94, 0.81 to 1.09). When statin drugs were considered alone, no substantial differences in results were found. Conclusions: Treatment with lipid lowering drugs lasting five to seven years reduces coronary heart disease events but not all cause mortality in people with no known cardiovascular disease.
Rates of colon cancer screening in the United States are low, in part because of poor communication between patients and providers about the availability of effective screening options.
To test ...whether a decision aid consisting of an educational video, targeted brochure, and chart marker increased performance of colon cancer screening in primary care practices.
Randomized, controlled trial.
Three community primary care practices in central North Carolina.
1657 consecutive adult patients 50 to 75 years of age were contacted. Of these, 651 (39%) agreed to participate; 249 of the 651 participants (38%) were eligible. Eligible patients had no personal or family history of colon cancer and had not had fecal occult blood testing in the past year or flexible sigmoidoscopy, colonoscopy, or barium enema in the past 5 years.
The 249 participants were randomly assigned to view an 11-minute video about colon cancer screening (intervention group) or a video about automobile safety (control group). After viewing the video, intervention group participants chose a color-coded educational brochure (based on stages of change) to indicate their degree of interest in screening. A chart marker of the same color was attached to their charts. Controls received a generic brochure on automobile safety, and no chart marker was attached.
Frequency of screening test ordering as reported by participants and frequency of completion of screening tests as verified by chart review.
Fecal occult blood testing or flexible sigmoidoscopy was ordered for 47.2% of intervention participants and 26.4% of controls (difference, 20.8 percentage points 95% CI, 8.6 to 32.9 percentage points). Screening tests were completed by 36.8% of the intervention group and 22.6% of the control group (difference, 14.2 percentage points CI, 3.0 to 25.4 percentage points).
A decision aid consisting of an educational video, brochure, and chart marker increased ordering and performance of colon cancer screening tests.
Since the beginning of the ongoing Amatrice seismic sequence on August 24, 2016, initiated by a Mw 6.0 normal faulting earthquake, the EMERGEO Working Group (an INGV team devoted to earthquake ...aftermath geological survey) set off to investigate any coseismic effects on the natural environment. Up to now, we surveyed about 750 km2 and collected more than 3200 geological observations as differently oriented tectonic fractures together with intermediate- to small- sized landslides, that were mapped in the whole area. The most impressive coseismic evidence was found along the known active Mt. Vettore fault system, where surface ruptures with clear vertical/horizontal offset were observed for more than 5 km, while unclear and discontinuous coseismic features were recorded along the Laga Mts. Fault systems.
Background: In systemic sclerosis (SSc), joint involvement may reduce the functional capacity of the hands. Intravenous immunoglobulins have previously been shown to benefit patients with SSc. Aim: ...To verify the efficacy of intravenous immunoglobulins on joint involvement and function in SSc. Patients and methods: 7 women with SSc, 5 with limited and 2 with diffuse SSc, with a severe and refractory joint involvement were enrolled in the study. Methotrexate and cyclophosphamide pulse therapy did not ameliorate joint symptoms. Hence, intravenous immunoglobulins therapy was prescribed at a dosage of 2 g/kg body weight during 4 days/month for six consecutive courses. The presence of joint tenderness and swelling, and articular deformities (due to primary joint involvement and not due to skin and subcutaneous changes) were evaluated. Before and after 6 months of treatment, patients were subjected to (1) Ritchie Index (RI) evaluation of joint involvement; (2) Dreiser Algo-Functional Index (IAFD) evaluation of hand joint function; (3) pain visual analogue scale (VAS) to measure joint pain; (4) Health Assessment Questionnaire (HAQ) to evaluate the limitations in everyday living and physical disability; and (5) modified Rodnan Skin Score for skin involvement. Results: After 6 months of intravenous immunoglobulins therapy, joint pain and tenderness, measured with the VAS, decreased significantly (p<0.03), and hand function (IAFD) improved significantly (p<0.02), together with the quality of life (HAQ; p<0.03). All patients significantly improved, except for one. The skin score after 6 months of intravenous immunoglobulins therapy was significantly reduced (p<0.003). Conclusion: This pilot study suggests that intravenous immunoglobulins may reduce joint pain and tenderness, with a significant recovery of joint function in patients with SSc with severe and refractory joint involvement. The cost of intravenous immunoglobulins might limit their use only to patients who failed disease-modifying antirheumatic drugs.
Many countries are planning or pilot-testing such programmes. The UK National Health Service recently reported the successful pilot-testing of faecal occult-blood screening in 500000 residents of ...England and Scotland.7 The accumulated evidence suggests that such implementation is warranted, and that no further trials need to be done that focus mainly on evaluating the effectiveness of faecal occult-blood testing for reducing mortality from colon cancer. We now need: to understand better the effect of screening on disease incidence; to determine how to integrate newer technologies, such as endoscopie or radiological screening, with faecal occult-blood screening; and to find ways to increase uptake and adherence.
To perform a systematic review of the cost-effectiveness of colorectal cancer screening for the U.S. Preventive Services Task Force.
MEDLINE and the British National Health Service Economic ...Evaluation Database, January 1993 through September 2001.
Original economic evaluations of colorectal cancer screening in average-risk patients were reviewed. The authors sought studies addressing the incremental cost-effectiveness of different screening strategies compared with no screening, of different screening strategies compared with one another, and of different ages of screening initiation and cessation. Two investigators independently reviewed each abstract, and potentially eligible articles were retrieved. A four-member working group reached consensus regarding final inclusion or exclusion of articles.
One reviewer extracted data into evidence tables. The results were checked by other members and discrepancies resolved by consensus.
Among 180 potential articles identified, 7 were retained in the final analysis. Compared with no screening, cost-effectiveness ratios for screening with any of the commonly considered methods were generally between 10, 000 dollars and 25, 000 dollars per life-year saved. No one strategy was consistently found to be the most effective or to have the best incremental cost-effectiveness ratio. Currently available models provided insufficient evidence to determine optimal starting and stopping ages for screening.
Screening for colorectal cancer appears cost-effective compared with no screening, but a single optimal strategy cannot be determined from the currently available data. Additional data regarding adherence with screening over time, complication rates in real-world settings, and colorectal cancer biology are needed. Additional analyses are necessary to determine optimal ages of initiation and cessation.
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