Background
Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities.
Objective
To determine whether a ...positive deviance approach would improve blood pressure (BP) control across diverse health systems.
Design
Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013–2017).
Participants
Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (
N
= 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative.
Interventions
Identification of a “positive deviant” and dissemination of this system’s best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (
low
: Learning Collaborative events describing the best practices;
moderate
: Learning Collaborative events plus consultation when requested; and
high
: Learning Collaborative events plus practice coaching).
Main Measures
We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics.
Key Results
BP control post-intervention improved by 7.6% 95% confidence interval (CI) 6.0–9.1, from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5–13.5), Hispanic (10.5%, 95% CI 8.4–12.5), and African American (9.0%, 95% CI 7.7–10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2–19.5; moderate: 5.2%, 95% CI 0.8–9.5; low: 0.2%, 95% CI−3.9 to 4.3).
Conclusions
Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.
Background Hypertension control is critical to reducing cardiovascular disease, challenging to achieve, and exacerbated by socioeconomic inequities. Few states have established statewide quality ...improvement (QI) infrastructures to improve blood pressure (BP) control across economically disadvantaged populations. In this study, we aimed to improve BP control by 15% for all Medicaid recipients and by 20% for non-Hispanic Black participants. Methodology This QI study used repeated cross-sections of electronic health record data and, for Medicaid enrollees, linked Medicaid claims data for 17,672 adults with hypertension seen at one of eight high-volume Medicaid primary care practices in Ohio from 2017 to 2019. Evidence-based strategies included (1) accurate BP measurement; (2) timely follow-up; (3) outreach; (4) a standardized treatment algorithm; and (5) effective communication. Payers focused on a 90-day supply (vs. 30-day) of BP medications, home BP monitor access, and outreach. Implementation efforts included an in-person kick-off followed by monthly QI coaching and monthly webinars. Weighted generalized estimating equations were used to estimate the baseline, one-year, and two-year implementation change in the proportion of visits with BP control (<140/90 mm Hg) stratified by race/ethnicity. Results For all practices, the percentage of participants with controlled BP increased from 52% in 2017 to 60% in 2019. Among non-Hispanic Whites, the odds of achieving BP control in year one and year two were 1.24 times (95% confidence interval: 1.14, 1.34) and 1.50 times (1.38, 1.63) higher relative to baseline, respectively. Among non-Hispanic Blacks, the odds for years one and two were 1.18 times (1.10, 1.27) and 1.34 times (1.24, 1.45) higher relative to baseline, respectively. Conclusions A hypertension QI project as part of establishing a statewide QI infrastructure improved BP control in practices with a high volume of disadvantaged patients. Future efforts should investigate ways to reduce inequities in BP control and further explore factors associated with greater BP improvements and sustainability.
The study of migrant groups within their new sociopolitical and geographical environments is no new phenomenon; people have been moving in groups and individually to 'foreign' lands for centuries in ...order to seek a'betterf way of life... When the emergent group is of a distinct race and culture, complex problems of adaptation or adjustment for the group may occur in the receiving society. This is often accompanied by some degree of rejection or ostracism of the newcomers by members of the host society. The present study attempts to analyse some aspects of the adaptive strategy of Guyanese now living in Winnipeg, Manitoba, Canada. The writer estimates that there are at least two hundred Guyanese families living in Winnipeg. A majority of these families represent Guyana's two major ethnic groups (Indo- and Afro-Guyanese)... The emphasis in the past in the study of minority groups by social scientists has been an analysis of the socioeconomic adjustment and achievement of the immigrants within their new country of residence... Scant attention is paid, however, to the immigrant's socio-cultural past within his country of birth. A recapitulation of the historical development of the socio-economic and cultural structures (kinship organization, job experience, education and training, cultural values. . .) of the immigrant's background is imperative in order to understand some aspects of his social behaviors and cultural values within the `receiving' society... Race, ethno-culture and socio-political differences are some of the more prominent features to be considered when a comparative analysis between the tsendingt and the rreceivingr countries is made... For practical purposes, Guyanese living in Winnipeg must not be considered as a homogeneous group of immigrants. Guyanese society is made up of a medley of ethnic groups and cultures, most of which are attempting to foster group identity through cultural af.filiations with the land of their ancestors (Africa, India, China. . .). More recently, various political organizations have made some attempts to construct some form of nationalism which rdere expected to have some positive effect on cultural integration among the various grouPs. Thus far, the perpetual striving for cultural identity (and supremacy) by the various groups has resulted in Guyana being considered one of the most culturally pluralistic societies in the world (the definition of `culturally plural societies' is dealt with in the thesis). Cultural persistence in the Guyanese case not only takes precedence over national solidarity and a cohesive society, but affects value orientation and aspirations of the members of the various group, thereby complicating the investigation of the adaptive strategies of Guyanese abroad..
The institutional frameworks that Indigenous groups put in place to govern economic processes within their communities are critical to the advancement of their diverse cultural-ecological, social, ...and economic development goals. Through the lens of institutional logics, this article examines the ways in which First Nations community sawmill enterprises in British Columbia, Canada, navigate the sectoral demands brought by a productivist paradigm of forestry. We find that First Nations community sawmill enterprises represent spaces of both logical tension and innovation where conflicts that arise between dominant “commercial” logics and culturally legitimate “Indigenous” logics can be reconciled. Through this analysis, this article offers an empirical example of the emergence of Indigenous institutional frameworks, as well as a contribution to the growing body of literature that addresses the ways in which hybrid organizations can and do navigate and overcome conflicting institutional logics.
Membrane rafts are rich in cholesterol and sphingolipids and have specific proteins associated with them. Due to their small size, their identification and isolation have proved to be problematic. ...Their insolubility in nonionic detergents, such as Triton-X 100, at 4°C has been the most common means of isolation. However, detergent presence can produce artifacts or interfere with ganglioside distribution. The direction is therefore toward the use of detergent-free protocols. We report an optimized method of raft isolation from lipid-rich brain tissue using a detergent-free method. We compared this to Triton-X 100-based isolation along sucrose or Optiprep™ gradients using the following endpoints: low protein content, high cholesterol content, presence of Flotillin 1 (Flot1), and absence of transferrin receptor (TfR) proteins. These criteria were met in raft fractions isolated in a detergent-free buffer along a sucrose gradient of 5%/35%/42.5%. The use of optiprep gave less consistent results with respect to protein distribution. We demonstrate that clean raft fractions with minimal myelin contamination can be reproducibly obtained in the top three low-density fractions along a sucrose step gradient.
Point of care testing to improve glycemic control Rust, George; Gailor, Morna; Daniels, Elvan ...
International journal of health care quality assurance,
01/2008, Letnik:
21, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Purpose - The purpose of this paper is to pilot-test the feasibility and impact of protocol-driven point-of-care HbA1c testing on levels of glycemic control and on rates of diabetic regimen ...intensification in an urban community health center serving low-income patients.Design methodology approach - The paper suggests a primary care process re-design, using point of care finger-stick HbA1c testing under a standing order protocol that provided test results to the provider at patient visit.Findings - The paper finds that the protocol was well received by both nurses and physicians. HbA1c testing rates increased from 73.6 percent to 86.8 percent (p=0.40, n=106). For the 69 patients who had both pre- and post-intervention results, HbA1c levels decreased significantly from 8.55 to 7.84 (p=0.004, n=69). At baseline, the health center as a system was relatively ineffective in responding to elevated HbA1c levels. An opportunity to intensify, i.e. a face-to-face visit with lab results available, occurred for only 68.6 percent of elevated HbA1c levels before the intervention, vs. 100 percent post-intervention (p<0.001). Only 28.6 percent of patients with HbA1c levels >8.0 had their regimens intensified in the pre-intervention phase, compared with 53.8 percent in the post-intervention phase (p=0.03).Research limitations implications - This was a pilot-study in one urban health center. Larger group-randomized controlled trials are needed.Practical implications - The health center's performance as a system, improved significantly as a way of intensifying diabetic regimens thereby achieving improved glycemic control.Originality value - This intervention is feasible, replicable and scalable and does not rely on changing physician behaviors to improve primary care diabetic outcomes.
Microglial phagocytosis contributes to the maintenance of brain homeostasis. Mechanisms involved, however, remain unclear. Using Abeta(42) solely as a stimulant, we provide novel insight into ...regulation of microglial phagocytosis by rafts. We demonstrate the existence of an Abeta(42) threshold level of 250 pg/mL, above which microglial phagocytic function is impaired. Low levels of Abeta(42) facilitate fluorescent bead uptake, whereas phagocytosis is inhibited when Abeta(42) accumulates. We also show that region-specific raft clustering occurs before microglial phagocytosis. Low Abeta(42) levels stimulated this type of raft aggregation, but high Abeta(42) levels inhibited it. Additionally, treatment with high Abeta(42) concentrations caused a redistribution of the raft structural protein flotillin1 from low to higher density fractions along a sucrose gradient. This suggests a loss of raft structural integrity. Certain non-steroidal anti-inflammatory drugs, e.g., the cyclooxygenase 2-specific nonsteroidal anti-inflammatory drugs, celecoxib, raise Abeta(42) levels. We demonstrated that prolonged celecoxib exposure can disrupt rafts in a manner similar to that seen in an elevated Abeta(42) environment: abnormal raft aggregation and Flot1 distribution. This resulted in aberrant receptor recruitment to rafts and impaired receptor-mediated phagocytosis by microglial cells. Specifically, recruitment of the scavenger receptor CD36 to rafts during active phagocytosis was affected. Thus, we propose that maintaining raft integrity is crucial for determining microglial phagocytic outcomes and disease progression.
Extract: The specific purposes of this paper are (a) to review research both recently completed and currently in progress on approaches being used to assess and respond to production, market, and ...financial risks in agriculture; and (b) to present an evaluation of production and marketing strategies designed to minimize variability of net farm income subject to receiving a specified level of income for a southwestern Oklahoma farm operation; and (c) to relate the effects of alternative assumptions regarding beginning equity level, rate of increase in land value, and rate of increase in the cost of agricultural inputs to the probability of "success" of risk efficient farm plans for the southwestern Oklahoma operation.
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