Publications (2)18.15 Total impact
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Article: Improving blood pressure control through a clinical pharmacist outreach program in patients with diabetes mellitus in 2 high-performing health systems: the adherence and intensification of medications cluster randomized, controlled pragmatic trial.
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ABSTRACT: Even in high-performing health systems, some patients with diabetes mellitus have poor blood pressure (BP) control because of poor medication adherence and lack of medication intensification. We examined whether the Adherence and Intensification of Medications intervention, a pharmacist-led intervention combining elements found in efficacy studies to lower BP, improved BP among patients with diabetes mellitus with persistent hypertension and poor refill adherence or insufficient medication intensification in 2 high-performing health systems. We conducted a prospective, multisite cluster randomized pragmatic trial with randomization of 16 primary care teams at 5 medical centers (3 Veterans Affairs and 2 Kaiser Permanente) to the Adherence and Intensification of Medications intervention or usual care. The primary outcome was relative change in systolic BP (SBP), comparing 1797 intervention with 2303 control team patients, from 6 months preceding to 6 months after the 14-month intervention period. We examined shorter-term changes in SBP as a secondary outcome. The mean SBP decrease from 6 months before to 6 months after the intervention period was ≈9 mm Hg in both arms. Mean SBPs of eligible intervention patients were 2.4 mm Hg lower (95% CI: -3.4 to -1.5; P<0.001) immediately after the intervention than those achieved by control patients. The Adherence and Intensification of Medications program more rapidly lowered SBPs among intervention patients, but usual-care patients achieved equally low SBP levels by 6 months after the intervention period. These findings show the importance of evaluating in different real-life clinical settings programs found in efficacy trials to be effective before urging their widespread adoption in all settings. URL: http://clinicaltrials.gov. Unique identifier: NCT00495794.Circulation 05/2012; 125(23):2863-72. · 14.74 Impact Factor -
Article: Building a better quality measure: are some patients with 'poor quality' actually getting good care?
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ABSTRACT: National performance measures monitor the proportion of diabetic patients with low-density lipoprotein (LDL) levels >/=130 mg/dL, but such simple intermediate outcomes measure poor control, not necessarily poor care. "Tightly linked" quality measures define good quality either by a good intermediate outcome (LDL <130 mg/dL) or by evidence of appropriate responses to poor control (eg, starting or optimizing medications for high LDL or not doing so in the face of contraindications). We examined hyperlipidemia therapy for patients with diabetes to determine the relative accuracy of quality assessment using simple intermediate outcome versus tightly linked quality measures. Retrospective longitudinal cohort. A total of 1154 diabetic patients with an LDL test done between October 1, 1998, and March 31, 1999, in 2 large VA facilities. LDL levels, medication treatment, and explanations for poor quality. Although 27% (307 of 1154) of patients had an LDL >/=130 mg/dL using the simple intermediate outcome measure, only 13% (148 of 1154) were classified as having substandard quality using the tightly linked measure. Among the 159 reclassified to adequate quality, 117 had lipid-lowering medication started or increased within 6 months of an LDL >/=130 mg/dL, 8 were already on high-dose medication, 12 had a repeat LDL <130 mg/dL, and 22 had contraindications to treatment. Simple intermediate outcome measures can be an inaccurate reflection of true quality of care, and many patients classified as having substandard quality by "poor control" might actually be receiving good quality of care.Medical Care 10/2003; 41(10):1173-82. · 3.41 Impact Factor
