[Show abstract][Hide abstract] ABSTRACT: Impact of Diabetes on Cardiac Rehabilitation Outcomes
Authors: Carrie Oser, MPH1; Dorota Carpenedo, MPH2; Michael McNamara, MS, FAACVPR1; Crystelle Fogle, MS, MBA, RD1; Dorothy Gohdes, MD1 – Cardiovascular Health Program1 and Diabetes Program2 -- Montana Department of Public Health and Human Services.
Introduction: Cardiac rehabilitation (CR) has long been indicated for patients recovering from coronary heart disease (CHD).
Significance: CHD is the leading cause of death in patients with diabetes mellitus (DM).
Purpose: We assessed if there were differences in CR outcomes in patients with DM compared to those without DM.
Design: A cross-sectional study design was used to analyze patient outcomes from 145 CR facilities participating in the Montana Outcomes Project (MOP) from 22 states. From October 2012 through June 2014, there were 16,432 adults completing Phase II visits in CR programs. We compared CR outcomes of patients with DM (26.8%) to those without DM.
Methods: Data were collected using an Excel spreadsheet and reported quarterly. Descriptive statistics were calculated for all response variables. Statistical analysis included Paired T-test, Chi-square and ANOVA tests with p-value of ≤ 0.05 indicating statistical significance.
Results: Patients attended an average of 26.7 (SD: 9.19) sessions. Patients with DM were slightly older (67.4 vs. 66.9 years, p<0.024), non-white (9.9% vs. 5.4%), and Hispanic (4.7% vs. 2.8%) compared to those without DM. Patients without DM were significantly more likely to have blood pressure at target (<140/90 mmHg) pre-CR (86% vs. 90%) and post-CR (90% vs. 92%) compared to patients with DM. Most CR-patients had body mass index (BMI) >25.0 kg/m2 (90% with DM and 75% without DM). Patients with DM were less likely to be referred for MI/PCI and valve replacement/repair and more likely to be referred post-CABG than patients without DM. After CR, patients with and without DM showed significant improvements in quality of life (SF-36), functional capacity (Duke Activity Status Index) and depression scores (PHQ-9). Patients without DM showed significant improvements in functional capacity compared to patients with DM (mean difference: 1.77 vs. 1.56 METs). Patients with DM showed greater improvement, although not significant (p=0.08) in depression scores compared to patients without DM (mean difference: 2.29 vs. 2.15).
Conclusion: Our findings confirm that patients with DM had lower functional capacity at the initiation of CR compared to patients without diabetes. Patients with DM were also more likely to have a BMI >25.0 kg/m2 and have higher depression scores compared to those without DM. Quality of life and depression scores as well as functional capacity improved in all participants regardless of DM status.
Implications: With the large sample from multiple CR programs, we were able to show benefits for subsets of patients with DM with the most common referring diagnoses.
[Show abstract][Hide abstract] ABSTRACT: Outpatient Cardiac Rehab Outcomes – Heart Failure vs. Non-Heart Failure
Michael McNamara, MS, FAACVPR, Carrie Oser, MPH, Crystelle Fogle, MS, MBA, RD, Dorothy Gohdes, MD – Cardiovascular Health Program -- Montana Department of Public Health and Human Services
Introduction: Heart failure (HF) is a growing problem across the US. With an increase in the aging population and the recent Medicare coverage expansion in cardiac rehab (CR) to include systolic heart failure, CR programs will be seeing increased numbers of HF patients.
Purpose: To investigate the differences in CR outcomes between patients with and without HF.
Significance: Cardiac rehab programs will be seeing a large increase in HF patients and this study provides data on expected outcomes compared to non-HF patients.
Design: A cross-sectional study design was used for CR facilities participating in the Montana Outcomes Project.
Methods: The sample included over 16,400 patients representing 145 programs from 22 states. The time frame for data collection was from October 2012 through June 2014. Statistical analysis included Chi-square and ANOVA tests with p-value of ≤ 0.05 indicating statistical significance.
Results: Seventy-one percent of the patients were male, and the average age was 67.0 years. Patients with HF were significantly more likely to have diabetes (DM) (35% vs. 26%) and myocardial infarction (MI) (10% vs. 5%) compared to patients without HF. Program completion rates were similar in both groups (79% vs. 78%) as were smoking rates at baseline (11.8% vs. 11.8%) and post CR (4.3% vs. 4.2%). However, smoking cessation referral rates were higher in the HF population compared to non-HF patients (79% vs. 68%). At baseline and follow-up, HF patients had significantly poorer quality of life (QOL), depression, and functional capacity scores. However, there was no significant difference in the improvement of mean scores related to QOL between groups (SF36 physical: 7.8 vs. 8.0 and SF-36 mental: 1.5 vs. 1.7). Improvements in the mean PHQ-9 depression scores were significantly better for HF patients compared to those without HF (2.54 vs. 2.17). Non-HF patients had significantly greater improvements in mean change related to functional capacity (METs) as measured by the Duke Activity Status Index (DASI) (1.73 vs. 1.52).
Conclusion: Patients with HF have a higher incidence of comorbidities, including DM and MI, but enjoy many of the same benefits from CR as non-HF patients. While patients with HF had poorer pre- and post-CR scores compared to non-HF patients, the rate of improvement was similar in the QOL scores and significantly better in relationship to the PHQ-9. In contrast, patients without HF had a rate of improvement in the DASI that was significantly greater than that of the HF population.
Implication: Patients with HF typically carry more comorbidities but elicit positive benefits from participating in CR. Efforts to recruit patients with HF into CR should be encouraged.
[Show abstract][Hide abstract] ABSTRACT: Angiotensin Converting Enzyme Inhibitors (ACEI) and Angiotensin II Receptor Blockers (ARB) are two common medication classes used for heart failure treatment. The ADAHF (Automated Data Acquisition for Heart Failure) project aimed at automatically extracting heart failure treatment performance metrics from clinical narrative documents, and these medications are an important component of the performance metrics. We developed two different systems to detect these medications, rule-based and machine learning-based. The rule-based system used dictionary lookups with fuzzy string searching and showed successful performance even if our corpus contains various misspelled medications. The machine learning-based system uses lexical and morphological features and produced similar results. The best performance was achieved when combining the two methods, reaching 99.3% recall and 98.8% precision. To determine the prescription status of each medication (i.e., active, discontinued, or negative), we implemented a SVM classifier with lexical features and achieved good performance, reaching 95.49% accuracy, in a five-fold cross-validation evaluation.
Full-text · Article · Aug 2015 · Studies in health technology and informatics
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES
We examined whether the interactions between primarily speaking English at home and community-level measures (median household income and immigrant composition) are associated with physical inactivity and obesity.
We pooled the 2005 and 2007 Los Angeles County Health Survey data to construct a multilevel data set, with community-level median household income and immigrant density as predictors at the community level. After controlling for individual-level demographic variables, we included the respondent's perceived community safety as a covariate to test the hypothesis that perceived public safety mediates the association between acculturation and health outcomes.
The interaction between community median household income and primarily speaking English at home was associated with lower likelihoods of physical inactivity (odds ratio [OR] = 0.644; 95% confidence interval [CI] = 0.502, 0.825) and obesity (OR = 0.674; 95% CI = 0.514, 0.882). These odds remained significant after we controlled for perceived community safety.
Resources in higher-income areas may be beneficial only to residents fully integrated into the community. Future research could focus on understanding how linguistic isolation affects community-level social learning and access to resources and whether this differs by family-level acculturation.
No preview · Article · May 2015 · American Journal of Public Health
[Show abstract][Hide abstract] ABSTRACT: The Health Belief Model (HBM) has been widely used as a framework to explain health
behaviors in diverse populations, but little HBM research has focused on HIV-infected women
and their increased risks for cervical cancer. We used Champion’s Health Belief Model and Self-
Efficacy scales to assess relationships between Pap test adherence and constructs of the HBM
among 300 HIV-infected women. In addition, we assessed the relationship between HPV and
cervical cancer knowledge and key HBM concepts. Participants reported low levels of
knowledge regarding risk for cervical cancer and HPV. They perceived lower personal risk for
cervical cancer. Women with higher perceived self-efficacy and lower perceived barrier scores
reported better Pap test adherence. Findings indicate that HIV-infected women are not aware of
the risk for cervical cancer and may not take preventive actions. Further research is needed to
identify the full range of factors that impact adherence to cervical cancer screening.
Key words: Health Belief Model, HIV, HPV, Pap smear, self-efficacy, susceptibility
Full-text · Article · May 2015 · The Journal of the Association of Nurses in AIDS Care: JANAC
[Show abstract][Hide abstract] ABSTRACT: The “Chevalier” John Taylor was perhaps the most important itinerant oculist of 18th
century Europe. His professional legacy is controversial, and he was accused by many contemporaries
and subsequent historians of being a quack. Nevertheless, his writings demonstrate
an understanding of ocular anatomy and disease better than that of most of his contemporaries,
including the first published illustration of the semidecussation of the optic nerves. Taylor’s
personal legacy is more favorable. His son, John Taylor, Jr., and his grandsons John and Jeremiah
Taylor, were respected oculists. Their lives give perspective on ophthalmic practice in
18th and 19th century Europe.
[Show abstract][Hide abstract] ABSTRACT: In Ethiopia, the under-five mortality rate (U5MR) was reduced by 28% between 2005 and 2011, but the neonatal mortality rate (NMR) remains unchanged and now accounts for 42% of all U5 deaths. This burden is even greater for the large rural population due to poor access to and utilization of maternal and newborn health services. To achieve Millennium Development Goal 4, neonatal mortality must be addressed, specifically the major direct causes – sepsis, birth asphyxia, and preterm delivery. Neonatal sepsis, the major newborn killer in Ethiopia, accounts for more than one third of neonatal deaths, 75% in first week of life when even modest delays in receiving effective care can be deadly. The national scale-up of integrated Community Case Management (iCCM) in 2010-2012 provided a needed boost to the Health Extension Program (HEP) by introducing a package of high quality basic curative interventions meeting the demand of the communities. According to the national guidelines for iCCM, Health Extension Workers assess and classify newborn infections and then refer them to health centers and hospitals for treatment. When re-ferral is not possible or delayed, they can provide pre-referral or even complete treatment with oral antibiotics. There is limited care seeking by caregivers for sick young infants under 2 months of age in the iCCM program. The Federal Ministry of Health (FMOH) established a working group that presented a strategy paper, " Exploring the potential for community-based case management of neonatal sepsis in Ethiopia " in February 2012. The paper analyzed the potential benefits and challenges of introducing community-based sepsis management. Reducing neo-natal mortality is increasingly important not only because the proportion of U5 deaths in the neonatal period is increasing, but also because the health interventions to address neonatal deaths generally differ from those to address other under-five deaths. High levels of home delivery (90%) and cultural beliefs of secluding the newborn challenge identifying and treating sick newborns. Active pregnancy and birth surveillance and postpartum home visits early in the first week are required to identify and manage sick neonates.
Full-text · Article · Oct 2014 · Ethiopian medical journal
[Show abstract][Hide abstract] ABSTRACT: Previous surveys of men who have sex with men (MSM) in Africa have not adequately profiled HIV status and risk factors by sex work status. MSM in Nairobi, Kenya, were recruited using respondent-driven sampling (RDS), completed a behavioral interview, and were tested for HIV and STIs. Overlapping recruitment among 273 male sex workers and 290 other MSM was common. Sex workers were more likely to report receptive anal sex with multiple partners (65.7% versus 18.0%, P<0.001) and unprotected receptive anal intercourse (40.0% versus 22.8%, P=0.005). Male sex workers were also more likely to be HIV infected (26.3% versus 12.2%, P=0.007).
No preview · Article · Sep 2014 · JAIDS Journal of Acquired Immune Deficiency Syndromes
[Show abstract][Hide abstract] ABSTRACT: In recent years, perceptions of performance and quality of healthcare organizations have begun to move beyond examining the provision of excellent clinical care, alone, and to consider and embrace the patient experience as an important indicator. There is a need to determine the extent to which clear and formal definitions exist, have common overarching themes, and/or have unique, but important constructs that should be considered more widely. In this article, we provide a 14-year synthesis of existing literature and other sources (2000-2014) that have been used to define patient experience. A total of 18 sources (articles or organizational websites) were identified that provided a tangible, explicit definition of patient experience. A narrative synthesis was undertaken to categorize literature (and other sources) according to constructs of the definitions provided. The objectives of the synthesis were to: (1) identify the key elements, constructs, and themes that were commonly and frequently cited in existing definitions of ‘patient experience,’
(2) summarize these findings into what might be considered a common shared definition, and (3) identify important constructs that may be missing from and may enhance existing definition(s). The overarching premise was to identify and promote a working definition of patient experience that is applicable and practical for research, quality improvement efforts, and general clinical practice. Our findings identified several concepts and recommendations to consider with regard to the definition of patient experience. First, the patient experience reflects occurrences and events that happen independently and collectively across the continuum of care. Also, it is important to move beyond results from surveys, for example those that specifically capture concepts such as ‘patient satisfaction,’ because patient experience is more than satisfaction alone. Embedded within patient experience is a focus on individualized care and tailoring of services to meet patient needs and engage them as partners in their care. Next, the patient experience is strongly tied to patients’ expectations and whether they were positively realized (beyond clinical outcomes or health status). Finally, the patient experience is integrally tied to the principles and practice of patient- and family- centered care. As patient experience continues to emerge as an important focus area across healthcare globally, the need for a standard consistent definition becomes even more evident, making it critical to ensure patient experience remains a viable, respected, and highly embraced part of the healthcare conversation.
[Show abstract][Hide abstract] ABSTRACT: Background: The Performance Review and Clinical Mentoring Meeting (PRCMM) is an approach to improve and sustain Health Extension Worker (HEW) skills and performance in integrated Community Case Management (iCCM). Objective: To compare HEW performance in recording case management before and after they participated in PRCMM. Methods: We conducted a historical cohort analysis of iCCM case records between September 2010 and Decem-ber 2012 from 622 randomly selected health posts representing 31 intervention woredas (districts) of Amhara, Oromia and Southern Nations Nationalities and Peoples' Regions. We used longitudinal regression analysis comparing the trend in the consistency of the classification with the assessment, treatment and follow-up date as well as caseload in the periods before and after PRCMM, with 5511 and 7901 case records, respectively. Results: Overall consistency improved after PRCMM for all common classifications as follows: pneumonia (54.1% [95% CI: 47.7%–60.5%] vs. 78.2% [73.9%–82.5%]), malaria (50.8% [42.9%–58.7%] vs. 78.9% [73.4%– 84.4%]), and diarrhea (33.7% [27.9%–39.5%] vs. 70.0% [64.7%–75.3%]). This improvement was consistently observed comparing the six months before and the six months after PRCMM in all the common classifications except for malaria where the improvement observed during the first three post-PRCMM months disappeared during the fifth and sixth months. Caseload increased significantly after PRCMM (6.6 [95% CI: 5.9–7.3] vs. 9.2 [8.5–9.9] cases/health post/month). Conclusion: PRCMM seemed to improve iCCM performance of HEWs and should be integrated within the PHC system and given about every six months, at least at first, to sustain improvement.
[Show abstract][Hide abstract] ABSTRACT: Importance Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy.
Objectives To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries.
Design We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages.
Results US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th.
Conclusions and Relevance From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations.
The United States spends the most per capita on health care across all countries,1- 2 lacks universal health coverage, and lags behind other high-income countries for life expectancy3 and many other health outcome measures.4 High costs with mediocre population health outcomes at the national level are compounded by marked disparities across communities, socioeconomic groups, and race and ethnicity groups.5- 6 Although overall life expectancy has slowly risen, the increase has been slower than for many other high-income countries.3 In addition, in some US counties, life expectancy has decreased in the past 2 decades, particularly for women.7- 8 Decades of health policy and legislative initiatives have been directed at these challenges; a recent example is the Patient Protection and Affordable Care Act, which is intended to address issues of access, efficiency, and quality of care and to bring greater emphasis to population health outcomes.9 There have also been calls for initiatives to address determinants of poor health outside the health sector including enhanced tobacco control initiatives,10- 12 the food supply,13- 15 physical environment,16- 17 and socioeconomic inequalities.18
With increasing focus on population health outcomes that can be achieved through better public health, multisectoral action, and medical care, it is critical to determine which diseases, injuries, and risk factors are related to the greatest losses of health and how these risk factors and health outcomes are changing over time. The Global Burden of Disease (GBD) framework19 provides a coherent set of concepts, definitions, and methods to do this. The GBD uses multiple metrics to quantify the relationship of diseases, injuries, and risk factors with health outcomes, each providing different perspectives. Burden of disease studies using earlier variants of this approach have been published for the United States for 199620- 22 and for Los Angeles County, California.23 In addition, 12 major risk factors have also been compared for 2005.24
In this report, we use the GBD Study 2010 to identify the leading diseases, injuries, and risk factors associated with the burden of disease in the United States, to determine how these health burdens have changed over the last 2 decades, and to compare the United States with other Organisation for Economic Co-operation and Development (OECD) countries.
Full-text · Article · Jul 2013 · JAMA The Journal of the American Medical Association