High school body mass index and body mass index at entry to a cardiac disease risk prevention clinic and the association to all-cause mortality and coronary heart disease: a PreCIS database study.

OBJECTIVE: : To investigate overweight/obese patients (body mass index [BMI], > or =25 kg/m) at entry to a preventive cardiology clinic who had a high school (HS) BMI of 25 kg/m or greater versus those with a BMI of less than 25 kg/m to determine coronary heart disease (CHD) prevalence, all-cause mortality. METHODS: : Patients (n = 4,597) who had a BMI of 25 kg/m or greater at the time of initial visit to the prevention clinic were asked to report their weight at graduation from HS. Patients with BMI of 25 kg/m or greater in HS (n = 1,285) were compared with patients (n = 3,312) with a BMI of less than 25 kg/m in HS. Prevalent CHD was assessed at entry. Patient mortality was assessed using the Social Security Death Index for a maximum of 7 years after the initial visit. RESULTS: : Mean/median values for most CHD risk factors were higher in the group with an HS BMI of 25 kg/m or greater, with the exception of low-density lipoprotein level (120 vs 132 mg/dL; P < .001), Lipoprotein (a) level (16 vs 19 mg/dL; P = .003), and systolic blood pressure (126 vs 128. 3 mm Hg; P < .001). Patients with an HS BMI of 25 kg/m or greater had a higher mean BMI at initial visit (33.9 vs 30.1; P < .001) and hemoglobin A1c (6.8% vs 6.3%; P < .001) and glucose concentrations (93 vs 91 mg/dL; P = .004), with a lower mean high-density lipoprotein level (43.2 vs 46.5 mg/dL; P < .001) as well as greater prevalence of smoking (16.2% vs 11.4%; P < .001), diabetes mellitus (32.4% vs 21.8%; P < .001), CHD (47.1% vs 43%; P = .01), and specifically myocardial infarction (25.8% vs 21.1%; P = .001). Fibrinogen and urine albumin-to-creatinine levels were elevated. After adjusting for risk factors, an HS BMI of 25 kg/m or greater was associated with a 21% higher prevalence of CHD (odds ratio, 1.20; P = .027). However, an HS BMI of 25 kg/m or greater was not a significant predictor of 7-year mortality (hazard ratio, 1.03; P = .84). CONCLUSION: : Patients with an HS BMI of 25 kg/m or greater had more CHD risk factors compared with those with an HS BMI of less than 25 kg/m. Prevalence of CHD was also significantly higher in this group. However, an HS BMI of 25 kg/m or greater was not a significant predictor of mortality.

Transition toward a nurse practitioner-managed clinic.

OBJECTIVE: Advanced practice nurses (APNs) have been shown to provide effective quality healthcare when treating dyslipidemia, diabetes, and hypertension. As these conditions become more prevalent, APNs are becoming more widely used and respected and are a cost-effective alternative to physician-based healthcare. The Cleveland Clinic Preventive Cardiology and Rehabilitation program has progressed toward an APN-managed clinic for the past 5 years. METHODS: From 1987 to 1994, the clinic was traditionally a physician-based model. In 1995, physician extenders became part of the practice. In 2002, the transition began toward an APN clinic. An initial change included continuity with one APN when scheduling follow-up visits, triaging telephone contacts, and giving prescriptions. Documentation was changed to include the APN. Policy was revised to allow "incident to" and independent billing to address revenue and accessibility issues. Schedules reflected APNs as providers. Algorithms were developed and revised jointly between APNs and physicians. RESULTS: Patients have verbalized satisfaction with APN care. Survey data over a 12-month period indicated that in 5 of 8 questions pertaining to provider care, percent excellent or very good scores were 83% to 96% using a Likert scale. In the remaining 3 questions, scores ranged from 84% to 94% for the "yes, definitely" response, which was the most favorable response. Total APN visits for May 1, 2006, to May 1, 2007, were 2,522, billed independently, providing $476,031 in charges. Outcomes data for primary and secondary prevention patients showed an average improvement in the following laboratory results: 48 mg/dL total cholesterol, 36 mg/dL low-density lipoprotein, 3.5 mg/dL high-density lipoprotein, 99 mg/dL triglycerides, 3.68 mg/L ultra sensitive C-reactive protein. CONCLUSIONS: APNs are an effective and efficient way to provide cardiovascular risk reduction with an emphasis on medical management, lifestyle habits, and patient education.