Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE): A randomized trial to improve post myocardial infarction management.

OBJECTIVE: We evaluated the impact of a low intensity web-based and intensive nurse-administered intervention to reduce systolic blood pressure (SBP) among patients with prior MI. METHODS: Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE) was a three-arm trial. Patients were randomized to 1) post-MI education-only; 2) nurse-administered telephone program; or 3) web-based interactive tool. The study was conducted 2009-2013. RESULTS: Participants (n = 415) had a mean age of 61 years (standard deviation [SD], 11). Relative to the education-only group, the 12-month differential improvement in SBP was - 3.97 and - 3.27 mmHg for nurse-administered telephone and web-based groups, respectively. Neither were statistically significant. Post hoc exploratory subgroup analyses found participants who received a higher dose (>12 encounters) in the nurse-administered telephone intervention (n = 60; 46%) had an 8.8 mmHg (95% CI, 0.69, 16.89; p = 0.03) differential SBP improvement versus low dose (<11 encounters; n = 71; 54%). For the web-based intervention, those who had higher dose (n = 73; 53%; >1 web encounter) experienced a 2.3 mmHg (95% CI, -10.74, 6.14; p = 0.59) differential SBP improvement versus low dose (n = 65; 47%). CONCLUSIONS: The main effects were not statistically significant. PRACTICAL IMPLICATIONS: Completing the full dose of the intervention may be essential to experience the intervention effect. CLINICAL TRIAL REGISTRATION: The unique identifier is NCT00901277 (http://www. CLINICALTRIALS: gov/ct2/show/NCT00901277?term=NCT00901277&rank=1).

Association of physical activity on blood glucose in individuals with type 2 diabetes.

Regular physical activity (PA) has been shown to improve glycemic control in persons with type 2 diabetes. This study aimed to investigate the impact of PA on blood glucose after controlling for medication use, demographics, and week of activation using a real-world population of individuals with type 2 diabetes. A longitudinal, retrospective study was performed evaluating weekly PA of Livongo members (N = 9,509), which analyzed fasting blood glucose (FBG), step counts, and daily active minutes. Linear mixed-effect modeling technique was used to investigate within member and between member effects of input variables on average weekly FBG. Of members enrolled, 6,336 (32%) had self-reported body mass index, qualified week with diabetes medications, and FBG measures. Members' baseline average age was 49.4 (SD 10.1) years old, 43% female, and 45,496 member weeks with an average of 7.2 qualified weeks (PA observable in ≥4 days) per member. Average weekly FBG was 140.5 mg/dL (SD 39.8), and average daily step counts were 4,833 (SD 3,266). Moving from sedentary (<5,000 steps per day) to active (≥5,000 steps per day) resulted in mean weekly FBG reduction of 13 mg/dL (95% CI: -22.6 to -3.14). One additional day of ≥8,000 steps reduced mean weekly FBG by 0.47 mg/dL (95% CI: -0.77 to -0.16). Members who completed 30 min of moderate to vigorous PA above the population average reduced mean weekly FBG by 7.7 mg/dL (95% CI: -13.4 to -2.0). PA is associated with a mean weekly FBG reduction of 13 mg/dL when changing from a sedentary to active lifestyle while participating in a remote diabetes monitoring program.

Trends of blood pressure control in the U.S. during the COVID-19 pandemic.

IMPORTANCE: COVID-19 altered lifestyles and disrupted routine health care. Whether blood pressure (BP) control worsened during COVID-19 is unknown. OBJECTIVE: To understand whether home BP control worsened during COVID-19 across the United States (US) . DESIGN, SETTING, AND PARTICIPANTS: A population-based analysis of home BP data from 72,706 participants enrolled in a digital health hypertension control program. Data was compared before (January 2019 to March 2020) and during (April 2020 to August 2020) COVID-19. MAIN OUTCOMES AND MEASURES: Monthly mean home BP readings, systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were quantified before and during the pandemic. Multivariable adjustments were made for age, sex, race, region, and months enrolled. Home BP readings were also classified based on monthly averages and highest home BP readings into risk groups: Stage 2 HTN: BP> = 135 or DBP> = 85; Uncontrolled HTN: SBP> = 145 or DBP> = 95; or Severely uncontrolled HTN: SBP> = 160 or DBP> = 100). RESULTS: Overall, 72,706 participants were enrolled in a digital health hypertension program between 1/1/2019 and 8/31/2020. Compared with participants pre-COVID-19 (n = 33,440), those during COVID-19 (n = 39,266) were of similar age (mean 53.0 ± 10.7 years vs 53.3 ± 10.8 years); sex (46% vs 50.6% female) and race (29.1% vs 34.2% non-white). Relative to pre-Covid (Apr-Aug 2019) the mean monthly number of home BP readings rose during COVID-19 (Apr-Aug, 2020), from 7.3 to 9.3 per month (P < .001). During COVID-19, participants had higher monthly adjusted mean SBP (131.6 mmHg vs. 127.5 mmHg, P < .001); DBP (80.2 mmHg vs. 79.2 mmHg, P < .001); and MAP (97.4 mmHg vs. 95.3 mmHg; P < .001). Relative to the pre-pandemic period, during COVID-19 the proportion of participants with a mean monthly BP classified as uncontrolled or severely uncontrolled hypertension also rose, 15% vs 19% and 4% vs 5%, respectively CONCLUSIONS AND RELEVANCE: Based on home BP readings, mean monthly BP rose modestly after COVID-19, despite increased utilization of home monitoring. Further studies are needed to examine the longitudinal effects of the pandemic on cardiovascular disease risk factors, the impact of these on long-term population health.

Impact of a diabetes remote monitoring program on medication adherence.

BACKGROUND: Medication nonadherence in diabetes is well documented to be associated with inadequate glycemic control. Through remote blood glucose (BG) monitoring, unlimited test strip and lancet supplies, personal coaching, and online access to clinical information and educational resources, diabetes remote monitoring (DRM) programs may provide a solution. OBJECTIVE: To examine the relationship between patient participation in a DRM solution and adherence to oral antidiabetic drugs (OAD). METHODS: A retrospective, propensity score-matched cohort study was conducted using deidentified administrative claims data from a large pharmacy benefit manager. Commercially insured patients aged 18 years or older and having 2 or more 30-day adjusted OAD claims comprised the target sample. Patients enrolled in insurance plans that implemented DRM, who had at least 1 BG check (ever engaged) between April 1, 2015, and March 31, 2018 (exposure) were matched to patients enrolled in insurance plans that did not implement DRM (nonexposure). After a 1:2 matching on baseline demographics, disease burden proxy, total pharmacy out-of-pocket costs, previous adherence and insulin use, nonexposure group participants were assigned the same first BG check date as their matched DRM participants. Medication adherence measured as proportion of days covered (PDC) in the 365 days following first BG check was examined as a continuous and binary outcome measure (PDC > 80% or adherent vs < 80% or nonadherent). Multivariable linear and logistic regression were conducted to examine differential magnitude in adherence and likelihood of being adherent, respectively. RESULTS: The final sample consisted of 6,002 exposure and 12,004 nonexposure group patients. DRM participants who were ever engaged had a 4.5% higher adherence rate (P < 0.001) and 42% higher odds of being adherent (P < 0.001) in the period after engagement compared with non-DRM participants. Sensitivity analyses showed that patients engaged continuously (> 1 BG check per week) for 3, 6, and 12 months had 5.1%, 5.2%, and 6.4% higher adherence rates, respectively (P < 0.001), and 52%, 64%, and 98% higher odds of being adherent, respectively (P < 0.001), compared with non-DRM participants. CONCLUSIONS: The study findings offer evidence that DRM engagement is associated with higher odds of medication adherence. DRM solutions that provide access to glucose test results, personalized coaching, educational resources, and lower testing supply cost can also influence adherence. Our findings have important implications for payers and patients related to improved health outcomes due to higher medication adherence. DISCLOSURES: Funding for this study was provided by Express Scripts. Munshi, Amelung, Carter, and Henderson are employed by Express Scripts. James and Shah are employed by Livongo, which provided the DRM solution.

Real-World Comparative Effectiveness and Cost Comparison of Thromboprophylactic Use of Enoxaparin versus Unfractionated Heparin in 376,858 Medically Ill Hospitalized US Patients.

BACKGROUND: Venous thromboembolism (VTE) is a serious complication in medically ill inpatients. Enoxaparin or unfractionated heparin (UFH) thromboprophylaxis has been shown to reduce VTE in clinical trials; however, comparative effectiveness and differences in hospital costs are unknown in US hospital practice. OBJECTIVE: This study compared clinical and economic outcomes between enoxaparin and UFH thromboprophylaxis in medically ill inpatients. METHODS: A retrospective cohort study was conducted using the Premier Healthcare Database between 1 January 2010 and 30 September 2016. Inpatients aged ≥ 18 years with a ≥ 6-day hospital stay for serious medical conditions were included. Two patient groups receiving thromboprophylaxis were identified during hospitalization: one receiving enoxaparin and other receiving UFH. Regression models were constructed to compare VTE events, in-hospital mortality, pulmonary embolism (PE)-related mortality, major bleeding, and total hospital costs during both the index hospitalization and the 90-day readmission period between the two groups. RESULTS: A total of 242,474 and 134,384 inpatients received enoxaparin or UFH for thromboprophylaxis, respectively. Compared with UFH prophylaxis, enoxaparin was significantly associated with 15%, 9%, 33%, and 41% reduced odds of VTE, in-hospital mortality, PE-related mortality, and major bleeding, respectively, during index hospitalization, and 10% and 19% reduced odds of VTE and bleeding, respectively, during the readmission period. Mean total hospital costs were significantly lower in patients receiving enoxaparin prophylaxis than in those given UFH. CONCLUSIONS: Thromboprophylaxis with enoxaparin was associated with significantly reduced in-hospital VTE events, death, and major bleeding and lower hospital costs compared with UFH in hospitalized medically ill patients.

Comparative Effectiveness and Costs of Enoxaparin Monotherapy Versus Unfractionated Heparin Monotherapy in Treating Acute Coronary Syndrome.

BACKGROUND: Enoxaparin and unfractionated heparin (UFH) are guideline-recommended anticoagulants for patients with acute coronary syndrome (ACS), including unstable angina (UA) and myocardial infarction with (STEMI) or without ST-segment elevation (NSTEMI). Prior efficacy and safety evidence are mainly from clinical trials. Economic data are insufficient. This study examined the differences in utilization, effectiveness, safety, and costs in treating ACS between enoxaparin and UFH monotherapy using real-world data. METHODS: Using data from 859 US hospitals, inpatients ≥ 18 years of age with a diagnosis of an initial episode of ACS between 2010 and 2016 were identified. Outcomes included 30-day risk of non-fatal myocardial infarction (MI), recurrent angina, in-hospital mortality, composite ischemic complication (having MI/recurrent angina/death), major bleeding, and costs. Multivariable regression was used to compare outcomes between enoxaparin and UFH monotherapy. RESULTS: Among 1,048,053 eligible patients (UA: 219,259; NSTEMI: 582,134; STEMI: 246,660), the prevalence of enoxaparin monotherapy was 12.0%, 13.9%, and 5.1%, and the prevalence of UFH monotherapy was 45.1%, 43.1% and 59.8%, for UA, NSTEMI, and STEMI patients, respectively. Enoxaparin was associated with a lower risk of ischemic complications and death among NSTEMI, but not in UA or STEMI patients, and with a lower risk of major bleeding in all patients. Cost savings per patient during index admission and 30-day follow-up for enoxaparin over UFH was $2972 for UA, $2475 for NSTEMI, and $3050 for STEMI. CONCLUSIONS: Enoxaparin was associated with a lower risk of ischemic complications (including death), lower costs, and better safety than UFH among NSTEMI patients. Improving upstream selection of anticoagulants in appropriate populations may help optimize clinical outcomes and costs.

Adherence to heart failure management medications following cardiac resynchronization therapy.

Objective: The purpose of this study is to assess the real-world impact of cardiac resynchronization therapy (CRT) on adherence to heart failure (HF) medications.Methods: MarketScan administrative health care claims data from 2008 to 2014 among patients with HF were used. The date of first CRT implantation served as the index date. Adherence to guideline-directed medical therapy (GDMT) classes were compared during pre- and post-index periods using proportion of days covered (PDC). Comparisons between the two periods were made using the Wilcoxon sign-rank test for continuous PDC and McNemar's test for dichotomized PDC.Results: Increases in medication adherence were observed for major classes of HF GDMT medications. Specifically, adherence to angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), beta blockers (BB), and furosemide increased by 22, 24, 32, and 28% (all p < .001), respectively, in the 12 months pre to 12 months post-CRT. Large increases between the pre- and post-CRT period were also observed when considering adherence as dichotomized PDC ≥0.80 in the 12 months pre- versus post-CRT.Conclusion: Adherence to HF medications significantly improved among HF patients post-CRT implantation. Further research is needed to better understand the underlying determinants of this effect, including whether the effect is attributable to factors such as enhanced patient monitoring and improved access to high-quality specialized HF care among patients receiving CRT.

In-Hospital Mortality in Patients with Idiopathic Pulmonary Fibrosis: A US Cohort Study.

PURPOSE: In patients with idiopathic pulmonary fibrosis (IPF), hospitalizations are associated with high mortality. We sought to determine in-hospital mortality rates and factors associated with in-hospital mortality in patients with IPF. METHODS: Patients with IPF were identified from the Premier Healthcare Database, a representative administrative dataset that includes > 20% of hospital discharges in the US, using an algorithm based on diagnostic codes and billing data. We used logistic regression to analyze associations between patient-, hospital-, and treatment-related characteristics and a composite primary outcome of death during the index visit, lung transplant during the index visit and > 1 day after admission, or death during a readmission within 90 days. RESULTS: The cohort comprised 6665 patients with IPF hospitalized between October 2011 and October 2014. A total of 963 (14.4%) met the primary outcome. Factors significantly associated with a higher risk of the primary outcome included mechanical ventilation [odds ratio 4.65 (95% CI 3.73, 5.80)], admission to the intensive care unit [1.83 (1.52, 2.21)], treatment with opioids (3.06 [2.57, 3.65]), and a diagnosis of pneumonia [1.44 (1.21, 1.71)]. Factors significantly associated with a lower risk included concurrent chronic obstructive pulmonary disease [0.65 (0.55, 0.77)] and female sex [0.67 (0.57, 0.79)]. CONCLUSIONS: Patients with IPF, particularly those receiving mechanical ventilation or intensive care, are at substantial risk of death or lung transplant during hospitalization or death during a readmission within 90 days.

A rapid evidence assessment of bleed-related healthcare resource utilization in publications reporting the use of direct oral anticoagulants for non-valvular atrial fibrillation.

Objective: Non-valvular atrial fibrillation (NVAF), a common cardiac arrhythmia, is associated with high morbidity and carries a substantial economic burden. Historically, vitamin K antagonists (VKAs; e.g. warfarin) have been used for therapy of NVAF, but recently several direct oral anticoagulants (DOACs) have been approved for prevention of stroke in patients with NVAF. This review summarizes the real-world evidence (RWE) for healthcare resource utilization (HRU) in patients receiving oral anticoagulants (VKAs and/or DOACs) for therapy of NVAF.Methods: A PRISMA-compliant literature search assessed Medline® and Embase® databases from 1 January 2011 to 4 May 2017, and the National Health Service Economic Evaluation Database from 1 January 2011 to 31 December 2015. Publications were included if they reported observational data from real-world use of one or more anticoagulant therapies. Outcomes of interest included hospitalizations, length of stay (LOS), mortality and costs.Results: Twenty-eight publications were included. Apixaban and dabigatran were associated with fewer bleed-related hospitalizations than warfarin. Bleed-related LOS were generally longer for warfarin than for DOACs. Bleed-related treatment costs were lower for patients receiving apixaban or receiving dabigatran than patients receiving rivaroxaban or receiving warfarin. Bleed-related mortality in patients receiving oral anticoagulation for treatment of NVAF were low across all DOACs and warfarin.Conclusions: The limited available evidence for HRU burden among patients receiving oral anticoagulation for NVAF suggests that DOACs (particularly apixaban and dabigatran) offer some degree of benefit in terms of HRU outcomes, compared with warfarin. Further work is required to understand HRU outcomes in patients receiving DOACs.

Clinical Quality Improvement Curriculum for Faculty in an Academic Medical Center.

Interested faculty enrolled in this 6-month-long quality improvement (QI) course to facilitate independent QI project work. The course included monthly 1.5-hour sessions: 20-minute presentations covering key QI concepts, then small group activities to facilitate project work. Faculty were required to identify, construct, and implement an independent QI project. They met individually with mentors twice during the course, with additional guidance offered virtually via phone or e-mail, and completed pretests and posttests of QI knowledge (maximum score = 15) and self-assessed confidence. A statistically significant difference in knowledge (pre-course mean = 7.75, standard deviation [SD] = 3.06; post-course mean = 11.75, SD = 3.28; P = .02) and self-assessed confidence (pre mean = 3.08, SD = 0.65; post mean = 4.5, SD = 0.68; P < .0001) was found. Of 8 faculty, 5 were able to conduct small tests of change; 3 studied the current processes and planned to run tests of change. Positive responses to this course helped obtain buy-in from leadership to develop a leadership program in QI.

The Association of Transfer Rate From Hospitals Without Revascularization Capabilities and Mortality Risk for Older Non-ST-Segment Elevation Myocardial Infarction Patients.

BACKGROUND: Interhospital transfer invasive management patterns and implications for older non-ST-segment elevation myocardial infarction (NSTEMI) patients initially presenting to non-revascularization-capable hospitals have not been explored. HYPOTHESIS: Patients admitted to hospitals with a higher transfer proportion have lower risk of long-term mortality. METHODS: We linked CRUSADE Registry data on 5678 patients age ≥65 years from 65 United States non-revascularization-capable hospitals (2003-2006) with inpatient Medicare longitudinal claims. Hospitals were categorized according to hospital-level patient transfer-out rates, low (≤40%) vs high (>40%). The associations between transfer-out rates and 30-day, 6-month, and 3-year mortality risk were evaluated using Cox proportional hazard models. RESULTS: Hospital-level transfer-out rates varied widely (median, 43%; interquartile range, 31%-54%). Compared with patients from low-transfer-out hospitals (n = 2715), patients from high-transfer-out hospitals (n = 2963) were more likely to be male, less likely to have renal insufficiency and prior heart failure, and had lower long-term CRUSADE mortality risk scores. These patients also more commonly received evidence-based acute medications before transfer and underwent subsequent revascularization after transfer. The adjusted risks of mortality at various time intervals were similar for those from high- vs low-transfer-out hospitals: 30 days (hazard ratio: 0.95, 95% confidence interval: 0.79-1.14), 6 months (0.97, 0.84-1.12), and 3 years (1.01, 0.91-1.11). CONCLUSIONS: Transfer rates for older NSTEMI patients vary widely among non-revascularization-capable hospitals. Despite lower predicted mortality risk and higher rates of post-transfer revascularization, patients from high-transfer-out hospitals had a similar risk for short- and long-term mortality compared with those from low-transfer-out hospitals.

The association of in-hospital guideline adherence and longitudinal postdischarge mortality in older patients with non-ST-segment elevation myocardial infarction.

BACKGROUND: Prior work has demonstrated that adherence to American College of Cardiology/American Heart Association guideline recommendations is associated with decreased in-hospital mortality in non-ST-segment elevation myocardial infarction (NSTEMI) patients; however, it is unknown whether this association persists after hospital discharge in older, real-world populations. METHODS: We evaluated 32,646 NSTEMI patients ≥65 years treated at 243 US hospitals participating in CRUSADE from 2003 to 2006, linked to Medicare longitudinal claims data (followed to January 1, 2010). Hospital composite adherence examined the use of 13 individual American College of Cardiology/American Heart Association Class IA guideline-recommended interventions. Among patients who survived to hospital discharge, we used Cox proportional hazards modeling to examine the association between hospital composite adherence and 1- and 3-year mortality conditional on surviving initial hospitalization and adjusting for patient baseline clinical factors and hospital characteristics. RESULTS: The overall median composite guideline adherence to all 13 interventions was 77.4% with median (25th, 75th percentiles) hospital adherence ranging from 66.7% (61.9%, 70.1%) in the lowest adherence quartile to 85.8% (83.7%, 88.7%) in the highest adherence quartiles. Overall survival at 1 and 3 years was 80.0% and 62.8%, respectively. Relative to patients treated at the lowest adherence hospitals, those treated at the highest had similar adjusted mortality risk at 1 year but significantly lower 3-year mortality risk (adjusted hazard ratio [95% CI] 0.90 [0.82-0.99]). For every 10% increase in adherence to all 13 hospital composite therapies, there was a 5% reduction in 3-year mortality risk (0.95 [0.91-0.98]). CONCLUSIONS: Use of guideline-based therapies during acute hospitalization for NSTEMI was associated with significant decreases in mortality up to 3 years post-hospital discharge.

Willingness of Patients to Use Computers for Health Communication and Monitoring Following Myocardial Infarction.

We describe the computer use characteristics of 406 post-myocardial infarction (MI) patients and their willingness to engage online for health communication and monitoring. Most participants were computer users (n = 259; 63.8%) and half (n = 209; 51.5%) read health information online at least monthly. However, most participants did not go online to track health conditions (n = 283; 69.7%), look at medical records (n = 287; 70.7%), or e-mail doctors (n = 351; 86.5%). Most participants would consider using a Web site to e-mail doctors (n = 275; 67.7%), share medical information with doctors (n = 302; 74.4%), send biological data to their doctor (n = 308; 75.9%), look at medical records (n = 321; 79.1%), track health conditions (n = 331; 81.5%), and read about health conditions (n = 332; 81.8%). Sharing health information online with family members (n = 181; 44.6%) or for support groups (n = 223; 54.9%) was not of much interest. Most post-MI participants reported they were interested in communicating with their provider and tracking their health conditions online. Because patients with a history of MI tend to be older and are disproportionately minority, researchers and clinicians must be careful to design interventions that embrace post-MI patients of diverse backgrounds that both improve their access to care and health outcomes.

Perception Versus Actual Performance in Timely Tissue Plasminogen Activation Administration in the Management of Acute Ischemic Stroke.

BACKGROUND: Timely thrombolytic therapy can improve stroke outcomes. Nevertheless, the ability of US hospitals to meet guidelines for intravenous tissue plasminogen activator (tPA) remains suboptimal. What is unclear is whether hospitals accurately perceive their rate of tPA "door-to-needle" (DTN) time within 60 minutes and how DTN rates compare across different hospitals. METHODS AND RESULTS: DTN performance was defined by the percentage of treated patients who received tPA within 60 minutes of arrival. Telephone surveys were obtained from staff at 141 Get With The Guidelines hospitals, representing top, middle, and low DTN performance. Less than one-third (29.1%) of staff accurately identified their DTN performance. Among middle- and low-performing hospitals (n=92), 56 sites (60.9%) overestimated their performance; 42% of middle performers and 85% of low performers overestimated their performance. Sites that overestimated tended to have lower annual volumes of tPA administration (median 8.4 patients [25th to 75th percentile 5.9 to 11.8] versus 10.2 patients [25th to 75th percentile 8.2 to 17.3], P=0.047), smaller percentages of eligible patients receiving tPA (84.7% versus 89.8%, P=0.008), and smaller percentages of DTN ≤60 minutes among treated patients (10.6% versus 16.6%, P=0.002). CONCLUSIONS: Hospitals often overestimate their ability to deliver timely tPA to treated patients. Our findings indicate the need to routinely provide comparative provider performance rates as a key step to improving the quality of acute stroke care.

Patient-provider communication, self-reported medication adherence, and race in a postmyocardial infarction population.

OBJECTIVES: Our objectives were to: 1) describe patient-reported communication with their provider and explore differences in perceptions of racially diverse adherent versus nonadherent patients; and 2) examine whether the association between unanswered questions and patient-reported medication nonadherence varied as a function of patients' race. METHODS: We conducted a cross-sectional analysis of baseline in-person survey data from a trial designed to improve postmyocardial infarction management of cardiovascular disease risk factors. RESULTS: Overall, 298 patients (74%) reported never leaving their doctor's office with unanswered questions. Among those who were adherent and nonadherent with their medications, 183 (79%) and 115 (67%) patients, respectively, never left their doctor's office with unanswered questions. In multivariable logistic regression, although the simple effects of the interaction term were different for patients of nonminority race (odds ratio [OR]: 2.16; 95% confidence interval [CI]: 1.19-3.92) and those of minority race (OR: 1.19; 95% CI: 0.54-2.66), the overall interaction effect was not statistically significant (P=0.24). CONCLUSION: The quality of patient-provider communication is critical for cardiovascular disease medication adherence. In this study, however, having unanswered questions did not impact medication adherence differently as a function of patients' race. Nevertheless, there were racial differences in medication adherence that may need to be addressed to ensure optimal adherence and health outcomes. Effort should be made to provide training opportunities for both patients and their providers to ensure strong communication skills and to address potential differences in medication adherence in patients of diverse backgrounds.

Translation of acute coronary syndrome therapies: from evidence to routine clinical practice.

BACKGROUND: The use of evidence-based therapies has improved the outcome of patients with acute coronary syndrome (ACS), but there is a time lag between the generation of clinical evidence and its application in routine clinical practice. We sought to quantify temporal lags in the lifecycle of American College of Cardiology (ACC)/American Heart Association (AHA) class IA ACS therapies. METHODS: Using current and historical ACC/AHA guideline publications, we retrieved publication dates of pivotal clinical trials (PCTs) and class IA guideline-recommended therapies for patients with ST-elevation myocardial infarction (STEMI) and unstable angina (UA)/non-STEMI (NSTEMI). Clinical practice uptake data for each therapy were retrieved from the National Registry for Myocardial Infarction, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines, and Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines, which are registries containing publicly available peer-reviewed data. Descriptive data were calculated and compared for each phase of the evidence lifecycle for both STEMI and UA/NSTEMI drug classifications. RESULTS: We identified 11 class IA- and 4 class IB/IC-recommended therapies for acute, inhospital, and discharge use for patients with STEMI or UA/NSTEMI. The median time lags were 2 years (interquartile range [IQR], 1-4 years) from PCT to practice guideline recommendation, 14 years (IQR, 11-15 years) from guideline recommendation to 90% practice uptake, and overall, a 16-year median (IQR, 13-19 years) from PCT to 90% practice uptake. CONCLUSIONS: The time of PCT publication to meaningful uptake of class IA ACS therapies into clinical practice took a median of 16 years. This significant time lag indicates systemic barriers to the translation of therapeutics into routine clinical practice.

Methods and initial findings from the Durham Diabetes Coalition: Integrating geospatial health technology and community interventions to reduce death and disability.

OBJECTIVE: The Durham Diabetes Coalition (DDC) was established in response to escalating rates of disability and death related to type 2 diabetes mellitus, particularly among racial/ethnic minorities and persons of low socioeconomic status in Durham County, North Carolina. We describe a community-based demonstration project, informed by a geographic health information system (GHIS), that aims to improve health and healthcare delivery for Durham County residents with diabetes. MATERIALS AND METHODS: A prospective, population-based study is assessing a community intervention that leverages a GHIS to inform community-based diabetes care programs. The GHIS integrates clinical, social, and environmental data to identify, stratify by risk, and assist selection of interventions at the individual, neighborhood, and population levels. RESULTS: The DDC is using a multifaceted approach facilitated by GHIS to identify the specific risk profiles of patients and neighborhoods across Durham County. A total of 22,982 patients with diabetes in Durham County were identified using a computable phenotype. These patients tended to be older, female, African American, and not covered by private health insurance, compared with the 166,041 persons without diabetes. Predictive models inform decision-making to facilitate care and track outcomes. Interventions include: 1) neighborhood interventions to improve the context of care; 2) intensive team-based care for persons in the top decile of risk for death or hospitalization within the coming year; 3) low-intensity telephone coaching to improve adherence to evidence-based treatments; 4) county-wide communication strategies; and 5) systematic quality improvement in clinical care. CONCLUSIONS: To improve health outcomes and reduce costs associated with type 2 diabetes, the DDC is matching resources with the specific needs of individuals and communities based on their risk characteristics.