A system approach to improving guideline-directed therapy for cardio-renal-metabolic conditions: The "beyond diabetes" initiative.

Objective: Despite demonstrating improvements in cardiovascular disease, kidney disease, and survival outcomes, guideline-directed antihyperglycemic medications such as sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like-peptide-1 receptor agonists (GLP1-RA), are underutilized. Many obstacles constrain their use including lack of systematic provider and patient education, concern for medication side effects, and patient affordability. Methods: We designed a multimodality, systems-based approach to address these challenges with the goal of increasing medication utilization across the largest healthcare system in New York State. This multispecialty collaborative included provider and patient education, an electronic health record-enabled platform to identify eligible patients, and access to pharmacists for medication guidance and addressing insurance coverage barriers. Surveys were administered following grand rounds lectures and knowledge-based questionnaires were given before and after case-based sessions for housestaff, with results analyzed using a two-sided Student's t-test. Rates of first prescriptions of SGLT2i/GLP1-RA in combined and individual analyses were compared between the pre- and post-education periods (6 months prior to 3/31/2021 and 6 months post 8/19/2021), and the change in prescriptions per 100 eligible-visits was assessed using the incidence density approach. Results: Among grand rounds participants, 69.3% of respondents said they would make changes to their clinical practice. Knowledge increased by 14.7% (p-value <0.001) among housestaff following case-based sessions. An increase in SGLT2i/GLP1-RA prescribing was noted for eligible patients among internal medicine, cardiology, nephrology, and endocrinology providers, from 11.9 per 100 eligible visits in the pre-education period to 14.8 in the post-education period (absolute increase 2.9 [24.4%], incidence risk ratio 1.24 [95% CI 1.18-1.31]; p-value <0.001). Increases in prescribing rates were also seen among individual medical specialties. Conclusions: Our "Beyond Diabetes" initiative showed an improvement in provider knowledge-base and was associated with a modest, but statistically significant increase in the use of SGLT2i and GLP1-RA throughout our healthcare system.

Fresh Shelves, Healthy Pantries: A Pilot Intervention Trial in Baltimore City Food Pantries.

The objective of this study was to evaluate the impact of a multi-modal pilot intervention on the stocking and acquisition of healthy foods in urban food pantries. An intervention that consisted of three 8-week phases, each focused on promotion of one food group: (1) lean & low-sodium proteins; (2) fruits & vegetables; and (3) healthy carbohydrates was conducted in 3 intervention and 4 comparison food pantries. Food stocking variety scores measured changes in the stocking of promoted healthful foods at pantries. Food Assortment Scoring Tool (FAST) scores measured healthfulness of client bags. Intervention and comparison pantries showed an increase during the study in the total variety score for promoted options, with no significant differences between groups. Mean healthfulness scores for intervention client bags (n = 34) significantly increased from 58.2 to 74.9 (p < 0.001). This pilot trial identified logistically feasible strategies to promote healthy options effectively in food pantries, even in pantries with limited resources.

Associations between Food Pantry Size and Distribution Method and Healthfulness of Foods Received by Clients in Baltimore City Food Pantries.

This study aimed to evaluate the association of the overall nutritional quality and the weight share of specific types of foods received by food pantry clients with food pantry size and distribution method. Data on healthy food weights using the gross weight share (GWS) of select foods and the validated Food Assortment Score Tool (FAST) were collected from 75 food pantry clients in Baltimore, Maryland. The average FAST score across the study population was 63.0 (SD: 10.4). Overall, no statistically significant differences in average FAST scores by pantry size and distribution method were found. However, among client-choice pantries, clients of small pantries had higher scores (p < 0.05) while among medium pantries, clients of traditional pantries had higher scores (p < 0.01). Subgroup analysis of GWS was stratified by pantry size and distribution methods. Findings suggested multi-level, multi-component interventions combining environmental strategies are needed to enhance the healthfulness of foods received by clients. Our analysis provided data to consider further refinements of pantry interventions and planning of more rigorous research on factors influencing the effectiveness of pantry interventions.

Individual- and household-level factors associated with fruit, vegetable, and dietary fiber adequacy among Native American adults in 6 reservation communities.

This study utilized baseline data collected in 2017 from the OPREVENT2 trial, which included 540 Native Americans in six Midwest and Southwest reservation communities. The objective was to identify correlates of fruit, vegetable, and dietary fiber adequacy among participants 18-75 years old who self-identified as the main food purchaser or preparer in their household. Mean daily servings of fruits and vegetables and grams of dietary fiber were quantified based on a 30-day semi-quantitative food frequency questionnaire. Participants consumed an average of 0.5 (±0.4) cup-equivalent servings of fruit, 2.5 (±1.8) cup-equivalent servings of vegetables, and 15.5 (±8.9) grams of fiber per day. <2% of the study population met the 2015-2020 Dietary Guidelines for Americans recommendations for fruit consumption, while 12 and 42% met recommendations for dietary fiber and vegetable consumption, respectively. Females had a prevalence ratio 1.4 times greater than males for adequate intakes of vegetables (p = 0.008) and over 6 times greater for dietary fiber (p < 0.001). Participants over the age of 30 were about twice as likely to meet dietary fiber recommendations (p = 0.031) compared to those 30 years and younger. Participants receiving food assistance from the USDA's Food Distribution Program on Indian Reservations (FDPIR) were nearly twice as likely as non-FDPIR recipients to meet recommendations for dietary fiber (p = 0.008). These findings can help guide the development of targeted interventions to improve diet quality; however, further work is needed to understand and address underlying reasons for low fruit consumption in these rural reservation communities.