Implementation of Strategies to Recognize and Control Hypertension in a Multispecialty Clinic, Montana, 2012-2013.

Benefis Medical Group, in Great Falls, Montana, improved identification and treatment of hypertension through multifaceted interventions. The interventions included adopting policies for collection of vital signs, enhancing system-level reporting capability, tracking patients for the registry, and conducting patient outreach activities. From baseline to follow-up (December 2012 through September 2013), the percentage of patients with a documented blood pressure increased from 67% to 80%, the percentage diagnosed with hypertension increased from 16% to 36%, and the percentage with blood pressure control increased from 41% to 64%. Benefis Medical Group plans to sustain the successful evidence-based strategies that were adopted.

Cooperative strategies to develop effective stroke and heart attack awareness messages in rural american Indian communities, 2009-2010.

INTRODUCTION: National initiatives to improve the recognition of heart attack and stroke warning signs have encouraged symptomatic people to seek early treatment, but few have shown significant effects in rural American Indian (AI) communities. METHODS: During 2009 and 2010, the Montana Cardiovascular Health Program, in collaboration with 2 tribal health departments, developed and conducted culturally specific public awareness campaigns for signs and symptoms of heart attack and stroke via local media. Telephone surveys were conducted before and after each campaign to evaluate the effectiveness of the campaigns. RESULTS: Knowledge of 3 or more heart attack warning signs and symptoms increased significantly on 1 reservation from 35% at baseline to 47% postcampaign. On the second reservation, recognition of 2 or more stroke signs and symptoms increased from 62% at baseline to 75% postcampaign, and the level of awareness remained at 73% approximately 4 months after the high-intensity campaign advertisements ended. Intent to call 9-1-1 did not increase in the heart attack campaign but did improve in the stroke campaign for specific symptoms. Recall of media campaigns on both reservations increased significantly from baseline to postcampaign for both media outlets (ie, radio and newspaper). CONCLUSION: Carefully designed, culturally specific campaigns may help eliminate disparities in the recognition of heart attack and stroke warning signs in AI communities.

Capacity of diabetes education programs to provide both diabetes self-management education and to implement diabetes prevention services.

OBJECTIVE: The purpose of this study was to assess the capacity of diabetes self-management education (DSME) programs in urban and rural counties to provide services to patients with diagnosed diabetes, lifestyle services to persons at high risk for developing diabetes, and to assess the potential barriers to providing diabetes prevention services. METHODS: In 2009, the Montana Department of Public Health and Human Services conducted an Internet-based survey of all DSME programs in Montana. RESULTS: Thirty of the 39 (77%) DSME programs completed the survey. Seventy-seven percent of the urban programs and 50% of the rural programs reported a capacity to provide DSME to additional patients with diagnosed diabetes. More than 70% of the urban and the rural programs currently provide lifestyle services to patients with abnormal glucose tolerance but without diabetes. Eighty-four percent of the urban programs and 60% of the rural programs reported a capacity to provide lifestyle services to additional persons at high risk for diabetes. Eighty-five percent of the urban programs and 58% of the rural programs have already implemented or intend to implement a lifestyle intervention service consistent with the Diabetes Prevention Program. Overall, the most frequently reported barriers to implementing a diabetes prevention services were lack of reimbursement (80%) and the lack of staff to provide the service (60%). CONCLUSION: Urban and rural DSME programs in Montana have the capacity to implement both DSME for patients with diagnosed diabetes and diabetes prevention lifestyle services to additional people at high risk for diabetes. Reimbursement for diabetes prevention services is critical to ensure program development and implementation.

Statewide efforts to narrow the rural-urban gap in acute stroke care.

BACKGROUND: Rural-urban gaps in stroke care remain challenging in part because of the lack of resources, personnel, and necessary infrastructure. PURPOSE: The purpose of this study was to assess changes in the acute stroke diagnosis and treatment capacity among rural hospitals before and after implementation of a regionwide stroke initiative. METHODS: In 2004, the Montana Cardiovascular Health Program partnered with stroke stakeholders throughout the state and surveyed hospitals in Montana and northern Wyoming to assess the availability of technology, services, and personnel for acute stroke care. The Montana Stroke Initiative (MSI) developed protocols, educational material, and stroke awareness campaigns to address the geographic disparities identified in the survey. From 2004 to 2006, protocols and educational material were made available on a website and distributed to rural and critical-access hospitals throughout the region. Stroke awareness campaigns were completed, and MSI members conducted acute stroke care training of prehospital, nursing, and primary providers throughout the region. A follow-up survey in 2008 assessed changes in the stroke systems of care between 2004 and 2008. Data were analyzed in 2009. RESULTS: There were significant increases in availability of prehospital stroke screens, written emergency department protocols, computed tomographic scanning capability, acute stroke teams, and community stroke awareness programs. CONCLUSIONS: A systematic statewide effort to improve stroke care led to improved acute stroke care capabilities in necessary infrastructure in rural facilities and a narrowing of the gap between these facilities and the urban facilities.

Impact of media on community awareness of stroke warning signs: a comparison study.

Prompt identification of the warning signs of ischemic stroke is critical to ensure appropriate and timely treatment. We implemented a 20-week public education campaign in one media market to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older in the intervention county and a comparison county before and after the campaign to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up in the intervention county (73%-82%) but not in the comparison county (68%-69%). Respondent awareness of stroke warning signs increased significantly in the intervention county among men (68%-79%) and women (76%-84%) and among respondents aged 45 to 64 years (77%-85%) and respondents aged 65 years and older (67%-78%). There was no significant change in the proportion of respondents indicating they would call 911 if they witnessed someone having a stroke in the intervention county (81%-84%). However, after the campaign, an increased proportion of respondents in the intervention county indicated they would call 911 if they experienced sudden numbness or loss of sensation (50%-56%). Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911 for specific symptoms.

Educational outreach to improve emergency medical services systems of care for stroke in Montana.

OBJECTIVE: To improve stroke knowledge, identification, and acute care among first responders (FRs) and emergency medical technicians (EMTs) through educational outreach and support. METHODS: Beginning in 2006, the Montana Stroke Initiative implemented outreach to FRs and EMTs and emergency medical services (EMS) statewide. Cross-sectional telephone surveys of FRs and EMTs were used to evaluate changes in stroke knowledge and practice in 2006 (n = 988) and 2009 (n = 944), overall and in rural and urban counties. RESULTS: The respondents to the 2009 survey were more likely to report the availability of a stroke protocol in their service (69% vs. 61%, p = 0.001), training in the use of a stroke screening tool (62% vs. 42%, p < 0.001), use of a stroke screening tool (62% vs. 40%, p < 0.001), and an adequate level of knowledge about stroke (81% vs. 66%, p < 0.001) compared with the respondents to the 2006 survey. Significant improvements in each of these areas were achieved for both rural and urban FRs and EMTs. CONCLUSIONS: Educational outreach to FRs and EMTs was associated with marked improvement in selected components of the EMS system of stroke care.

The Montana cardiac rehabilitation regional outcomes project.

PURPOSE: Outcomes evaluation is a critical component in early outpatient cardiac rehabilitation (CR). The goal of this project was to develop a regional CR outcomes program to help facilitate quality improvement. METHODS: The Montana Outcomes Project initiated data collection on a uniform set of outcomes indicators. Each participating program submitted de-identified data for analysis on a quarterly basis. Results were sent back to each program with its individual program data plotted against the regional mean. RESULTS: Year 1 data collection included outcomes information from 22 facilities and 850 patients. Mean age was 68 years, 96% were white, 68% were men, and the mean number of CR visits was 24. The mean resting blood pressure at program completion was 118/68 mm Hg, with 90% of patients meeting criteria for blood pressure control (<140/90 or <130/80 mm Hg for patients at high risk). Mean low-density lipoprotein was 87 mg/dL; 94% were on lipid-lowering medications; and 73% achieved low-density lipoprotein values of less than 100 mg/dL. Upon program completion, significant improvements (P < .001) were noted in prescore versus postscore for functional capacity measured by the Duke Activity Status Index (5.5 metabolic equivalents vs 7.3 metabolic equivalents), Medical Outcomes Study SF-36 Health Status Questionnaire physical (36.9 vs 45.8) and mental (47.2 vs 52.2) composite scores, Dartmouth Primary Care Cooperative questionnaire (22 vs 15.9), and fat intake measured by the Block Dietary Fat Screener (19.6 vs 14.7). CONCLUSION: Our findings suggest that the development of a regional CR outcomes project is feasible and could aid in the development of quality improvement projects.

Monitoring prehospital stroke care in Utah to assess the feasibility of using EMS data for surveillance.

Many states are developing data systems that use the data elements from the National Emergency Medical Services Information System (NEMSIS) to monitor prehospital stroke care. To explore the feasibility of using emergency medical services data to monitor prehospital stroke care in Utah, the Heart Disease and Stroke Prevention Program and the state emergency medical services agency identified variables that could potentially be used to describe prehospital stroke care and explored the actual data from the first 16 months since inception of a system compatible with NEMSIS. We were able to develop a case definition for possible stroke and to describe modes of response, response times, destination hospitals, and stroke screening practices. Although not all emergency medical services agencies in Utah used the system and the data were not always complete for each stroke case, it was feasible to design a basic surveillance system for prehospital stroke care by using the data.

Translating the diabetes prevention program into practice in the general community: findings from the Montana Cardiovascular Disease and Diabetes Prevention Program.

PURPOSE: The purpose of this study was to evaluate the feasibility of translating the Diabetes Prevention Program (DPP) lifestyle intervention into practice in the general community. METHODS: In 2008, the Montana Diabetes Control Program, working collaboratively with 4 health care facilities, implemented an adapted group-based DPP lifestyle intervention. Adults at high risk for diabetes and cardiovascular disease were recruited and enrolled (n = 355). Eighty-three percent (n = 295) of participants completed the 16-session program. Participants set targets to reduce fat intake and increase physical activity (>or=150 minutes per week) to achieve a weight loss goal of 7%. RESULTS: Seventy percent of participants achieved the physical activity goal of >or=150 minutes per week. There was a significant decrease among participants' weight from baseline (mean +/- SD, 99.3 +/- 19.7 kg) to week 16 (92.6 +/- 18.8 kg; mean difference, 6.7 +/- 4.0 kg, P < .001). Forty-five percent of the participants achieved the 7% weight loss goal, and 67% achieved at least 5% weight loss. Participants who were 60 years of age and older, had a diagnosis of hypertension, met their physical activity goal of >or=150 minutes per week, and those more frequently monitoring their fat intake were more likely to meet the 7% weight loss goal compared with participants without these characteristics. CONCLUSION: The findings suggest that it is feasible to recruit and retain high-risk participants and achieve weight loss and physical goals in a group setting that are comparable with those achieved in the DPP.

How are we diagnosing cardiometabolic risk in primary care settings?

AIMS: To assess attitudes, barriers and practices of clinicians in assessing and treating cardiometabolic risk in overweight adults. METHODS: In 2006, primary care physicians and mid-level practitioners in Montana were surveyed (N=430). RESULTS: Most primary care clinicians (95%) recognized the clinical benefit of weight loss, but many cited patient motivation (87%), lack of support services (61%), and lack of time (58%) as barriers. Over 80% identified obesity, hypertension, abnormal lipids, history of gestational diabetes, and family history as indications for diabetes screening. Most clinicians used fasting glucose (89%), random glucose (58%), and A1c (42%) as initial screens for diabetes. To confirm the diagnosis, the majority of respondents used A1c testing (80%) or fasting glucose (64%). Approximately one-quarter used the diagnosis pre-diabetes (26%), but just over half (52%) used alternative diagnoses of glucose intolerance. Sixty-five percent used the diagnosis of metabolic syndrome. Of those using metabolic syndrome, mid-level practitioners were more likely than physicians to assess waist circumference (49% vs. 63%). CONCLUSIONS: Despite citing significant barriers, clinicians routinely assessed cardiometabolic risk with diabetes screening, but relatively few reported using the diagnosis pre-diabetes. Metabolic syndrome was used commonly to diagnose overweight adults at risk for diabetes and cardiovascular disease.

Public education strategies to increase awareness of stroke warning signs and the need to call 911.

Rapid identification and treatment of ischemic stroke can lead to improved patient outcomes. We implemented a 20-week public education campaign to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older before and after the intervention to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up (67% to 83%). Awareness increased significantly among both men and women and younger and older respondents. There was no significant change in the proportion of respondents indicating that they would call 911 if they witnessed someone having a stroke (74% to 76%). However, after the campaign, an increased proportion of respondents indicated that they would call 911 if they experienced sudden speech problems (51% to 58%), numbness or loss of sensation (41% to 51%), or paralysis (46% to 59%) that would not go away. Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911.

Stroke knowledge among urban and frontier first responders and emergency medical technicians in Montana.

PURPOSE: To assess stroke knowledge and practice among frontier and urban emergency medical services (EMS) providers and to evaluate the need for additional prehospital stroke training opportunities in Montana. METHODS: In 2006, a telephone survey of a representative sample of EMS providers was conducted in Montana. Respondents were stratified into 2 groups: those working in urban and frontier counties. FINDINGS: Compared to EMS providers from urban counties, those from frontier counties were significantly more likely to be older (mean age 44.7 vs 40.1 years), have fewer personnel working in their service (mean 17.7 vs 28.6), to be located farther away from a computed tomography scan (CT scan) (mean 41.3 vs 17.6 miles), and to be volunteers (84% vs 49%). They were also less likely to have a stroke protocol (58% vs 66%) and use a stroke screening tool (36% vs 47%) than their urban counterparts. There were no significant differences between frontier and urban EMS respondents' ability to correctly identify 4 or more stroke warning signs (58% vs 61%), 4 or more stroke risk factors (46% vs 43%), or the 3-hour recombinant tissue plasminogen activator (rt-PA) treatment window (56% vs 57%). Approximately two thirds of respondents from urban and frontier counties believed they had adequate stroke knowledge, but 90% indicated they were interested in additional stroke-related training. CONCLUSIONS: Although stroke knowledge did not differ between urban and frontier groups, stroke screens and stroke protocols were less likely to be used in the frontier areas. Training opportunities and the implementation of stroke protocols and screening tools are needed for EMS providers, particularly in frontier counties.

Utilization of a tobacco quit line prior to and after a tobacco tax increase.

OBJECTIVE: To evaluate the utilization of a tobacco quit line prior to and after an increase in tobacco taxes. METHODS: Intake data were utilized to assess the number of callers to the quit line between May 2004 and April 2006. The characteristics of callers were also compared over three time periods; the 5 months prior to a voter initiative to increase the tax (May-September 2004), the 3 months just prior to the tax increase (October-December 2004), and the 5 months after the tax became effective (January-May 2005). RESULTS: The mean number of intake calls to the quit line between May 2004 and April 2006 was 388 per month (range = 200-1 088). The number of calls per month increased just prior to and just after the tax increase (3-month moving average = 691-731 calls). Persons completing an intake between October to December 2004 and January to May 2005 were more likely to be younger than 45 years, woman, White, smoke one or more packs of cigarettes per day, and were less likely to have tried to quit using tobacco in the past year than did persons calling between May and September 2004. CONCLUSIONS: Organizations supporting quit lines should anticipate an increase in the utilization of these services and changes in the characteristics of callers prior to and following an increase in tobacco taxes.

Improving access to quality diabetes education in a rural state: the Montana Quality Diabetes Education Initiative.

PURPOSE: Diabetes self-management education (DSME) is an integral component of diabetes care; however, skilled educators and recognized programs are not uniformly available in rural communities. METHODS: To increase access to quality DSME, the Montana Diabetes Control Program and the Montana chapter of the American Association of Diabetes Educators developed a mentoring program with 3 levels: basic, intermediate, and advanced. All participants were assisted by a volunteer certified diabetes educator (CDE) mentor. In addition, the program provided technical support for recognition through the American Diabetes Association and the Indian Health Service. RESULTS: From 2000 to 2005, 90 individuals participated; 76% were nurses and 21% dietitians. Twenty-seven of the 90 enrollees (30%) completed their structured option, and 13 achieved CDE certification. Most provided services in frontier counties (66%). Statewide, the number of CDEs in Montana increased 46% from 52 in 2000 to 76 in 2005. Twenty-five of the 30 facilities that received technical assistance achieved recognition. Statewide, the number of recognized education programs increased from 2 in 2000 to 22 in 2005. Twelve (55%) of these programs were located in frontier counties. CONCLUSIONS: Mentoring and technical support is an effective method to increase personnel skills for DSME and to increase access to quality education programs in rural areas.

Training effective interpreters for diabetes care and education: a new challenge.

PURPOSE: This article describes a pilot project to improve knowledge, attitudes, and skills of ad hoc interpreters working with Native American diabetes patients with limited English proficiency. METHODS: Case-based studies reflecting clinical situations were developed. Key concepts and terms from the cases were translated into the Navajo language and carefully back translated using the newly standardized Navajo diabetes terminology. Twenty-two health care workers from 2 Indian Health Service facilities were recruited for a pilot study to compare the performance of interpreters trained in a formal workshop using the case studies with that of interpreters who independently reviewed a video made from the training. RESULTS: Workshop participants noted significant improvements in their knowledge and comfort level in interpretation of diabetes concepts but not about unrelated topics; the independent study group perceived less improvement. CONCLUSION: Formal training for interpreters working with diabetes patients should be considered by diabetes educators working in settings where medical interpreters are needed. Diabetes educators should encourage back translation of key diabetes concepts to understand exactly what is being said to patients. Those working with multiple interpreters should make sure there are opportunities for interpreters to discuss translations of key concepts with each other and the educators so that translations are accurate and consistent among interpreters. Independent study did not appear to be an effective way to improve the ability of interpreters to translate current diabetes concepts accurately.

Availability of diagnostic and treatment services for acute stroke in frontier counties in Montana and Northern Wyoming.

CONTEXT: Rapid diagnosis and treatment of ischemic stroke can lead to improved patient outcomes. Hospitals in rural and frontier counties, however, face unique challenges in providing diagnostic and treatment services for acute stroke. PURPOSE: The aim of this study was to assess the availability of key diagnostic technology and programs for acute stroke evaluation and treatment in Montana and northern Wyoming. METHODS: In 2004, hospital medical directors or their designees were mailed a survey about the availability of diagnostic technology, programs, and personnel for acute stroke care. FINDINGS: Fifty-eight of 67 (87%) hospitals responded to the survey. Seventy-nine percent (46/58) of responding hospitals were located in frontier counties, with an average bed size of 18 (11 SD). Of the hospitals in frontier counties, 44% reported emergency medical services prehospital stroke identification programs, 39% had 24-hour computed tomography capability, 44% had an emergency department stroke protocol, and 61% had a recombinant tissue plasminogen activator protocol. Thirty percent of hospitals in frontier counties reported that they met 6-10 of the criteria established by the Brain Attack Coalition to improve acute stroke care compared to 67% of hospitals in the nonfrontier counties. CONCLUSION: A stroke network model could enhance care and improve outcomes for stroke victims in frontier counties.

Cancer incidence in Montana: rates for American Indians exceed those for whites.

OBJECTIVES: Previous studies suggested that the cancer incidence rates in American Indians and Alaska Natives were lower than in other groups. The objective of this study was to compare the cancer incidence rates in American Indians and whites in Montana. METHODS: Age-adjusted 6-year cancer incidence rates were calculated for American-Indian and white men and women in Montana to allow comparison of rates in 1991-1996 to those in 1997-2002. RESULTS: The age-adjusted rates for American-Indian men were significantly higher than those for white men for all cancer sites (755+/-74 [95% confidence interval] per 100,000 vs 544+/-9 per 100,000), lung cancer (167+/-35 per 100,000 vs 83+/-4 per 100,000), and colorectal cancer (115+/-29 per 100,000 vs 61+/-4 per 100,000) from 1997 to 2002. The adjusted rates for American-Indian women were significantly higher than those for white women for all cancer sites (526+/-47 per 100,000 vs 412+/-8 per 100,000) and lung cancer (120+/-24 per 100,000 vs 56+/-3 per 100,000) during this same time period. There was a significant increase in the age-adjusted rates for all cancer sites among white men and women but not for American-Indian men or women between 1991-1996 and 1997-2002. CONCLUSIONS: There is a significant disparity in the cancer incidence rates between American Indians and whites in Montana. Regional or state-level surveillance data will be needed to describe the changing patterns of cancer incidence in many native communities in the United States.

Racial and ethnic differences in premature heart disease deaths in New Mexico: what is the role of diabetes?

Multiple-cause mortality files from 1999-2001 were obtained to describe premature heart disease (PHD) deaths and the role of diabetes as a contributing cause in heart disease (HD) mortality in American Indians, Hispanics, and non-Hispanic Whites in New Mexico. The proportion and rate of PHD and diabetes-related HD death were calculated and reported by race/ethnicity and gender. Results indicate that from 1999 to 2001, 24% of all deaths in New Mexico reported HD as the leading cause of death. Of these, 16.6% occurred in persons <65 years of age and were therefore classified as premature. The proportion of premature HD deaths was substantially higher in the American-Indian (29.2%) and Hispanic (20.8%) populations compared to Whites (13.7%). Furthermore, diabetes contributed to almost 18% of premature HD deaths in American Indians and Hispanics and to 10% of premature HD among Whites. These findings suggest that American Indians and Hispanics are disproportionately affected by premature HD death and that diabetes as a contributing cause is greater among these populations compared to non-Hispanic Whites.

Awareness of cardiovascular disease risk in American Indians.

OBJECTIVES: The objective of this study was to identify factors associated with perceived risk for cardiovascular disease (CVD) among older American Indians. DESIGN: In 2003, a telephone survey was conducted in American Indians aged > or = 45 years who lived on or near the seven reservations in Montana. Respondents were asked about their history of CVD and selected risk factors and their perceived risk for CVD. The prevalence of CVD and risk factors among men and women aged > or = 45 years (N = 516) was high: CVD (26% and 15%), diabetes (24% and 26%), high blood pressure (48% and 46%), high cholesterol (34% and 40%), smoking (28% and 33%), and obesity (37% vs 46%). Men with a history of CVD (87% vs 46%), high blood pressure (70% vs 44%), high cholesterol (71% vs 53%), and obesity (67% vs 52%) were more likely to report being at risk for heart disease compared to men without these conditions. Women with a history of CVD (98% vs 58%), diabetes (74% vs 60%), high blood pressure (73% vs 56%), high cholesterol (72% vs 60%), and obesity (74% vs 55%) were more likely to report being at risk for heart disease compared to women without these conditions. Neither men nor women associated smoking with their own risk for heart disease. CONCLUSIONS: The prevalence of CVD risk factors was high in this population, and most people recognized the risks associated with the modifiable CVD risk factors. However, neither men nor women who smoked reported being at risk for heart disease more frequently than nonsmokers.

Extending the public health impact of screening for diabetes in high-risk populations: opportunities in American Indian communities.

OBJECTIVE: To assess trends in diabetes screening among American Indian adults and identify opportunities to extend blood glucose screening to those at risk for undiagnosed diabetes and prediabetes. METHODS: In 1999, 2001, and 2003, approximately 1,000 American Indian adults aged 18 years and older living on or near the seven reservations in Montana were interviewed through telephone surveys. RESULTS: Of respondents without diagnosed diabetes, the proportion who recalled blood glucose screening for diabetes within the past 3 years increased from 68 percent in 1999 to 78 percent in 2003. Between 1999 and 2003, screening increased among men (64%-75%), women (71%-80%), those aged 18-44 years (64%-72%), and those aged 45 years and older (76%-84%). Factors independently associated with screening included age more than 45 years, family history of diabetes, and a history of high cholesterol. Current smokers were less likely to report screening compared to nonsmokers. Gender, obesity, and a history of high blood pressure were not associated with screening. CONCLUSIONS: Although self-reported diabetes screening increased over a 5-year period among Indians in Montana, additional groups who could benefit from screening include younger and obese individuals, and those with hypertension.