Implementation of the YMCA Diabetes Prevention Program throughout an Integrated Health System: A Translational Study.

CONTEXT: HealthSpan Physicians (HSP), an integrated medical system in Northeast Ohio, partnered with the Young Men's Christian Association (YMCA) of Greater Cleveland to implement a referral system for the evidence-based Diabetes Prevention Program (DPP) throughout HSP. The YMCA of USA employs a cost-effective, customized version of the original DPP in which coaches take the place of in-house clinical staff. Efficacy of the YMCA DPP was shown earlier in the DEPLOY Study. OBJECTIVE: To improve outcomes of metrics used in the DEPLOY Study. DESIGN: Observational study focusing on engagement, persistence, recruitment, and adherence to the DPP. In August 2014, HSP mailed an invitation to 2200 patients identified as both Medicare eligible and at risk of prediabetes to attend no-obligation information sessions about the DPP. After these sessions, YMCA staff called interested participants and asked them to enroll in and to commit to the program. Motivation and reinforcement were provided to patients through YMCA-provided signs, brochures, and posters; the HSP Web site; and in-person conversations with primary care physicians. MAIN OUTCOME MEASURES: Average weight loss at the end of 16 weeks in the program and average retention through Session 9. RESULTS: Of the 2200 patients contacted, 351 (16.0%) responded by attending the information session, and 228 enrolled in the YMCA DPP (11.3%) and persisted through at least Week 9. This result is an improvement over the 1.7% of eligible enrollees who responded to the DEPLOY Study's mailing. CONCLUSIONS: A marketing approach to implementing the YMCA DPP in an integrated medical system results in excellent outcomes.

Electronic health records and quality of diabetes care.

BACKGROUND: Available studies have shown few quality-related advantages of electronic health records (EHRs) over traditional paper records. We compared achievement of and improvement in quality standards for diabetes at practices using EHRs with those at practices using paper records. All practices, including many safety-net primary care practices, belonged to a regional quality collaborative and publicly reported performance. METHODS: We used generalized estimating equations to calculate the percentage-point difference between EHR-based and paper-based practices with respect to achievement of composite standards for diabetes care (including four component standards) and outcomes (five standards), after adjusting for covariates and accounting for clustering. In addition to insurance type (Medicare, commercial, Medicaid, or uninsured), patient-level covariates included race or ethnic group (white, black, Hispanic, or other), age, sex, estimated household income, and level of education. Analyses were conducted separately for the overall sample and for safety-net practices. RESULTS: From July 2009 through June 2010, data were reported for 27,207 adults with diabetes seen at 46 practices; safety-net practices accounted for 38% of patients. After adjustment for covariates, achievement of composite standards for diabetes care was 35.1 percentage points higher at EHR sites than at paper-based sites (P<0.001), and achievement of composite standards for outcomes was 15.2 percentage points higher (P=0.005). EHR sites were associated with higher achievement on eight of nine component standards. Such sites were also associated with greater improvement in care (a difference of 10.2 percentage points in annual improvement, P<0.001) and outcomes (a difference of 4.1 percentage points in annual improvement, P=0.02). Across all insurance types, EHR sites were associated with significantly higher achievement of care and outcome standards and greater improvement in diabetes care. Results confined to safety-net practices were similar. CONCLUSIONS: These findings support the premise that federal policies encouraging the meaningful use of EHRs may improve the quality of care across insurance types.

Hypertensive crises.

The key points of this article are: (1) A hypertensive crisis is present when markedly elevated blood pressure is accompanied by progressive or impending acute target organ damage. (2) Most instances of very elevated blood pressure encountered in the office setting will not be crises and will not require acute reduction of blood pressure. (3) Hypertensive crises are largely preventable and often result from inadequate management of hypertension or poor adherence to therapy. (4) Effective triage of patients into categories of severe hypertension, hypertensive urgency, and hypertensive emergency through an expeditious history, examination, and testing should guide therapy. (5) Hypertensive urgency is managed with oral medications and usually on an outpatient basis; a hypertensive emergency warrants intensive care unit admission and parenteral therapy. (6) Ensuring adequate follow-up after treatment of very elevated blood pressure is a critical step that is often mishandled.

Quality measurement: who is measuring outcomes and what are patients being told?

Change is inevitable, but participation is optional. An array of quality measures is being used by various government entities, health care purchasers and payers, and other groups. Many of the quality-measurement initiatives have not only gained the attention of large employers, but are also beginning to pique the public's interest. Novel approaches to measuring and rewarding quality are also emerging, such as pay-for-performance schemes and the use of APR-DRGs. Health care organizations that participate in the quality-measurement process and provide input will benefit by the type of measures that are ultimately created. It is much better to be part of the development process than to have insurer- or employer-designed quality measures imposed on your institution. At the very least, health care organizations would be wise to serve as watchdogs to ensure that currently proposed quality measures truly measure high-quality care.

Should the target for blood pressure control specify both a systolic and a diastolic component?

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Report recommends, as the target for hypertension control, achieving both a systolic and diastolic goal. We suggest, however, that specifying both a systolic and a diastolic component for the blood pressure goal can be confusing to physician and patient. Furthermore, literal interpretation and application of this JNC 7 recommendation could result in overtreatment, undertreatment, or institution of treatment for hypertension when none is needed. Specific scenarios illustrating how inappropriate treatment could result from literal interpretation and application of the JNC 7 recommendations are presented. Our recommended blood pressure goal for hypertensives is: Sitting systolic blood pressure consistently in the 120s or less, if tolerated. This recommendation is evidence based, easy to understand, and achievable. Its rationale is discussed.

Management of glomerular proteinuria: a commentary.

It is widely accepted that proteinuria reduction is an appropriate therapeutic goal in chronic proteinuric kidney disease. Based on large randomized controlled clinical trials (RCT), ACE inhibitor (ACEI) and angiotensin receptor blocker (ARB) therapy have emerged as the most important antiproteinuric and renal protective interventions. However, there are numerous other interventions that have been shown to be antiproteinuric and, therefore, likely to be renoprotective. Unfortunately testing each of these antiproteinuric therapies in RCT is not feasible. The nephrologist has two choices: restrict antiproteinuric therapies to those shown to be effective in RCT or expand the use of antiproteinuric therapies to include those that, although unproven, are plausibly effective and prudent to use. The goal of this work is to provide the documentation needed for the nephrologist to choose between these strategies. This work describes 25 separate interventions that are either antiproteinuric or may block injurious mechanisms of proteinuria. Each intervention is assigned a level of recommendation (Level 1 is the highest; Level 3 is the lowest) according to the strength of the evidence supporting its antiproteinuric and renoprotective efficacy. Pathophysiologic mechanisms possibly involved are also discussed. The number of interventions at each level of recommendation are: Level 1, n = 7; Level 2, n = 9; Level 3, n = 9. Our experience indicates that we can achieve in most patients the majority of Level 1 and many of the Level 2 and 3 recommendations. We suggest that, until better information becomes available, a broad-based, multiple-risk factor intervention to reduce proteinuria can be justified in those with progressive nephropathies. This work is intended primarily for clinical nephrologists; therefore, each antiproteinuria intervention is described in practical detail.

Preventing kidney failure: primary care physicians must intervene earlier.

Mild chronic kidney disease often goes unnoticed until a substantial loss of renal function has occurred. Given the increasing incidence of chronic kidney disease, primary care physicians play a critical role in the early evaluation and intervention of patients at risk. This article discusses the key steps, with emphasis on patients with mild disease due to diabetes or hypertension.