Residing in a Food Desert and Adverse Cardiovascular Events in US Veterans With Established Cardiovascular Disease.

Residents living in a "food desert" are known to be at a higher risk for developing cardiovascular disease (CVD). However, national-level data regarding the influence of residing in a food desert in patients with established CVD is lacking. Data from veterans with established atherosclerotic CVD who received outpatient care in the Veterans Health Administration system between January 2016 and December 2021 were obtained, with follow-up information collected until May 2022 (median follow-up: 4.3 years). A food desert was defined using the United States Department of Agriculture criteria, and census tract data were used to identify Veterans in these areas. All-cause mortality and the occurrence of major adverse cardiovascular events (MACEs; a composite of myocardial infarction/stroke/heart failure/all-cause mortality) were evaluated as the co-primary end points. The relative risk for MACE in food desert areas was evaluated by fitting multivariable Cox models adjusted for age, gender, race, ethnicity, and median household income, with food desert status as the primary exposure. Of the 1,640,346 patients (mean age 72 years, women 2.7%, White 77.7%, Hispanic 3.4%), 25,7814 (15.7%) belonged to the food desert group. Patients residing in food deserts were younger; more likely to be Black (22% vs 13%)or Hispanic (4% vs 3.5%); and had a higher prevalence of diabetes mellitus (52.7% vs 49.8%), chronic kidney disease (31.8% vs 30.4%,) and heart failure (25.6% vs 23.8%). Adjusted for covariates, food desert patients had a higher risk of MACE (hazard ratio 1.040 [1.033 to 1.047]; p <0.001) and all-cause mortality (hazard ratio 1.032 [1.024 to 1.039]; p <0.001). In conclusion, we observed that a large proportion of US veterans with established atherosclerotic CVD reside in food desert census tracts. Adjusting for age, gender, race, and ethnicity, residing in food deserts was associated with a higher risk of adverse cardiac events and all-cause mortality.

Significant HbA1c Lowering in Patients Achieving a Hepatitis C Virus Cure.

The immediate clinically significant reduction in hemoglobin A1c following HCV treatment observed in this study contrasts with the expected rise seen with normal disease progression.

Serious Mental Illness and Its Impact on Diabetes Care in a VA Nurse/ Pharmacist-Managed Population.

Collaboration between a registered nurse-certified diabetes educator and clinical pharmacy specialist improved access to care and glycemic control in veterans with diabetes and mental illness.

Shared medical appointments for patients with diabetes: glycemic reduction in high-risk patients.

PURPOSE: To assess the impact on glycemic control (A1c, %) in a primary care urban Veterans Affairs (VA) shared medical appointments (SMAs). DATA SOURCES: A retrospective pretest/posttest study included all patients who had attended ≥1 SMA from 4/06 to 12/10. A1cs 810 days pre- and postinitial SMA were obtained from 90-day time periods. A1c levels were averaged within patient in these 90-day intervals and data were aggregated based upon corresponding time intervals. CONCLUSIONS: Of 1290 individuals seen in SMAs, 1288 (99.8%) had ≥1 A1c levels and 1170 (90.7%) individuals had ≥1 level collected both before and after attendance. The sample was predominantly (96%) male and middle aged or older (mean [±1 SD] age of 62.6 + 9.09 years) with a mean Diabetes Severity Index 3.01 (2.34). There were significant A1c reductions (∼1%) in A1c overall (n = 1170) and for patients with ≥1 measurement in the 180-day periods preceding and following their first SMA appointment (n = 815). Linear regression analysis showed a significant (p < .001) pre-SMA positive trend (r(2) = 0.90). IMPLICATIONS FOR PRACTICE: Limitations notwithstanding (single site and design lacking a control group), the large number of patients demonstrates SMA clinical effectiveness in improving A1c for high-risk patients with diabetes.

Polypharmacy in the elderly: focus on drug interactions and adherence in hypertension.

Polypharmacy is highly prevalent in the elderly due to an increased number of co-morbid disease states that accompany aging. Hypertension is one common disease that can be challenging to treat in the elderly due to the body's physiologic changes, potential risks for side effects, medication interactions, and decreased medication adherence. A thorough medication assessment for each patient is essential when determining pharmacotherapeutic options in the elderly.

Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk.

OBJECTIVE: The epidemic proportions and management complexity of diabetes have prompted efforts to improve clinic throughput and efficiency. One method of system redesign based on the chronic care model is the Shared Medical Appointment (SMA) in which groups of patients (8-20) are seen by a multi-disciplinary team in a 1-2 h appointment. Evaluation of the impact of SMAs on quality of care has been limited. The purpose of this quality improvement project was to improve intermediate outcome measures for diabetes (A1c, SBP, LDL-cholesterol) focusing on those patients at highest cardiovascular risk. SETTING: Primary care clinic at a tertiary care academic medical center. SUBJECTS: Patients with diabetes with one or more of the following: A1c >9%, SBP blood pressure >160 mm Hg and LDL-c >130 mg/dl were targeted for potential participation; other patients were referred by their primary care providers. Patients participated in at least one SMA from 4/05 to 9/05. STUDY DESIGN: Quasi-experimental with concurrent, but non-randomised controls (patients who participated in SMAs from 5/06 through 8/06; a retrospective period of observation prior to their SMA participation was used). INTERVENTION: SMA system redesign. ANALYTICAL METHODS: Paired and independent t tests, chi(2) tests and Fisher Exact tests. RESULTS: Each group had up to 8 patients. Patients participated in 1-7 visits. At the initial visit, 83.3% had A1c levels >9%, 30.6% had LDL-cholesterol levels >130 mg/dl, and 34.1% had SBP >or=160 mm Hg. Levels of A1c, LDL-c and SBP all fell significantly postintervention with a mean (95% CI) decrease of A1c 1.4 (0.8, 2.1) (p<0.001), LDL-c 14.8 (2.3, 27.4) (p = 0.022) and SBP 16.0 (9.7, 22.3) (p<0.001). There were no significant differences at baseline between control and intervention groups in terms of age, baseline intermediate outcomes, or medication use. The reductions in A1c in % and SBP were greater in the intervention group relative to the control group: 1.44 vs -0.30 (p = 0.002) for A1c and 14.83 vs 2.54 mm Hg (p = 0.04) for SBP. LDL-c reduction was also greater in the intervention group, 16.0 vs 5.37 mg/dl, but the difference was not statistically significant (p = 0.29). CONCLUSIONS: We were able to initiate a programme of group visits in which participants achieved benefits in terms of cardiovascular risk reduction. Some barriers needed to be addressed, and the operations of SMAs evolved over time. Shared medical appointments for diabetes constitute a practical system redesign that may help to improve quality of care.