Using Facebook to communicate mammography messages to rural audiences.

OBJECTIVE: The purpose of this scholarly project was to answer the following question: What is the highest level of engagement achieved with a mammography campaign on Facebook? DESIGN AND SAMPLE: An Idaho public health department implemented a tailored message mammography campaign on Facebook during Breast Cancer Awareness Month. Target sample for the Facebook campaign were women and men over the age of 40 in rural Idaho. MEASURES: Data collected from Facebook were used to measure and stratify engagement into a hierarchy of six levels, with intent to get a mammogram representing the highest level of engagement. A survey measuring women's intent to a get a mammogram was distributed via an online link. RESULTS: The posts reached 48,503 Facebook users-11,147 of the total reach were unique users. Intent to get a mammogram, the highest level of engagement, was stated both in Facebook comments and on the online survey. Forty-nine women completed the survey, and 82% of women expressed intent to get a mammogram in the next year. CONCLUSION: This project conducted as a program evaluation demonstrates how public health nurses can develop, implement, and evaluate Facebook mammography campaigns in the future.

Implementation of a follow-up telephone call process for patients at high risk for readmission.

This project included the development and implementation of a follow-up telephone call within 72 hours of discharge, targeting patients at high risk for readmission. The goal was to improve understanding of aftercare instructions and decrease readmissions. Clinical nurse leaders provided an intervention in 66% of patient contacts. Readmission rate within 7 days of discharge was significantly lower (P < .05), and the rate within 30 days of discharge trended lower (P = .053), in the clinical nurse leader contact group than in patients who were not contacted.

Pilot Results of the Early Detection by Ultrasound of Carotid Artery Intima-Media Thickness Evaluation (EDUCATE) study.

BACKGROUND: Limitations of current models for risk stratification are known. Noninvasive imaging is being advocated as an adjunct to improve risk prediction; however, studies documenting outcomes are rare. Therefore, we aimed to evaluate the negative and positive predictive values of carotid atherosclerosis for future cardiovascular events. METHODS: The Early Detection by Ultrasound of Carotid Artery intima media Thickness Evaluation (EDUCATE) study prospectively enrolled 253 consecutive young to middle-aged adults undergoing elective coronary angiography. Bilateral carotid ultrasound and lipid profiles were performed. Carotid atherosclerosis was defined as intima media thickness >/=1.0 mm in the main body, or focal plaque within the body, bulb, or proximal branch. Future events included major (death, myocardial infarction, stroke) and minor (revascularization and new onset heart failure). RESULTS: Of the enrolled patients 236 completed all tests; mean age was 51 +/- 8 years; 58% women. Sensitivity, specificity, and negative predictive values for carotid atherosclerosis in predicting severe coronary artery disease were 72%, 49% and 79%, with an odds ratio (OR) of 2.2 (95% confidence interval [CI] 1.2-4.0). Of patients suffering major events, 90% had carotid atherosclerosis. Only 1 of 95 without carotid atherosclerosis experienced a major event. Kaplan-Meier analysis revealed differences in event-free survival in favor of subjects without carotid atherosclerosis for major (P = .051) and any event (P = .015). Cox analysis revealed a hazard ratio (HR) of 2.7 (95% CI 1.2-6.2; P = .020) for predicting future events. The relationship remained significant after adjusting for traditional risk factors (HR 2.5, 95% CI 1.1-5.9; P = .034). CONCLUSIONS: Carotid atherosclerosis is associated with severe coronary artery disease and future events. Negative carotid ultrasound is associated with excellent prognosis.

Carotid ultrasound for risk clarification in young to middle-aged adults undergoing elective coronary angiography.

BACKGROUND: An important aspect of risk prediction is the apparent difference between calculated risk and true risk. Current risk predictor models are not sensitive enough to identify many subjects at risk for future events or to prevent overuse of expensive tests. The aim of this study was to determine the usefulness of carotid ultrasound for risk stratification in subjects undergoing elective coronary angiography. METHODS: A total of 253 individuals (men < or =55 years of age and women < or =65 years of age) who were scheduled for elective coronary angiography underwent carotid ultrasonography. Noncoronary atherosclerosis was defined based on a maximal intima-media thickness of > or =1.0 mm or the presence of focal plaque. RESULTS: Of the subjects, 236 completed all of the tests. The mean age was 51 +/- 8 years, and 58% were women and 42% men. Severe angiographic disease (> or =50%) was present in 72 subjects. Carotid atherosclerosis was present in 141 subjects. Use of the Framingham risk score classified 172 subjects as low risk. Carotid atherosclerosis was diagnosed in 57% of the low-risk group compared with 70% of the high-risk group (P = .122). Carotid atherosclerosis was associated with severe coronary angiographic disease (OR = 2.2, CI = 1.2 to 4.0). CONCLUSION: Noncoronary atherosclerosis was associated with severe coronary disease as determined by angiography. Carotid atherosclerosis had a high negative predictive value in subjects with negative stress test results or risk-stratified as low risk. Noninvasive imaging by carotid ultrasonography for noncoronary atherosclerosis may be a good adjunct to clinical risk stratification for premature coronary heart disease.

Improving outcomes in heart failure in the community: long-term survival benefit of a disease-management program.

OBJECTIVES: The purpose of our current study was to determine whether our disease-management model was associated with long-term survival benefits. A secondary objective was to determine whether program involvement was associated with medication maintenance and reduced hospitalization over time compared to usual care management of heart failure. DESIGN: A retrospective chart review was conducted in patients who had been hospitalized for congestive heart failure between April 1999 and March 31, 2000, and had been discharged from the hospital for follow-up in the Heart Failure Clinic vs usual care. SETTING: An integrated health-care center serving a tristate area. PATIENTS: Patients (n = 101) were followed up for 4 years after their index hospitalization for congestive heart failure. MEASUREMENTS AND RESULTS: The patients followed up in the Heart Failure Clinic comprised group 1 (n = 38), and the patients receiving usual care made up group 2 (n = 63). The mean (+/- SD) age of the patients in group 1 was 68 +/- 16 years compared to 76 +/- 11 years for the patients in group 2 (p = 0.002). The patients in group 1 were more likely to have renal failure (p = 0.035), a lower left ventricular ejection fraction (p = 0.005), and hypotension at baseline (p = 0.002). At year 2, more patients in group 1 were maintained by therapy with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) [p = 0.036]. The survival rate over 4 years was better for group 1. Univariate Cox proportional hazard ratios revealed that age, not receiving ACEIs or ARBs, and renal disease or cancer at baseline were associated with mortality. When controlling for these variables in a multivariate Cox proportional hazards ratio model, survival differences between groups remained significant (p = 0.021). Subjects in group 2 were 2.4 times more likely to die over the 4-year period than those in group 1. CONCLUSIONS: Our study demonstrated that, after controlling for baseline variables, patients participating in a heart failure clinic enjoyed improved survival.

Using a systemwide care path to enhance compliance with guidelines for acute myocardial infarction.

BACKGROUND: Several acute myocardial infarction (MI) guidelines and policy statements have been developed, but compliance rates are suboptimal. The cardiology section at Gundersen Lutheran Medical Center (La Crosse, Wisconsin) used a systemwide approach to enhance compliance with guidelines. METHODS AND RESULTS: Data were collected prospectively for a 4-year period (May 15, 1995-May 15, 1999) for all patients presenting with acute MI. In 1995 a multidisciplinary team developed protocols for each phase of MI management and designed clinical care paths with built-in accountability. The initiative resulted in improvements in all phases of acute MI care and met the benchmark recommendations in mean time to electrocardiogram, thrombolytic therapy, and aspirin and beta-blocker administration. Rates of prescriptions for secondary prevention were 92% for aspirin and beta-blocker and 97% for smoking cessation education at 4 years. SUMMARY: The care path for acute MI involved multiple disciplines and empowerment of nonspecialists and nonphysician practitioners during development and implementation, as well as continual education and retraining. The care path led to several improvements in performance scores. These findings indicate that the recommendations as set forth in the American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines for managing acute MI are realistic and achievable, and they do not require additional resources.

Preventing myocardial infarction in the young adult in the first place: how do the National Cholesterol Education Panel III guidelines perform?

OBJECTIVES: The purpose of this study was to investigate the utility of the new National Cholesterol Education Program (NCEP) III guidelines in a group of young adults. BACKGROUND: These guidelines have been hailed as an improvement in their potential to identify individuals at risk for coronary heart disease (CHD) complications. Compared with the NCEP II, the new guidelines will increase the number of patients who qualify for medical management. However, the effectiveness of these guidelines to identify young adults at risk for a cardiac event is yet to be studied. METHODS: A retrospective review of clinical data from young adults (age

Improving care for patients with chronic heart failure in the community: the importance of a disease management program.

STUDY OBJECTIVE: Utilizing a comparison group of patients with congestive heart failure (CHF) discharged to their primary care physicians, we sought to determine if disease management in a short-term, aggressive-intervention heart failure clinic (HFC) following hospital discharge is associated with improved outcomes. DESIGN: Chart review. SETTING: An integrated health-care center serving a tristate area. PATIENTS: Inclusion criteria were discharge from the hospital with a primary diagnosis of CHF, outpatient follow-up within the hospital system, and the presence of left ventricular systolic dysfunction as the basis for CHF. Patients were categorized into group 1 if they were referred to the HFC after hospital discharge, and into group 2 if follow-up care was provided by their primary care physician. MEASUREMENTS AND RESULTS: There were 38 patients in group 1 and 63 patients in group 2. There was a trend toward a shorter time to the first outpatient visit following discharge (11 days vs 15 days, p = 0.09), more outpatient visits within 90 days (10 visits vs 2 visits, p < 0.001), and more patient-initiated contacts (four contacts vs one contact, p = < 0.001) in group 1 compared to group 2, respectively. The combined hospital readmission and mortality rate at 90 days (10% vs 30%, p < 0.018) and 1 year (21% vs 43%, p < 0.02) was lower in group 1. There was a 77% relative risk reduction for 30-day hospital readmission in favor of group 1, and a statistically lower rate of readmissions at 90 days and 1 year. Utilization and maintenance of standardized CHF medications were significantly higher in patients who attended the HFC. CONCLUSIONS: A comprehensive disease management program for patients discharged with a diagnosis of CHF resulted in fewer rehospitalizations and improved event-free survival compared to patients followed up by their primary care physicians.