Health system strengthening and hypertension awareness,treatment and control: data from the China Health and Retirement Longitudinal Study

Objective

To monitor hypertension prevalence, awareness, treatment and control in China two to three years after major reform of the health system.

Methods

Data from a national survey conducted in 2011–2012 among Chinese people aged 45 years or older – which included detailed anthropometric measurements – were used to estimate the prevalence of hypertension and the percentages of hypertensive individuals who were unaware of, receiving no treatment for, and/or not controlling their hypertension well. Modified Poisson regressions were used to estimate relative risks (RRs).

Findings

At the time of the survey, nearly 40% of Chinese people aged 45 years or older had a hypertensive disorder. Of the individuals with hypertension, more than 40% were unaware of their condition, about 50% were receiving no medication for it and about 80% were not controlling it well. Compared with the other hypertensive individuals, those who were members of insurance schemes that covered the costs of outpatient care were more likely to be aware of their hypertension (adjusted RR, aRR: 0.737; 95% confidence interval, CI: 0.619–0.878) to be receiving treatment for it (aRR: 0.795; 95% CI: 0.680–0.929) and to be controlling it effectively (aRR: 0.903; 95% CI: 0.817–0.996).

Conclusion

In China many cases of hypertension are going undetected and untreated, even though the health system appears to deliver effective care to individuals who are aware of their hypertension. A reduction in the costs of outpatient care to patients would probably improve the management of hypertension in China.     

Implementing Asthma Guidelines Using Practice Facilitation and Local Learning Collaboratives: A Randomized Controlled Trial

PURPOSE

Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined.

METHODS

In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute’s Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar’s test and multivariate modeling were used to evaluate the impact of the interventions.

RESULTS

Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7–3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5–3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation.

CONCLUSIONS

Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.     

Annals Journal Club: Changes in Office Visit Use Associated With Electronic Messaging and Telephone Encounters Among Patients With Diabetes in the PCMH

PURPOSE

Telephone- and Internet-based communication are increasingly common in primary care, yet there is uncertainty about how these forms of communication affect demand for in-person office visits. We assessed whether use of copay-free secure messaging and telephone encounters was associated with office visit use in a population with diabetes.

METHODS

We used an interrupted time series design with a patient-quarter unit of analysis. Secondary data from 2008–2011 spanned 3 periods before, during, and after a patient-centered medical home (PCMH) redesign in an integrated health care delivery system. We used linear regression models to estimate proportional changes in the use of primary care office visits associated with proportional increases in secure messaging and telephone encounters.

RESULTS

The study included 18,486 adults with diabetes. The mean quarterly number of primary care contacts increased by 28% between the pre-PCMH baseline and the postimplementation periods, largely driven by increased secure messaging; quarterly office visit use declined by 8%. In adjusted regression analysis, 10% increases in secure message threads and telephone encounters were associated with increases of 1.25% (95% CI, 1.21%–1.29%) and 2.74% (95% CI, 2.70%–2.77%) in office visits, respectively. In an interaction model, proportional increases in secure messaging and telephone encounters remained associated with increased office visit use for all study periods and patient subpopulations (P <.001).

CONCLUSIONS

Before and after a medical home redesign, proportional increases in secure messaging and telephone encounters were associated with additional primary care office visits for individuals with diabetes. Our findings provide evidence on how new forms of patient-clinician communication may affect demand for office visits.     

Tobacco smoking and tuberculosis treatment outcomes: a prospective cohort study in Georgia

Objective

To assess the effect of tobacco smoking on the outcome of tuberculosis treatment in Tbilisi, Georgia.

Methods

We conducted a prospective cohort study of adults with laboratory-confirmed tuberculosis from May 2011 to November 2013. History of tobacco smoking was collected using a standardized questionnaire adapted from the global adult tobacco survey. We considered tuberculosis therapy to have a poor outcome if participants defaulted, failed treatment or died. We used multivariable regressions to estimate the risk of a poor treatment outcome.

Findings

Of the 591 tuberculosis patients enrolled, 188 (31.8%) were past smokers and 271 (45.9%) were current smokers. Ninety (33.2%) of the current smokers and 24 (18.2%) of the participants who had never smoked had previously been treated for tuberculosis (P < 0.01). Treatment outcome data were available for 524 of the participants, of whom 128 (24.4%) – including 80 (32.9%) of the 243 current smokers and 21 (17.2%) of the 122 individuals who had never smoked – had a poor treatment outcome. Compared with those who had never smoked, current smokers had an increased risk of poor treatment outcome (adjusted relative risk, aRR: 1.70; 95% confidence interval, CI: 1.00–2.90). Those who had ceased smoking more than two months before enrolment did not have such an increased risk (aRR: 1.01; 95% CI: 0.51–1.99).

Conclusion

There is a high prevalence of smoking among patients with tuberculosis in Georgia and smoking increases the risk of a poor treatment outcome.     

A follow-up of cancer incidence among former Finnish dump site residents: 1999–2011

Background:

In an analysis of the years 1976–1998, a 50% excess in cancer incidence was observed among residents in twelve blockhouses in Helsinki, Finland on a former dump area containing industrial and household waste.

Objective:

To assess cancer risk over a 13-year period 1999–2011 among residents formerly living in houses built on a dump area.

Methods:

All 1879 persons who ever lived in the former dump area were identified and the number of cancer cases in this population was obtained from the Finnish Cancer Registry.

Results:

After 5 years of residence at the dump site, the standardized incidence ratio of cancer (all sites combined) was 1.32 (95% CI: 0.94–1.79) in men and 0.53 (95% CI: 0.33–0.82) for women, in comparison with the general Helsinki population (1999–2011). No significant excess cancer risks were found.

Conclusions:

Residing on a former dump area was not found to result in an increased risk of cancer.     

Association of Depression With Increased Risk of Severe Hypoglycemic Episodes in Patients With Diabetes

PURPOSE

Although psychosocial and clinical factors have been found to be associated with hypoglycemic episodes in patients with diabetes, few studies have examined the association of depression with severe hypoglycemic episodes. This study examined the prospective association of depression with risk of hypoglycemic episodes requiring either an emergency department visit or hospitalization.

METHODS

In a longitudinal cohort study, a sample of 4,117 patients with diabetes enrolled between 2000 and 2002 were observed from 2005 to 2007. Meeting major depression criteria on the Patient Health Questionnaire-9 was the exposure of interest, and the outcome of interest was an International Classification of Disease, Ninth Revision code for a hypoglycemic episode requiring an emergency department visit or hospitalization. Proportional hazard models were used to analyze the association of baseline depression and risk of one or more severe hypoglycemic episodes. Poisson regression was used to determine whether depression status was associated with the number of hypoglycemic episodes.

RESULTS

After adjusting for sociodemographic, clinical measures of diabetes severity, non–diabetes-related medical comorbidity, prior hypoglycemic episodes, and health risk behaviors, depressed compared with nondepressed patients who had diabetes had a significantly higher risk of a severe hypoglycemic episode (hazard ratio = 1.42, 95% CI, 1.03–1.96) and a greater number of hypoglycemic episodes (odds ratio = 1.34, 95% CI, 1.03–1.74).

CONCLUSION

Depression was significantly associated with time to first severe hypoglycemic episode and number of hypoglycemic episodes. Research assessing whether recognition and effective treatment of depression among persons with diabetes prevents severe hypoglycemic episodes is needed.     

A Multicenter Study of Physician Mindfulness and Health Care Quality

PURPOSE

Mindfulness (ie, purposeful and nonjudgmental attentiveness to one’s own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care.

METHODS

We conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care.

RESULTS

In adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58–10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46–1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17–1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15–1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues.

CONCLUSIONS

Clinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.     

Association of Exposure to Phthalates with Endometriosis and Uterine Leiomyomata: Findings from NHANES, 1999–2004

Background

Phthalates are ubiquitous chemicals used in consumer products. Some phthalates are reproductive toxicants in experimental animals, but human data are limited.

Objective

We conducted a cross-sectional study of urinary phthalate metabolite concentrations in relation to self-reported history of endometriosis and uterine leiomyomata among 1,227 women 20–54 years of age from three cycles of the National Health and Nutrition Examination Survey (NHANES), 1999–2004.

Methods

We examined four phthalate metabolites: mono(2-ethylhexyl) phthalate (MEHP), monobutyl phthalate (MBP), monoethyl phthalate (MEP), and monobenzyl phthalate (MBzP). From the last two NHANES cycles, we also examined mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP) and mono(2-ethyl-5-oxohexyl) phthalate (MEOHP). We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for potential confounders.

Results

Eighty-seven (7%) and 151 (12%) women reported diagnoses of endometriosis and leiomyomata, respectively. The ORs comparing the highest versus lowest three quartiles of urinary MBP were 1.36 (95% CI, 0.77–2.41) for endometriosis, 1.56 (95% CI, 0.93–2.61) for leiomyomata, and 1.71 (95% CI, 1.07–2.75) for both conditions combined. The corresponding ORs for MEHP were 0.44 (95% CI, 0.19–1.02) for endometriosis, 0.63 (95% CI, 0.35–1.12) for leiomyomata, and 0.59 (95% CI, 0.37–0.95) for both conditions combined. Findings for MEHHP and MEOHP agreed with findings for MEHP with respect to endometriosis only. We observed null associations for MEP and MBzP. Associations were similar when we excluded women diagnosed > 7 years before their NHANES evaluation.

Conclusion

The positive associations for MBP and inverse associations for MEHP in relation to endometriosis and leiomyomata warrant investigation in prospective studies.     

Traffic-Related Air Pollution and QT Interval: Modification by Diabetes,Obesity, and Oxidative Stress Gene Polymorphisms in the Normative Aging Study

Background

Acute exposure to ambient air pollution has been associated with acute changes in cardiac outcomes, often within hours of exposure.

Objectives

We examined the effects of air pollutants on heart-rate–corrected QT interval (QTc), an electrocardiographic marker of ventricular repolarization, and whether these associations were modified by participant characteristics and genetic polymorphisms related to oxidative stress.

Methods

We studied repeated measurements of QTc on 580 men from the Veterans Affairs Normative Aging Study (NAS) using mixed-effects models with random intercepts. We fitted a quadratic constrained distributed lag model to estimate the cumulative effect on QTc of ambient air pollutants including fine particulate matter ≤ 2.5 μm in aerodynamic diameter (PM_2.5), ozone (O₃), black carbon (BC), nitrogen dioxide (NO₂), carbon monoxide (CO), and sulfur dioxide (SO₂) concentrations during the 10 hr before the visit. We genotyped polymorphisms related to oxidative stress and analyzed pollution–susceptibility score interactions using the genetic susceptibility score (GSS) method.

Results

Ambient traffic pollutant concentrations were related to longer QTc. An interquartile range (IQR) change in BC cumulative during the 10 hr before the visit was associated with increased QTc [1.89 msec change; 95% confidence interval (CI), −0.16 to 3.93]. We found a similar association with QTc for an IQR change in 1-hr BC that occurred 4 hr before the visit (2.54 msec change; 95% CI, 0.28–4.80). We found increased QTc for IQR changes in NO₂ and CO, but the change was statistically insignificant. In contrast, we found no association between QTc and PM_2.5, SO₂, and O₃. The association between QTc and BC was stronger among participants who were obese, who had diabetes, who were nonsmokers, or who had higher GSSs.

Conclusions

Traffic-related pollutants may increase QTc among persons with diabetes, persons who are obese, and nonsmoking elderly individuals; the number of genetic variants related to oxidative stress increases this effect.     

Air Pollution,Aeroallergens, and Emergency Room Visits for Acute Respiratory Diseases and Gastroenteric Disorders among Young Children in Six Italian Cities

Background

Past studies reported evidence of associations between air pollution and respiratory symptoms and morbidity for children. Few studies examined associations between air pollution and emergency room (ER) visits for wheezing, and even fewer for gastroenteric illness. We conducted a multicity analysis of the relationship between air pollution and ER visits for wheezing and gastroenteric disorder in children 0–2 years of age.

Methods

We obtained ER visit records for wheezing and gastroenteric disorder from six Italian cities. A city-specific case–crossover analysis was applied to estimate effects of particulate matter (PM), nitrogen dioxide, sulfur dioxide, ozone, and carbon monoxide, adjusting for immediate and delayed effects of temperature. Lagged effects of air pollutants up to 6 prior days were examined. The city-specific results were combined using a random-effect meta-analysis.

Results

CO and SO₂ were most strongly associated with wheezing, with a 2.7% increase [95% confidence interval (CI), 0.5–4.9] for a 1.04-μg/m³ increase in 7-day average CO and a 3.4% (95% CI, 1.5–5.3) increase for an 8.0-μg/m³ increase in SO₂. Positive associations were also found for PM with aerodynamic diameter ≤ 10 μg and NO₂. We found a significant association between the 3-day moving average CO and gastroenteric disorders [3.8% increase (95% CI, 1.0–6.8)]. When data were stratified by season, the associations were stronger in summer for wheezing and in winter for gastroenteric disorders.

Conclusion

Air pollution is associated with triggering of wheezing and gastroenteric disorders in children 0–2 years of age; more work is needed to understand the mechanisms to help prevent wheezing in children.     

Adverse events attributed to traditional Korean medical practices: 1999–2010

Objective

To investigate adverse events attributed to traditional medical treatments in the Republic of Korea.

Methods

Adverse events recorded in the Republic of Korea between 1999 and 2010 – by the Food and Drug Administration, the Consumer Agency or the Association of Traditional Korean Medicine – were reviewed. Records of adverse events attributed to the use of traditional medical practices, including reports of medicinal accidents and consumers’ complaints, were investigated.

Findings

Overall, 9624 records of adverse events attributed to traditional medical practices – including 522 linked to herbal treatments – were identified. Liver problems were the most frequently reported adverse events. Only eight of the adverse events were recorded by the pharmacovigilance system run by the Food and Drug Administration. Of the 9624 events, 1389 – mostly infections, cases of pneumothorax and burns – were linked to physical therapy (n = 285) or acupuncture/moxibustion (n = 1104).

Conclusion

In the Republic of Korea, traditional medical practices often appear to have adverse effects, yet almost all of the adverse events attributed to such practices between 1999 and 2010 were missed by the national pharmacovigilance system. The Consumer Agency and the Association of Traditional Korean Medicine should be included in the national pharmacovigilance system.     

Peer Reviewed: Employer Adoption of Evidence-Based Chronic Disease Prevention Practices: A Pilot Study

Background

We conducted a pilot test of American Cancer Society Workplace Solutions, an intervention that takes a marketing approach to increasing employers'' adoption of evidence-based practices to prevent and control chronic diseases among their employees.

Context

We delivered the intervention and assessed the changes in practices of 8 large employers in the Pacific Northwest.

Methods

Workplace Solutions recommends 15 employer practices in 5 categories: 1) health insurance benefits, 2) policies, 3) workplace programs, 4) health-promoting communication, and 5) tracking of employee health behaviors to measure progress. The intervention includes 4 meetings with employers over 2 months and begins with a questionnaire-based assessment of employer practices. Tailored recommendations follow, along with practice-specific implementation assistance on requested topics. We tested the intervention in a before–after study without a comparison group.

Consequences

The employers ranged in size from 7500 to 115,522 employees and included private companies and public employers. Seven of the eight employers implemented more of the recommended practices at follow-up (an average of 13 months after the intervention) than at baseline. Overall, implementation of the practices increased from 38% at baseline to 61% at follow-up (P = .02).

Interpretation

Workplace Solutions is a promising new approach to bringing evidence-based best practices for preventing chronic disease to large numbers of adults.     

Risk Factors for Community-Based Reports of Gastrointestinal,Respiratory, and Dermal Symptoms: Findings From a Cohort Study in Australia

Background

Although gastrointestinal (GI), respiratory, and dermal symptoms are common, few studies have conducted concurrent and comparative prospective analyses of risk factors for these 3 morbidity outcomes.

Methods

We used data from a community-based randomized controlled trial among 277 South Australian families to analyze GI (diarrhea, vomiting), respiratory (sore throat, runny nose, cough) and dermal (rash, generalized itch, dermal infection) symptoms.

Results

Log-binomial regression analysis revealed similar risks of GI (adjusted risk ratio [RR], 1.65; 95% CI, 1.05–2.58) and respiratory (RR, 1.68; 95% CI, 1.31–2.15) symptoms among childcare/kindergarten attendees. Swimming in public pools/spas in the current or previous week was associated with all 3 symptom complexes, conferring similar risk for each (RR for GI: 1.33; 95% CI, 0.99–1.77; respiratory: 1.20; 95% CI, 1.04–1.38; dermal: 1.41; 95% CI, 1.08–1.85). Pet ownership was not associated with symptoms. Household clustering of GI and respiratory symptoms was common, and clustering of respiratory symptoms correlated with number of individuals per household.

Conclusions

This simultaneous examination of risk factors for 3 health outcomes yielded new comparative data that are useful for developing prevention strategies.Key words: risk factors, respiratory symptoms, gastrointestinal symptoms, dermal symptoms, swimming, swimming pools, household clustering