Long-term exposure to traffic-related air pollution associated with blood pressure and self-reported hypertension in a Danish cohort

Background: Short-term exposure to air pollution has been associated with changes in blood pressure (BP) and emergency department visits for hypertension, but little is known about the effects of long-term exposure to traffic-related air pollution on BP and hypertension.Objectives: We studied whether long-term exposure to air pollution is associated with BP and hypertension.Methods: In 1993–1997, 57,053 participants 50–64 years of age were enrolled in a population-based cohort study. Systolic and diastolic BP (SBP and DBP, respectively) were measured at enrollment. Self-reported incident hypertension during a mean follow-up of 5.3 years was assessed by questionnaire. We used a validated dispersion model to estimate residential long-term nitrogen oxides (NO_x), a marker of traffic-related air pollution, for the 1- and 5-year periods prior to enrollment and before a diagnosis of hypertension. We conducted a cross-sectional analysis of associations between air pollution and BP at enrollment with linear regression, adjusting for traffic noise, measured short-term NO_x, temperature, relative humidity, and potential lifestyle confounders (n = 44,436). We analyzed incident hypertension with Cox regression, adjusting for traffic noise and potential confounders.Results: A doubling of NO_x exposure during 1- and 5-year periods preceding enrollment was associated with 0.53-mmHg decreases [95% confidence interval (CI): –0.88, –0.19 mmHg] and 0.50-mmHg decreases (95% CI: –0.84, –0.16 mmHg) in SBP, respectively. Long-term exposure also was associated with a lower prevalence of baseline self-reported hypertension (per doubling of 5-year mean NO_x: odds ratio = 0.96; 95% CI: 0.91, 1.00), whereas long-term NO_x exposure was not associated with incident self-reported hypertension during follow-up.Conclusions: Long-term exposure to traffic-related air pollution was associated with a slightly lower prevalence of BP at baseline, but was not associated with incident hypertension.     

Innovative reflecting interview: effect on high-utilizing patients with medically unexplained symptoms.

This pilot study was conducted to determine the effect of an innovative reflecting interview on the health care utilization, physical health, mental function, and health care satisfaction of high-utilizing primary care patients with medically unexplained physical symptoms. Twenty-four high-utilizing patients met study selection criteria and were randomly assigned to a no-intervention control group or a reflecting interview intervention group. Outcomes were measured at 4 weeks, 6 months, and 1 year after the date of study enrollment. Results indicated that high-utilizing patients with medically unexplained physical symptoms who participated in a reflecting interview had reduced total health care costs, primarily through the reduction of hospitalization or inpatient expenses, despite a modest increase in outpatient primary care clinic visits. These data suggest that participation in a reflecting interview and regular visits with a primary care clinician can decrease health care utilization without adversely affecting patient satisfaction.     

Patient satisfaction in primary health care. A comparative study of two modes of treatment for hypertension.

The object of this study was to compare patients' experiences of two different treatments of hypertension (one mainly non-pharmacological and one pharmacological) and study the degree of patient satisfaction and experiences of treatment in general. The 165 patients in the non-pharmacological group participated in a two-year-long study of non-pharmacological treatment of hypertension (NPTH) at eight health centres in mid-Sweden. In addition to regular visits to the same doctor at the health centre, patients received monthly check-ups by a nurse at the health centre and participated in information programmes and group activities. The NPTH patients also used cuffs for home measurements of blood pressure. The 85 patients in the control group were recruited from two health centres and received traditional, pharmacological treatments of hypertension. The hypothesis was that the patients in the NPTH group would experience satisfaction with the treatment and perceive the treatment in general as more positive than those in the control group. The 250 patients have answered a postal inquiry with structured and open questions concerning the treatment. The results show that the patients in the NPTH group throughout this study have experienced higher satisfaction with the treatment and had a more positive attitude towards the treatment than the controls. The content and design of the treatment obviously had a positive influence on patient satisfaction.     

Evaluation of a complex intervention for changing professional behaviour: the Evidence Based Out Reach (EBOR) Trial

OBJECTIVES: To identify the effect of a complex intervention (educational outreach visits by pharmacists) designed to change general practitioners' (GPs') prescribing on each step of a hypothesised pathway of change leading to the final primary trial outcome of change in prescribing. METHOD: The study was undertaken in six health authorities in the North of England and six in London. We described three steps leading to this outcome: the general practices agreeing to participate; GPs in each practice attending the outreach visit conducted by the pharmacists; and the GPs' prescribing practice being influenced by these visits. The outcomes of each step were assessed using a combination of quantitative and qualitative methods. RESULTS: Of the 102 practices randomly selected, 75 (73.5%) agreed to participate. The odds of all the doctors attending the outreach meeting in small practices (i.e. 1-2 partners) was 6.7 (95% CI: 4.4-23.5) compared with other practices (i.e. > 3 partners). Although the pharmacists reported that they had established a good rapport at 100 (72%) first visits and had agreed management plans for 110 (79%) of these visits, they were confident that the practice was likely to alter its prescribing in only 41% of these visits. Pharmacists' and GPs' satisfaction with the outreach visits did not necessarily lead to prescribing changes after the practice visit, and the GPs' knowledge of the guidelines promoted by the pharmacists did not necessarily translate into changes in clinical practice. The main barriers to the implementation of guidelines identified by the pharmacists at the follow-up visits were organisational difficulties, the GPs' scepticism of the evidence presented to them and the doctors' lack of interest in changing their prescribing behaviour. CONCLUSIONS: Although our study is limited by a post hoc rather than a pre hoc design, it provides a pragmatic approach to understanding the factors influencing the pathway of change in prescribing behaviour in response to academic outreach visits.     

Perceptions around concordance – focus groups and semi-structured interviews conducted with consumers, pharmacists and general practitioners

BACKGROUND: Achieving concordance by identifying beliefs about illness, treatment and medicine-taking should impact positively on behaviour and consumer satisfaction with respect to treatment, and health outcomes may be improved. OBJECTIVE: To explore, in the Australian context, beliefs and expectations of general practitioners (GPs), consumers and pharmacists in relation to concordance to allow further exploration of the implementation of principles of concordance in Australia. DESIGN: Qualitative analysis of focus group and semi-structured interview data. SETTING AND PARTICIPANTS: Focus groups were held with seven consumers and nine pharmacists and, in-depth, semi-structured interviews were held with 10 GPs between February and May 2003, in Brisbane (Australia). RESULTS: This explorative study identified a variety of issues. Consumers expressed the need for more input from health professionals - being given more information on their treatments and conditions, more time spent in discussion, and establishing a system where harmonious relationships between health professionals could take place, which would result in a more consumer-friendly health care system. The main issues voiced by the pharmacists were about the idea of organizing the health care system in a way that would accommodate more quality information sharing between all partners. GPs' issues included better and unlimited information-sharing, having more time to promote quality in health care and receiving remuneration for increased verbal contact with other health care professionals. Suggestions were made about ways to achieve concordance by improved information-sharing and shared decision-making. CONCLUSION: The data from this study will lead to the development of models to explore and attempt to incorporate principles of concordance in Australian pharmacy and medical practice.     

Case identification,retention and blood pressure control in Kenya

BACKGROUND:Prevalence of hypertension in Africa is rising but it remains underdiagnosed and poorly controlled. In Kenya, only 22% of individuals known to have hypertension were on treatment, and only 51.7% were controlled. This study will assess screening outcomes, retention and blood pressure (BP) control of a hypertension programme in Kenya.DESIGN:This was a retrospective cohort study using data routinely collected between 2015 and 2018. All patients aged >18 years screened and treated in the programme were included.RESULTS:Of 663,028 screening encounters, 70.4% were female; the median age was 34 years. Overall, 19% of the study population, mainly males and older persons, had high BP higher rates. Of 66,981 patients started on treatment, the majority were females (71.2%); the median age was 55 years. Only 12% of patients were reported as having been retained after 12 months, and 48.6% of patients on treatment 10.5–13.5 months after enrolment had controlled BP. Older age and treatment at primary care level were associated with better retention and females had better BP control.CONCLUSIONS:The programme screened primarily females and younger individuals at lower risk. Retention was poor and close to half of patients retained had controlled BP. Hypertension programmes should target high-risk individuals, decentralise treatment, incorporate retention strategies and improve longitudinal data management.     

The impact of a health education program targeting patients with high visit rates in a managed care organization

PURPOSE: To determine if a mailed health promotion program reduced outpatient visits while improving health status. DESIGN: Randomized controlled trial. SETTING: A midsized, group practice model, managed care organization in Ohio. SUBJECTS: Members invited (N = 3214) were high utilizers, 18 to 64 years old, with hypertension, diabetes, or arthritis (or all). A total of 886 members agreed to participate, and 593 members returned the initial questionnaires. The 593 members were randomized to the following groups: 99 into arthritis treatment and 100 into arthritis control, 94 into blood pressure treatment and 92 into blood pressure control, and 104 into diabetes treatment and 104 into diabetes control. MEASURES: Outpatient utilization, health status, and self-efficacy were followed over 30 months. INTERVENTIONS: Health risk appraisal questionnaires were mailed to treatment and control groups before randomization and at 1 year. The treatment group received three additional condition-specific (arthritis, diabetes, or hypertension) questionnaires and a health information handbook. The treatment group also received written health education materials and an individualized feedback letter after each returned questionnaire. The control group received condition-specific written health education materials and reimbursement for exercise equipment or fitness club membership after returning the 1-year end of the study questionnaire. RESULTS: Changes in visit rates were disease specific. Parameter estimates were calculated from a Poisson regression model. For intervention vs. controls, the arthritis group decreased visits 4.84 per 30 months (p < 0.00), the diabetes group had no significant change, and the hypertension group increased visits 2.89 per 30 months (p < 0.05), the overall health status improved significantly (-6.5 vs. 2.3, p < 0.01) for the arthritis group but showed no significant change for the other two groups, and coronary artery disease and cancer risk scores did not change significantly for any group individually. Overall self-efficacy for intervention group completers improved by -8.6 points (p < 0.03) for the arthritis group, and the other groups showed no significant change. CONCLUSIONS: This study demonstrated that in a population of 18 to 64 years with chronic conditions, mailed health promotion programs might only benefit people with certain conditions.     

Health services utilization of a care coordination/home-telehealth program for veterans with diabetes: a matched-cohort study

This study examined the effectiveness of a veterans affairs (VA) patient-centered care coordination/home-telehealth (CC/HT) program as an adjunct to treatment for veterans with diabetes. Using an adapted version of the Chronic Care Model, we analyzed the differences in healthcare service use between a cohort of 400 veterans with diabetes who were enrolled in a VA CC/HT program and a matched comparison cohort of 400 veterans with diabetes who received no CC/HT intervention. Propensity scores were used to improve the balance between the treatment and comparison groups. Service use outcomes were assessed at 12 months before and after enrollment. A difference-in-differences approach was used in the multivariate models to assess the treatment effect for patients in the CC/HT programs. Twelve months after enrollment, there was a significant difference between the treatment and comparison groups in terms of need-based primary care visits (newly scheduled visits that enable the veteran to be seen "just in time," where the health status is monitored and met before health deteriorates), increasing in the treatment group and decreasing in the comparison group (P < .01). In a subgroup analysis, where we were able to control for the patients' Hb A1c values, we found that the treatment group had a lower likelihood of having 1 or more hospitalizations than patients in the comparison group. Our findings have implications for management in that the CC/HT program appears to improve the ability of older veterans with diabetes to receive appropriate, timely care, thereby improving the quality of care for them and making more efficient use of VA healthcare resources.     

Visit-specific expectations and patient-centered outcomes: a literature review

BACKGROUND: Primary care patients often have certain expectations when visiting physicians, many of which may be undetected. These unmet expectations can affect outcomes such as satisfaction with care. We performed a formal literature review to examine the effect of fulfillment of patients' visit-specific expectations on their satisfaction as well as on health status and compliance. PATIENTS AND METHODS: Included studies were conducted in primary care settings, systematically recruited patients, elicited previsit and/or postvisit expectations relative to specific visits, and measured patient-centered outcomes. Two reviewers abstracted information on study characteristics; types, timing, and method of expectation ascertainment; and outcomes. Disagreements were resolved by consensus. RESULTS: Twenty-three studies were reviewed including 7 trials, 4 cohort studies, and 12 cross-sectional studies. Patients frequently expected information rather than specific physician actions, but physicians often did not accurately perceive patients' visit-specific expectations. In 19 studies that assessed postvisit patient satisfaction, a positive association between meeting patient expectations and overall satisfaction was demonstrated in 11 studies, inconclusive in 3, and not established in 5. In 2 studies assessing physician satisfaction, physicians with access to patients' expectations were more satisfied than those without access. Other outcomes (symptom or disease improvement, health status, test ordering, health care costs, psychological symptoms) were measured in only a few studies, and the results were inconclusive. CONCLUSIONS: Addressing patients' visit-specific expectations appears to affect satisfaction to a modest degree. Future studies should evaluate methods that efficiently elicit, prioritize, and provide patients' previsit expectations for physicians and should examine the longitudinal effect of expectation fulfillment on patient outcomes. Arch Fam Med. 2000;9:1148-1155     

Competing demands from physical problems: effect on initiating and completing depression care over 6 months

OBJECTIVE AND DESIGN: To evaluate a cohort of patients with major depression to examine the effect of competing demands on depression care during multiple visits over 6 months. PARTICIPANTS AND SETTING: Ninety-two patients with 5 or more symptoms of depression and no recent depression treatment were evaluated by 12 primary care physicians in 6 practices in the usual-care arm of an effectiveness trial of the Agency for Health Care Policy and Research Depression Guidelines. MAIN OUTCOME MEASURE: Treatment was considered to be initiated if the patient reported starting a guideline-concordant antidepressant medication or making a visit for specialty counseling. Treatment completion was defined as either a 3-month course of guideline-concordant antidepressant use or completion of 8 or more specialty counseling visits. RESULTS: Among the 92 patients reporting no recent treatment at study enrollment, 57% reported starting and 17% reported completing a course of guideline-concordant antidepressant medication and or specialty counseling at the 6-month interview. The severity of physical problems among patients with high enthusiasm for depression treatment decreased the odds that patients would initiate depression therapy. Severity of physical problems had no observable effect on completing depression therapy in the group of patients who initiated treatment. CONCLUSIONS: Physical problems compete with depression for attention over multiple visits in untreated patients who are enthusiastic about getting care for their emotional problems. Interventions are needed for this high-risk group, because depression treatment could potentially enhance patients' treatment of their physical problems. Arch Fam Med. 2000;9:1059-1064     

A randomized trial of primary intensive care to reduce hospital admissions in patients with high utilization of inpatient services.

Randomized controlled trials of case management in primary care have been infrequent and contradictory. The aim of this study was to determine if a clinic-based ambulatory case management intervention, Primary Intensive Care (PIC), would reduce hospital utilization and total cost and/or improve health outcomes among primary care patients with a recent history of high use of inpatient services. Current patients with > or =2 hospital admissions per year in the 12-18 months prior to recruitment in an urban primary care clinic were enrolled in a randomized clinical trial. Patients were randomized to the PIC intervention or usual care. PIC patients underwent a comprehensive multidisciplinary assessment with the result being a team-generated plan. The PIC team nurse practitioner served as case manager for the 12 months of follow-up and provided services designed to implement the care plan for those in the experimental group. Health care use, function, and a medication adherence scale were measured at baseline and at 12 months. There were no significant differences when either comparing the number of admissions pre and post enrollment within groups or the followup results post intervention between groups. A similar result was noted for the number of emergency department visits. The number of clinic visits increased in the intervention group by 1.5 visits per year which was statistically significant when compared to the control group. Overall functional status, health outcomes, and the Mental Health Functional Status subscore did not change significantly in either group during the study. We were unable to detect a difference in hospital use or functional status, mental health function, or medication adherence among patients who require frequent hospital admissions using our intervention.     

Cardiovascular risk education and social support (CaRESS): report of a randomized controlled trial from the Kentucky Ambulatory Network (KAN)

PURPOSE: Test a practice-based intervention to foster involvement of a relative or friend for the reduction of cardiovascular risk in patients with type 2 diabetes. METHODS: We enrolled in a randomized controlled trial 199 patients and 108 support persons (SPs) from 18 practices within a practice-based research network. All patient participants had type 2 diabetes with suboptimal blood pressure control and were prepared to designate a SP. A subset of the patients also had dyslipidemia. All study visits were conducted at the practice sites where staff took standardized blood pressure measurements and collected blood samples. All patients completed one education session and received newsletters aimed at improving key health behaviors. Intervention group patients included their chosen SP in the education session and the SPs received newsletters. RESULTS: After 9 to 12 months, the intervention had no significant effect on systolic blood pressure, HbA1C, health-related quality of life, patient satisfaction, medication adherence, or perceived health competence. Power was insufficient to detect an effect on low-density lipoprotein cholesterol. Baseline cardiovascular risk values were not very high, with mean systolic blood pressure at 140 mm Hg; mean HbA1C at 7.6%; and mean low-density lipoprotein at 137 mg/dL. Patient health care satisfaction was high. CONCLUSION: This practice-based intervention to foster social support for chronic care management among diabetics had no significant impact on the targeted outcomes.     

A randomized trial among women with heavy menstruation – impact of a decision aid on treatment outcomes and costs

OBJECTIVE: To evaluate the effects of a decision aid for menorrhagia on treatment outcomes and costs over a 12-month follow-up. DESIGN: Randomized trial and pre-trial prospective cohort study. SETTING AND PARTICIPANTS: Gynaecology outpatient clinics in 14 Finnish hospitals, 363 (randomized trial) plus 206 (cohort study) patients with menorrhagia. INTERVENTION: A decision aid booklet explaining menorrhagia and treatment options, mailed to patients before their first clinic appointment. MAIN OUTCOME MEASURES: Health related quality of life, psychological well-being, menstrual symptoms, satisfaction with treatment outcome, use and cost of health care services. RESULTS: All study groups experienced overall improvement in health-related quality of life, anxiety, and psychosomatic and menstrual symptoms, but not in sexual life. Treatment in the intervention group was more active than in the control group, with more frequent course of medication and less undecided treatments. However, there were no marked disparities in health outcomes, satisfaction with treatment outcome and costs. Total costs (including productivity loss) per woman because of menorrhagia over the 12-month follow-up were 2760 and 3094 in the intervention and control group, respectively (P = 0.1). The pre-trial group also had a significantly lower rate of uterus saving surgery compared with the control group, but no difference in costs because of menorrhagia treatment. CONCLUSION: Despite some differences in treatment courses, a decision aid for menorrhagia in booklet form did not increase the use of health services or treatment costs, nor had it impact on health outcomes or satisfaction with outcome of treatment.     

Hypertension, diabetes, hypercholesterolemia, and their combinations increased health care utilization and decreased health status

BACKGROUND AND OBJECTIVE: For individuals with hypertension, diabetes, or hypercholesterolemia, the relative magnitude of cardiovascular risk factors and the effect of multiple risk factors remains controversial and both treatment practices and health care usage vary. We sought to determine the effect of hypertension, diabetes, hypercholesterolemia, and their combinations on health care utilization and health status through analysis of data from a large national survey. METHODS: We applied the Anderson model to a cross-sectional representative sample (n=15,107) of the U.S. civilian, noninstitutionalized population (the 1996 Medical Expenditure Panel Survey). RESULTS: For diabetes, additional risk factors did not increase the likelihood of emergency room (ER) visits or hospitalizations but were associated with increased outpatient visits and poorer health status. For hypertension, additional risk factors increased the likelihood of hospitalization (but not ER visits), the number of outpatient visits, and poorer health status. For hypercholesterolemia, additional risk factors were associated with increased likelihood of ER visits, hospitalizations, and poorer health status but not more outpatient visits. Diabetes had the largest effect on health care utilization and health status. CONCLUSION: These findings re-emphasize the magnitude of diabetes as a major risk factor associated with increased ER visits, hospitalizations, outpatients visits, and lower health status.     

The Medicaid expansion did not crowd out access for medicaid recipients with disabilities in Oregon

BackgroundThe Affordable Care Act (ACA) substantially increased the number of Medicaid enrollees, which could have reduced access to health care services for those already on Medicaid before the expansion.ObjectiveTo examine the association of the ACA expansion on health care access and utilization for adults ages 18–64 years who have qualified for Supplemental Security Income (SSI) in Oregon.MethodsWe used Oregon Medicaid claims and enrollment data from 2012 to 2015 and information from the American Community Survey and the Local Area Unemployment Statistics. Multivariate regressions compared changes in health care access and utilization before and after the expansion among Medicaid recipients who qualified for SSI across counties in Oregon with higher and lower Medicaid enrollment increases due to the expansion. Health care access and utilization outcome measures included: primary care visits, non-behavioral health outpatient visits, behavioral health outpatient visits, emergency department (ED) visits and potentially avoidable ED visits.ResultsThe Medicaid expansion led to an uneven increase in Medicaid enrollment across Oregon’s counties (mean increase from the first quarter of 2012 to the third quarter of 2015: 12.4% points; range: 7.3 to 18.6% points). Access and utilization outcomes for SSI Medicaid recipients were mostly unaffected by differential enrollment increases. ED visits increased more in counties with a larger Medicaid enrollment increase (estimate: 1.8, p < 0.05), but adjusting for pre-expansion trends eliminated this association.ConclusionsWe did not find evidence that an increase in Medicaid enrollment due to the ACA negatively impacted access and utilization for adult Medicaid recipients on SSI, who were eligible for Medicaid prior to expansion.     

It pays to be nice: employer-worker relationships and the management of back pain claims

OBJECTIVE: To quantify the influence that workers' satisfaction with the firm's treatment of their disability claim and their health care provider has on workers' return to work (RTW) following onset of occupational LBP. METHODS: Using a prospective survey on back pain, medical treatment, and workers' satisfaction, we employ nonparametric and logistic analyses to see how satisfaction affects RTW. RESULTS: Workers' satisfaction with their employer's treatment of their disability claim is more important in explaining RTW than satisfaction with health care providers or expectations about recovery. Dissatisfied workers have worse return to work outcomes because they are more likely to have time lost claims and are more likely to have multiple spells of joblessness. CONCLUSIONS: Workers' RTW is more responsive to their satisfaction with how the firm treated their disability claim than with their satisfaction with the health care provider. Satisfaction of both types plays an important role in determining RTW.     

不同类型降压药物对老年高血压患者动脉僵硬度的影响

目的评价不同类型降压药物对老年原发性高血压患者动脉僵硬度的影响。方法60例老年男性原发性高血压患者,随机分为缬沙坦组（80mg,l/d）、贝那普利组（10mg,l/d）、硝苯地平缓释片组（20mg,2／d）各20例,疗程共3个月。分析治疗前后肱一踝脉搏波速度（baPWV）及血压。结果治疗3个月后各组血压均有显著降低,硝苯地平缓释片组舒张压的下降幅度（△DBP）、脉压下降幅度（△PP）与另两组差异显著（分别为-40．1±11．3 vs-16．6±5．5、-14．6±4．2mmHg和-10．0±19．3vs -28．8±6．6、-25．7±6．5mmHg,P〈0．01）。缬沙坦组及贝那普利组治疗前后baPWV均显著下降,其下降幅度（AbaPWV）分别为-401±90、-280±97cm／s,显著大于硝苯地平缓释片组的-11±127cm／s（P〈0．01）。baPWV与APP在总体患者中呈显著正相关（r=0．64．P〈0．001）,贝那普利组或硝苯地平缓释片组ΔbaPWV至少与一项血压参数（APP,ASBP,ADBP）相关,而在缬沙坦组均不相关。结论与贝那普利或硝苯地平缓释片相比,缬沙坦对老年原发性高血压患者具有独立于降压功效外的减低动脉僵硬度的作用。     

Appropriate reductions in compliance among well-controlled hypertensive patients

Physicians have traditionally viewed partial compliance with medications as a concern only in hypertensive patients whose blood pressure (BP) is poorly controlled. However, partial compliance also occurs in patients whose BP: has become normal on medications; in them, reduced compliance may, indicate that they have been prescribed more medication than they need. During enrollment for a study of medication reduction in hypertensive patients, we identified 118 male veterans who were eligible for the, study because their diastolic BP had been less than 95 mmHg for more than 6 months. Fifty-nine of these patients (50.0%) agreed to participate in the study, of whom 71% successfully reduced or stopped (“stepped down”) one or more of their antihypertensive drugs over a 1-year period. The 59 patients who' did not enroll continued to receive routine care for hypertension in the clinic without intensive efforts at stepdown. Nevertheless, 24% o of these patients reduced or stopped at least one medication over the same time period. In the year prior to the study, 29 of the 118 eligible patients (24.6%) had obtained less than 80% of their medications, measured by pharmacy refill records. Compliance in obtaining antihypertensive medications prior to the study was lower among eligible patients who stepped down mediations during the study year (90.4% ± 18.7%) than in those who did not (1p2.1% ± 26.1%, p =0.006). After adjustment for other predictors of stepdown (number of medications, duration of clinic enrollment, and pre-reduction systolic BP), each 10% increase in compliance among all eligible patients was associated with a reduction in the odds ratio for successful stepdown of 0.8 (95% CI 0.5–1.0, p = 0.01). We conclude that many well-controlled hypertensives appropriately obtain less medications than they are prescribed. Such patients should be considered for reduction of antihypertensive drugs.     

Using physician-led automated communications to improve patient health

One common thread to health care reform in the United States is an emphasis on effectively managing the care of patients with chronic conditions. A landmark study by McGlynn et al demonstrated that patients receive about 55% of the treatment they need. While technological advances allow automated means for identifying and reaching out to patients in need of treatment, few studies have evaluated their impact. The purpose of this study is to measure how an automated outreach program can be used to improve the quality of care for patients with diabetes and hypertension. Billing and electronic medical records data from a large health system in Wisconsin were studied, identifying patients with a history of diabetes and hypertension but no visits recorded in billing data related to their condition in the past 6 months. The outcomes of interest were the occurrence of a chronic care-related visit and a necessary test within 6 months of the nonadherence date. Diabetes patients who were successfully contacted were significantly more likely to have both a chronic care-related visit and an HbA1c test (odds ratio [OR]?=?4.61, 95% confidence interval [CI] 3.87-5.49) than their counterparts who were not contacted. As well, hypertension patients were significantly more likely to have both a chronic care-related visit and a systolic blood pressure reading recorded in an electronic medical record (OR?=?3.18, 95% CI 2.90-3.48). An automated patient identification and outreach program can be an effective means to supplement existing practice patterns to ensure that patients with chronic conditions in need of care receive the necessary treatment.