Patient centered primary care is associated with patient hypertension medication adherence

There is increasing evidence that patient centered care, including communication skills, is an essential component to chronic illness care. Our aim was to evaluate patient centered primary care as a determinant of medication adherence. We mailed 1,341 veterans with hypertension the Short Form Primary Care Assessment Survey (PCAS) which measures elements of patient centered primary care. We prospectively collected each patient’s antihypertensive medication adherence for 6 months. Patients were characterized as adherent if they had medication for >80%. 654 surveys were returned (50.7%); and 499 patients with complete data were analyzed. Antihypertensive adherence increased as scores in patient centered care increased [RR 3.18 (95% CI 1.44, 16.23) bootstrap 5000 resamples] for PCAS score of 4.5 (highest quartile) versus 1.5 (lowest quartile). Future research is needed to determine if improving patient centered care, particularly communication skills, could lead to improvements in health related behaviors such as medication adherence and health outcomes.     

Blood Pressure Control in a Hypertension Telemedicine Intervention: Does Distance to Primary Care Matter?

Although telemedicine may help overcome geographic access barriers, it is unknown whether rural patients receive greater benefits. In a secondary analysis of 503 veterans participating in a hypertension telemedicine study, the authors hypothesized that patients with greater travel distances would have greater improvements in 18‐month systolic blood pressure (SBP). Patients were categorized by telemedicine exposure and travel distance to primary care, derived from zip codes. Comparisons were (1) usual care (UC), distance <30 miles (reference); (2) UC, distance ≥30 miles; (3) telemedicine, distance <30 miles; (4) telemedicine, distance ≥30 miles. Compared with patients receiving UC, distance <30 miles (intercept=127.7), no difference in 18‐month SBP was observed in patients receiving UC, distance ≥30 miles (0.13 mm Hg, 95% confidence interval [−6.6 to 6.8]); telemedicine, distance <30 miles (−1.1 mm Hg [−7.3 to 5.2]); telemedicine, distance ≥30 miles (−0.80 mm Hg [−6.6 to 5.1]). Although telemedicine may help overcome geographic access barriers, additional studies are needed to identify patients most likely to benefit.

Primary care providers manage the majority of the 65 million individuals with hypertension in the United States.¹ However, the primary care workforce is currently unable to meet the demand for clinic visits to manage patients with chronic diseases.², ³ The demand for primary care is expected to increase further with expansion of healthcare availability under the 2010 Patient Protection and Affordable Care Act (PPACA).⁴ Furthermore, our current healthcare system is designed to deliver services primarily through face‐to‐face encounters between a patient and healthcare provider. This model, however, is likely unsustainable as the demand for healthcare services continues to grow.³, ⁵ Telemedicine is the use of telecommunication technologies and the exchange of electronic medical information between different sites to improve patients'' health status.⁶ Telemedicine can support the delivery of health services over geographic distances⁷ and increase access to healthcare services for patients who live in rural areas.⁸ Telemedicine may also provide an alternative to traditional face‐to‐face clinic‐based encounters by increasing the capacity to manage chronic diseases through non–face‐to‐face visits.⁹ Hypertension telemedicine interventions have been shown to improve blood pressure (BP) control in individuals with hypertension.¹⁰, ¹¹ However, in order to optimize the effectiveness of telemedicine interventions in chronic disease management, it is critical to identify characteristics of patients most likely to benefit from this service.Although telemedicine may increase access to healthcare for patients who live in rural areas, it remains unknown whether those patients with greater travel distances to primary care have improved outcomes with telemedicine interventions compared with those with shorter travel distances. Thus, we sought to determine whether distance to primary care modified the response to a telemedicine intervention designed to improve hypertension control among veterans. We hypothesized that greater travel distance to primary care would be associated with a greater reduction in systolic BP (SBP) among veterans enrolled in a hypertension telemedicine study.     

Validation of ICD-9 codes with a high positive predictive value for incident strokes resulting in hospitalization using Medicaid health data

PURPOSE: To validate ICD 9 codes with a high positive predictive value (PPV) for incident strokes. The study population consisted of Tennessee Medicaid enrollees aged from 50 to 84 years. METHODS: We identified all patients who were hospitalized with a discharge diagnosis of stroke between 1999 and 2003 using highly specific codes (ischemic stroke ICD 9-CM codes 433.x1, 434 [excluding 434.x0], or 436; intracerebral hemorrhage [431]; and subarachnoid hemorrhage [430]). We reviewed medical records of a systematic sample of 250 cohort members. We randomly selected 10-30 eligible records for review from hospitals with at least 10 stroke hospitalizations. RESULTS: We reviewed 231 charts (93% of total sampled), and 205 (89%) met study criteria for new outpatient stroke. Of the 205 confirmed new outpatient strokes, 196 had stroke listed as the primary discharge diagnosis (PPV = 96%). However, 46 (23%) of the 196 patients identified by the primary diagnosis also had a remote stroke history (recurrent stroke not incident). Thus the PPV of the primary discharge diagnosis for identifying incident stroke decreased to 74%. When we applied an algorithm that restricted our population to those with stroke as the primary diagnosis and excluded patients with any prior outpatient diagnosis of stroke, we identified incident stroke events with more precision (PPV = 80%). CONCLUSION: The PPV of incident strokes was 80% using our strategy of primary discharge diagnosis and excluding prior outpatient diagnoses of stroke. Although an unknown percentage of incident strokes are missed, this group of proven incident stroke patients can be used for etiologic studies of medication exposures.