Andrew McWilliams

Effect of Intensive Versus Standard Clinic-Based Hypertension Management on Ambulatory Blood Pressure: Results From the SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory Blood Pressure Study.

The effect of clinic-based intensive hypertension treatment on ambulatory blood pressure (BP) is unknown. The goal of the SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory BP ancillary study was to evaluate the effect of intensive versus standard clinic-based BP targets on ambulatory BP. Ambulatory BP was obtained within 3 weeks of the 27-month study visit in 897 SPRINT participants. Intensive treatment resulted in lower clinic systolic BP (mean difference between groups=16.0 mm Hg; 95% confidence interval, 14.1–17.8 mm Hg), nighttime systolic BP (mean difference=9.6 mm Hg; 95% confidence interval, 7.7–11.5 mm Hg), daytime systolic BP (mean difference=12.3 mm Hg; 95% confidence interval, 10.6–13.9 mm Hg), and 24-hour systolic BP (mean difference=11.2 mm Hg; 95% confidence interval, 9.7–12.8 mm Hg). The night/day systolic BP ratio was similar between the intensive (0.92±0.09) and standard-treatment groups (0.91±0.09). There was considerable lack of agreement within participants between clinic systolic BP and daytime ambulatory systolic BP with wide limits of agreement on Bland–Altman plots. In conclusion, targeting a systolic BP of <120 mm Hg, when compared with <140 mm Hg, resulted in lower nighttime, daytime, and 24-hour systolic BP, but did not change the night/day systolic BP ratio. Ambulatory BP monitoring may be required to assess the effect of targeted hypertension therapy on out of office BP. Further studies are needed to assess whether targeting hypertension therapy based on ambulatory BP improves clinical outcomes. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835249.

Electrocardiography-inclusive screening strategies for detection of cardiovascular abnormalities in high school athletes

BACKGROUND The best protocol for cardiovascular preparticipation screening (PPS) in young athletes is uncertain. OBJECTIVE The purpose of this study was to determine the value of integrating electrocardiographic (ECG) testing with standard history and physical examination during PPS to identify potentially serious cardiovascular abnormalities in young athletes. METHODS A total of 2017 high school athletes seeking clearance for competitive sports were prospectively evaluated using a standardized history and physical examination, 12-lead ECG, and two-dimensional echocardiogram (echo). Primary outcome measures included the identification of cardiac disorders associated with sudden cardiac death. Secondary outcome measures included identification of abnormal, but nonlethal, cardiac conditions that required medical follow-up. RESULTS Of these athletes, 14.7% had an abnormal history or physical examination and 3.1% had an abnormal ECG based on modern ECG interpretation criteria. Five primary outcomes (1 hypertrophic cardiomyopathy, 4 Wolff-Parkinson-White syndrome) and four secondary outcomes were identified. History and physical examination detected 40% of primary and 50% of secondary abnormalities. ECG detected all five primary abnormalities but none of the secondary abnormalities. Echo was abnormal in 1.2% and detected one primary and four secondary abnormalities. The false-positive rates for primary and secondary outcomes for history and physical examination and ECG were 14.5% and 2.8%, respectively. CONCLUSION ECG adds value to PPS through increased detection of arrhythmogenic and structural cardiovascular conditions associated with sudden cardiac death. Use of modern ECG interpretation standards allows a low false-positive rate. Routine echo may detect other clinically important cardiac abnormalities, but its role in PPS remains uncertain.

Obesity and asthma: Pathophysiology and implications for diagnosis and management in primary care

The effects of obesity on asthma diagnosis, control, and exacerbation severity are increasingly recognized; however, the underlying pathophysiology of this association is poorly understood. Mainstream clinical practice has yet to adopt aggressive management of obesity as a modifiable risk factor in asthma care, as is the case with a risk factor like tobacco or allergen exposure. This review summarizes existing data that support the pathophysiologic mechanisms underlying the association between obesity and asthma, as well as the current and future state of treatment for the obese patient with asthma. Our review suggests that evidence of chronic inflammatory response linking obesity and asthma indicates a need to address obesity during asthma management, possibly using patient-centered approaches such as shared decision making. There is a need for research to better understand the mechanisms of asthma in the obese patient and to develop new therapies specifically targeted to this unique patient population.

Planning for Action: The Impact of an Asthma Action Plan Decision Support Tool Integrated into an Electronic Health Record (EHR) at a Large Health Care System

Introduction: Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes and high costs. Asthma action plans assist patients with self-management, but provider compliance with this recommendation is limited in part because of guideline complexity. This project aimed to embed an electronic asthma action plan decision support tool (eAAP) into the medical record to streamline evidence-based guidelines for providers at the point of care, create individualized patient handouts, and evaluate effects on disease outcomes. Methods: eAAP development occurred in 4 phases: web-based prototype creation, multidisciplinary team engagement, pilot, and system-wide dissemination. Medical record and hospital billing data compared frequencies of asthma exacerbations before and after eAAP receipt with matched controls. Results: Between December 2012 and September 2014, 5174 patients with asthma (∼10%) received eAAPs. Results showed an association between eAAP receipt and significant reductions in pediatric asthma exacerbations, including 33% lower odds of requiring oral steroids (P < .001), compared with controls. Equivalent adult measures were not statistically significant. Conclusions: This study supports existing evidence that patient self-management plays an important role in reducing asthma exacerbations. We show the feasibility of leveraging technology to provide guideline-based decision support through an eAAP, addressing known challenges of implementation into routine practice.

Effect of combined patient decision aid and patient navigation vs usual care for colorectal cancer screening in a vulnerable patient population: A randomized clinical trial

Importance Colorectal cancer (CRC) screening is underused, especially among vulnerable populations. Decision aids and patient navigation are potentially complementary interventions for improving CRC screening rates, but their combined effect on screening completion is unknown. Objective To determine the combined effect of a CRC screening decision aid and patient navigation compared with usual care on CRC screening completion. Design, Setting, and Participants In this randomized clinical trial, data were collected from January 2014 to March 2016 at 2 community health center practices, 1 in North Carolina and 1 in New Mexico, serving vulnerable populations. Patients ages 50 to 75 years who had average CRC risk, spoke English or Spanish, were not current with recommended CRC screening, and were attending primary care visits were recruited and randomized 1:1 to intervention or control arms. Interventions Intervention participants viewed a CRC screening decision aid in English or Spanish immediately before their clinician encounter. The decision aid promoted screening and presented colonoscopy and fecal occult blood testing as screening options. After the clinician encounter, intervention patients received support for screening completion from a bilingual patient navigator. Control participants viewed a food safety video before the encounter and otherwise received usual care. Main Outcomes and Measures The primary outcome was CRC screening completion within 6 months of the index study visit assessed by blinded medical record review. Results Characteristics of the 265 participants were as follows: their mean age was 58 years; 173 (65%) were female, 164 (62%) were Latino; 40 (15%) were white non-Latino; 61 (23%) were black or of mixed race; 191 (78%) had a household income of less than

Colorectal Cancer Screening in Vulnerable Patients: Promoting Informed and Shared Decisions.

20 000; 101 (38%) had low literacy; 75 (28%) were on Medicaid; and 91 (34%) were uninsured. Intervention participants were more likely to complete CRC screening within 6 months (68% vs 27%); adjusted-difference, 40 percentage points (95% CI, 29-51 percentage points). The intervention was more effective in women than in men (50 vs 21 percentage point increase, interaction P = .02). No effect modification was observed across other subgroups. Conclusions and Relevance A patient decision aid plus patient navigation increased the rate of CRC screening completion in compared with usual care invulnerable primary care patients. Trial Registration clinicaltrials.gov Identifier: NCT02054598

Effect of Intensive Versus Standard Clinic-Based Hypertension Management on Ambulatory Blood Pressure

INTRODUCTION Low-income, low-literacy, limited English-proficient populations have low colorectal cancer (CRC) screening rates and experience poor patient-provider communication and decision-making processes around screening. The purpose of this study was to test the effect of a CRC screening decision aid on screening-related communication and decision making in primary care visits. STUDY DESIGN RCT with data collected from patients at baseline and immediately after the provider encounter. SETTING/PARTICIPANTS Patients aged 50-75 years, due for CRC screening, were recruited from two safety net clinics in North Carolina and New Mexico (data collection, January 2014-September 2015; analysis, 2015). INTERVENTION Participants viewed a CRC screening decision aid or a food safety (control) video immediately before their provider encounter. MAIN OUTCOME MEASURES CRC screening-related knowledge, discussion, intent, test preferences, and test ordering. RESULTS The study population (N=262) had a mean age of 58.3 years and was 66% female, 61% Latino, 17% non-Latino black, and 16% non-Latino white. Among Latino participants, 71% preferred Spanish. Compared with controls, intervention participants had greater screening-related knowledge (on average 4.6 vs 2.8 of six knowledge items correct, adjusted difference [AD]=1.8, 95% CI=1.5, 2.1) and were more likely to report screening discussion (71.0% vs 45.0%, AD=26.1%, 95% CI=14.3%, 38.0%) and high screening intent (93.1% vs 84.7%, AD=9.0%, 95% CI=2.0%, 16.0%). Intervention participants were more likely to indicate a specific screening test preference (93.1% vs 68.0%, AD=26.5%, 95% CI=17.2%, 35.8%) and to report having a test ordered (56.5% vs 32.1%, AD=25.8%, 95% CI=14.4%, 37.2%). CONCLUSIONS Viewing a CRC screening decision aid before a primary care encounter improves knowledge and shared decision making around screening in a racially, ethnically, and linguistically diverse safety net clinic population. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02054598.

Patient Engagement and Informed Decision Making Regarding Medical Imaging

The effect of clinic-based intensive hypertension treatment on ambulatory blood pressure (BP) is unknown. The goal of the SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory BP ancillary study was to evaluate the effect of intensive versus standard clinic-based BP targets on ambulatory BP. Ambulatory BP was obtained within 3 weeks of the 27-month study visit in 897 SPRINT participants. Intensive treatment resulted in lower clinic systolic BP (mean difference between groups=16.0 mm Hg; 95% confidence interval, 14.1–17.8 mm Hg), nighttime systolic BP (mean difference=9.6 mm Hg; 95% confidence interval, 7.7–11.5 mm Hg), daytime systolic BP (mean difference=12.3 mm Hg; 95% confidence interval, 10.6–13.9 mm Hg), and 24-hour systolic BP (mean difference=11.2 mm Hg; 95% confidence interval, 9.7–12.8 mm Hg). The night/day systolic BP ratio was similar between the intensive (0.92±0.09) and standard-treatment groups (0.91±0.09). There was considerable lack of agreement within participants between clinic systolic BP and daytime ambulatory systolic BP with wide limits of agreement on Bland–Altman plots. In conclusion, targeting a systolic BP of <120 mm Hg, when compared with <140 mm Hg, resulted in lower nighttime, daytime, and 24-hour systolic BP, but did not change the night/day systolic BP ratio. Ambulatory BP monitoring may be required to assess the effect of targeted hypertension therapy on out of office BP. Further studies are needed to assess whether targeting hypertension therapy based on ambulatory BP improves clinical outcomes. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835249.

Using CBPR to Decrease Health Disparities in a Suburban Latino Neighborhood

Misuse and overuse of medical imaging have gained widespread attention due to rising costs, radiation exposure risks, and limited comparative effectiveness evidence. Involving patients in shared decision making offers an opportunity to more clearly define risks and benefits, thus allowing patients to consider both personal values and the best available evidence.

A Multidisciplinary Intervention Utilizing Virtual Communication Tools to Reduce Health Disparities: A Pilot Randomized Controlled Trial

Introduction: This project tested the feasibility of using a community-based participatory research (CBPR) approach to deliver health and social resources in two high-risk, suburban neighborhoods. Method: An established research network was used to engage stakeholders to design and deliver a neighborhood-based intervention targeting a Latino immigrant population. The intervention provided screenings for hypertension, diabetes, and depression; primary care provider visits; and information about navigating health care delivery systems and related community-based resources. Participants (N = 216) were consented for participation and their subsequent use of health and social services were measured at baseline and 1 year post intervention. Results: At baseline, 5.1% of participants had health insurance, 16.7% had a primary care provider, and 38.4% had a chronic illness. SF-12 scores showed a majority of participants with low perceived health status (56%) and high risk for clinical depression (33%). Self-reported use of primary care services increased from 33.8% at baseline to 48% 1 year after the intervention, and 62% reported use of social services. Conclusion: Neighborhood-based interventions informed by a CBPR approach are effective in both identifying community members who lack access to health care–related services and connecting them into needed primary care and social services.