Cheryl R. Dennison

The Health-Related Quality of Life and Economic Burden of Constipation

Constipation is a prevalent condition that disproportionately affects women and older adults and leads to self-medication and/or medical consultation. It occurs as a result of functional idiopathic causes or secondarily as a result of a variety of factors including dietary and exercise patterns, adverse effects of medication and disease processes. Constipation is often perceived to be a benign, easily treated condition with short-term treatment being relatively straightforward; however, chronic constipation is associated with mild complications that, left untreated, can develop into more serious bowel complaints (faecal impaction, incontinence and bowel perforations) with further implications for healthcare costs and the patient’s health-related quality of life (HR-QOL). This review summarises the evidence of the HR-QOL impact and economic burden of constipation on patients.Relatively few studies have systematically explored the HR-QOL and economic impact of constipation; however, the existing evidence suggests that HR-QOL is lower in patients with constipation than in non-constipated individuals, and treatments for constipation improve HR-QOL. Additionally, constipation represents an economic burden for the patient and healthcare provider. Resource utilisation associated with the diagnosis and management of constipation is a significant cost driver, whereas constipation prevention programmes have demonstrated cost savings.

Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months*

BACKGROUND African American men with hypertension in low socioeconomic urban populations achieve poor rates of hypertension control and suffer early from its complications. METHODS In a randomized clinical trial with 309 hypertensive urban African American men aged 21 to 54 years, we evaluated the effectiveness of a more intensive comprehensive educational-behavioral-pharmacologic intervention by a nurse practitioner-community health worker-physician (NP/CHW/MD) team and a less intensive education and referral intervention in controlling blood pressure (BP) and minimizing progression of left ventricular hypertrophy (LVH) and renal insufficiency. Changes in BP, left ventricular mass (LVM), and serum creatinine from baseline to 36 months were compared between groups. RESULTS At 36 months, the mean systolic BP/diastolic BP change from baseline was -7.5/-10.1 mm Hg for the more intensive group and +3.4/-3.7 mm Hg for the less intensive group (P =.001 and.005 for between-group differences in systolic BP and diastolic BP, respectively). The proportion of men with controlled BP (<140/90 mm Hg) was 44% in the more intensive group and 31% in the less intensive group (P =.045). The LVM was significantly lower in the more intensive group than in the less intensive group (more intensive, 274 g; less intensive, 311 g; P =.004). There was a trend toward slowing of the progression of renal insufficiency (incidence of 50% increase in serum creatinine) in the more intensive group compared to the less intensive group (more intensive, 5.2%; less intensive, 8.0%; P =.08). CONCLUSIONS During 36 months, the more intensive intervention led to a lower BP and decreased progression of LVH in a sample of hypertensive young African American men.

Barriers to hypertension care and control in young urban black men.

Barriers to high blood pressure (HBP) care and control have been reported in the literature for > 30 years. Few reports on barriers, however, have focused on the young black man with HBP, the age/sex/race group with the highest rates of early severe and complicated HBP and the lowest rates of awareness, treatment, and control. In a randomized clinical trial of comprehensive care for hypertensive young urban black men, factors potentially associated with care and control were assessed at baseline for the 309 enrolled men. A majority of the men encountered a variety of barriers including economic, social, and lifestyle obstacles to adequate BP care and control, including no current HBP care (49%), risk of alcoholism (62%), use of illicit drugs (45%), social isolation (47%), unemployment (40%), and lack of health insurance (51%). Having health insurance (odds ratio = 7.20, P = .00) and a negative urine drug screen (odds ratio = .56, P = .04) were significant predictors of being in HBP care. Low alcoholism risk and employment were identified as significant predictors of compliance with HBP medication-taking behavior. Men currently using illicit drugs were 2.64 times less likely to have controlled BP compared with their counterparts who did not use illicit drugs, and men currently taking HBP medication were 63 times more likely have controlled BP compared with men not taking HBP medication. Comprehensive interventions are needed to address socioeconomic and lifestyle issues as well as other barriers to care and treatment, if HBP care is to be salient and effective in this high risk group.

Adequate health literacy is associated with higher heart failure knowledge and self-care confidence in hospitalized patients.

Heart failure (HF) patients with inadequate health literacy are at increased risk for poor self-care and negative health outcomes such as hospital readmission. The purpose of the present study was to examine the prevalence of inadequate health literacy, the reliability of the Dutch HF Knowledge Scale (DHFKS) and the Self-care of Heart Failure Index (SCHFI), and the differences in HF knowledge, HF self-care, and 30-day readmission rate by health literacy level among patients hospitalized with HF. The convenience sample included adults (n = 95) admitted to a large, urban, teaching hospital whose primary diagnosis was HF. Measures included the Short Test of Functional Health Literacy in Adults, the DHFKS, the SCHFI, and readmission at 30 days after discharge. The sample was 59 ± 14 years in age, 51% male, and 67% African American; 35% had less than a high school education, 35% were employed, 73% lived with someone who helps with their HF care, and 16% were readmitted within 30 days of index admission. Health literacy was inadequate for 42%, marginal for 19%, and adequate for 39%. Reliability of the DHFKS and SCHFI scales was comparable to prior reports. Mean knowledge score was 11.43 ± 2.26; SCHFI subscale scores were 56.82 ± 17.12 for maintenance, 63.64 ± 18.29 for management, and 65.02 ± 16.34 for confidence. Those with adequate health literacy were younger and had higher education level, HF knowledge scores, and HF self-care confidence compared with those with marginal or inadequate health literacy. Self-care maintenance and management scores and 30-day readmission rate did not differ by health literacy level. These findings demonstrate the high prevalence of inadequate and marginal health literacy and that health literacy is an important consideration in promoting HF knowledge and confidence in self-care behaviors, particularly among older adults and those with less than a high school education.

Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure: systematic review.

Objective:This systematic review of recent randomized trials was conducted to determine if cardiovascular nursing interventions improve outcomes in patients with coronary artery disease (CAD) and/or heart failure. Methods:Randomized controlled trials of nursing interventions in patients with CAD or heart failure published from January 2000 to December 2008 were eligible. Pilot studies and trials with greater than 25% attrition with no intention-to-treat analyses were excluded. Study characteristics and results were extracted and trials were graded for methodological quality. Results:A total of 2,039 citations from electronic databases were identified; 55 articles were eligible for inclusion. The primary intervention strategy was education plus behavioral counseling and support (65% of interventions) using a combination of intervention modes. More than half of the trials (57%) reported statistically significant results in at least 1 outcome of blood pressure, lipids, physical activity, dietary intake, cigarette smoking, weight loss, healthcare utilization, mortality, quality of life, and psychosocial outcomes. However, there were no consistent relationships observed between intervention characteristics and the effects of interventions. The average measure of study quality was 2.8 (possible range, 0-4, with higher score equaling higher quality). Conclusion:Most trials reviewed demonstrated a beneficial impact of nursing interventions for secondary prevention in patients with CAD or heart failure. However, the optimal combination of intervention components, including strategy, mode of delivery, frequency, and duration, remains unknown. Establishing consensus regarding outcome measures, inclusion of adequate, representative samples, along with cost-effectiveness analyses will promote translation and adoption of cost-effective nursing interventions.

Patient and intensive care unit organizational factors associated with low tidal volume ventilation in acute lung injury.

Background:Barriers to evidence-based practice are not well understood. Within the intensive care unit (ICU) setting, low tidal volume ventilation (LTVV) in patients with acute lung injury (ALI) significantly decreases mortality. However, LTVV has not achieved widespread adoption. Objectives:To evaluate patient demographic and clinical factors, and ICU organizational factors associated with its use. Design, Setting and Patients:Prospective cohort study of 250 patients with ALI in 9 ICUs at 3 teaching hospitals in Baltimore, MD. Measurements:Use of LTVV the day after ALI onset and association of patients’ demographic and clinical factors and ICU organizational factors with LTVV using a multivariable logistic regression model adjusted for clustering of patients within ICUs. Results:On the day after ALI onset, 46% and 81% of patients received a tidal volume ≤6.5 and ≤8.5 mL/kg predicted body weight (PBW), respectively, with no significant changes at 3 and 5 days after ALI. Using a strict definition of LTVV (≤6.5 mL/kg PBW), no patient demographic factors were independently associated with LTVV; however, two patient clinical and ICU organizational factors (odds ratio, 95% confidence interval) were independently associated: serum HCO3 level (<22: .3, .1–.9, and >26: .6, .1–3.5, versus 22–26) and use of a written protocol for LTVV (6.0, 1.3 – 27.2). In a sensitivity analysis using tidal volume ≤8.5 mL/kg PBW, use of a written protocol remained significantly associated with LTVV. Conclusions:Patient demographic factors were not associated with LTVV. Given its strong association with LTVV, ICUs should use a written protocol for ventilation of ALI patients to help translate this evidence-based therapy into practice.

Strategies for Implementing and Sustaining Therapeutic Lifestyle Changes as Part of Hypertension Management in African Americans

Abstract African Americans with high blood pressure (BP) can benefit greatly from therapeutic lifestyle changes (TLC) such as diet modification, physical activity, and weight management. However, they and their health care providers face many barriers in modifying health behaviors. A multidisciplinary panel synthesized the scientific data on TLC in African Americans for efficacy in improving BP control, barriers to behavioral change, and strategies to overcome those barriers. Therapeutic lifestyle change interventions should emphasize patient self-management, supported by providers, family, and the community. Interventions should be tailored to an individuals cultural heritage, beliefs, and behavioral norms. Simultaneously targeting multiple factors that impede BP control will maximize the likelihood of success. The panel cited limited progress with integrating the Dietary Approaches to Stop Hypertension (DASH) eating plan into the African American diet as an example of the need for more strategically developed interventions. Culturally sensitive instruments to assess impact will help guide improved provision of TLC in special populations. The challenge of improving BP control in African Americans and delivery of hypertension care requires changes at the health system and public policy levels. At the patient level, culturally sensitive interventions that apply the strategies described and optimize community involvement will advance TLC in African Americans with high BP.

Intensive care unit hypoglycemia predicts depression during early recovery from acute lung injury

Objective:To evaluate the association between intensive care unit blood glucose levels and depression after acute lung injury. Design:Prospective cohort study. Setting:Twelve intensive care units in four hospitals in Baltimore, MD. Patients:Consecutive acute lung injury survivors (n = 104) monitored during 1717 intensive care unit patient-days and screened for depression at 3 months after acute lung injury. Interventions:None. Measurements and Main Results:The prevalence of a positive screening test for depression (Hospital Anxiety and Depression subscale score ≥8) at follow-up was 28%. After adjustment for confounders, patients with a mean daily minimum intensive care unit glucose level <100 mg/dL had significant increases in mean depression score (2.1 points, 95% confidence interval 0.6–3.7) and in the likelihood of a positive depression screening test (relative risk 2.6, 95% confidence interval 1.2–4.2). Patients with documented hypoglycemia <60 mg/dL during their intensive care unit stay also had greater symptoms of depression (2.0 points, 95% confidence interval 0.5–3.5; relative risk 3.6, 95% confidence interval 1.8–5.1). Other factors independently associated with a positive depression screening test included body mass index >40 kg/m2 (relative risk 3.3, 95% confidence interval 1.2–4.2), baseline depression/anxiety (relative risk 3.9, 95% confidence interval 1.5–6.5), and mean daily intensive care unit benzodiazepine dose >100 mg of midazolam-equivalent agent (relative risk 2.4, 95% confidence interval 1.1–3.8). Conclusions:Hypoglycemia in the intensive care unit is associated with an increased risk of positive screening for depression during early recovery from acute lung injury. Baseline depressive symptoms, morbid obesity, and intensive care unit benzodiazepine dose were also associated with postacute lung injury depressive symptoms. These findings warrant increased glucose monitoring for intensive care unit patients at risk for hypoglycemia and further research on how patient and intensive care unit management factors may contribute to postintensive care unit depression.

Patient-, provider-, and system-level barriers to heart failure care.

Background: The effectiveness of many heart failure (HF) treatments has been demonstrated, and national guidelines have been widely disseminated, yet HF care remains suboptimal. Numerous studies have examined barriers to HF care, but to date, there has been limited synthesis of these findings. Methods and Results: Sixty articles reporting data on barriers to HF care published between 1998 and 2007 met the criteria for inclusion in this review. Barriers to care were reported at the patient, provider, and system levels. Patient barriers were reported in 45 studies and were categorized in the main themes of knowledge, adherence, communication, functional limitations, comorbidities, psychosocial, and socioeconomic factors. Provider barriers were examined in 23 studies and included knowledge, diagnostic challenges, pharmacological concerns, communication issues, and personal factors. Barriers at the healthcare system level were reported in 13 studies and pertained to problems with organizational structure, communication, and lack of resources. Several barriers were interrelated and could not be exclusively categorized to a single level of care, with overlap also occurring within the main barrier themes. Conclusions: Barriers to HF care were common and pervasive throughout the continuum of care. To effectively improve the quality of care and outcomes among HF patients, obstacles to HF care must be addressed at multiple levels.

High prevalence of target organ damage in young, African American inner-city men with hypertension

Young, urban, African American men are at particularly high risk of hypertension and its cardiovascular complications. Left ventricular hypertrophy and renal dysfunction are manifestations of target organ damage from hypertension that predict adverse cardiovascular events. The subjects of this study were 309 African American men, age 18–54 years, with hypertension, residing in inner‐city Baltimore. Echocardiograms, electrocardiograms, serum creatinine, and the urinary albumin‐creatinine ratio were obtained to evaluate hypertensive target organ damage. Fifty‐three percent of the men reported use of antihypertensive medications, of whom 80% were on monotherapy. Calcium channel blockers were used most frequently. The mean echocardiographic left ventricular mass was 211±68 g, with a prevalence of echocardiographic left ventricular hypertrophy of 30%. There were 14 men (5%) with extremely high left ventricular mass, >350 grams. Left ventricular systolic dysfunction was seen in 9% of the men with uncontrolled hypertension, and none of the men with controlled hypertension (p=0.02). Renal dysfunction was found in 12% of the subjects, and microalbuminuria or gross proteinuria in 34%. The authors conclude that there is a high prevalence of cardiac and renal abnormalities in inner‐city African American men with hypertension, especially in men on antihypertensive therapy with uncontrolled hypertension. It is imperative that cost‐effective medications and culturally acceptable health care delivery programs be developed, tested, and integrated into health systems, with strategies specifically relevant to this high‐risk population, to decrease the largely preventable morbidity and mortality associated with hypertension.