David S. Kountz

Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension.

Clinical Practice Guidelines for the Management of Hypertension in the Community A Statement by the American Society of Hypertension and the International Society of Hypertension

Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.

Michael A. Weber, MD; Ernesto L. Schiffrin, MD; William B. White, MD; Samuel Mann, MD; Lars H. Lindholm, MD; John G. Kenerson, MD; John M. Flack, MD; Barry L. Carter, Pharm D; Barry J. Materson, MD; C. Venkata S. Ram, MD; Debbie L. Cohen, MD; Jean-Claude Cadet, MD; Roger R. Jean-Charles, MD; Sandra Taler, MD; David Kountz, MD; Raymond R. Townsend, MD; John Chalmers, MD; Agustin J. Ramirez, MD; George L. Bakris, MD; Jiguang Wang, MD; Aletta E. Schutte, MD; John D. Bisognano, MD; Rhian M. Touyz, MD; Dominic Sica, MD; Stephen B. Harrap, MD

Clinical Practice Guidelines for the Management of Hypertension in the Community

Michael A. Weber, MD; Ernesto L. Schiffrin, MD; William B. White, MD; Samuel Mann, MD; Lars H. Lindholm, MD; John G. Kenerson, MD; John M. Flack, MD; Barry L. Carter, Pharm D; Barry J. Materson, MD; C. Venkata S. Ram, MD; Debbie L. Cohen, MD; Jean-Claude Cadet, MD; Roger R. Jean-Charles, MD; Sandra Taler, MD; David Kountz, MD; Raymond R. Townsend, MD; John Chalmers, MD; Agustin J. Ramirez, MD; George L. Bakris, MD; Jiguang Wang, MD; Aletta E. Schutte, MD; John D. Bisognano, MD; Rhian M. Touyz, MD; Dominic Sica, MD; Stephen B. Harrap, MD

ORIGINAL RESEARCH—EDUCATION: Sexual Communication Skills in Residency Training: The Robert Wood Johnson Model

Few medical schools or residency programs offer adequate training in sexual medicine. Using the experience gained in our long-standing program in human sexuality for medical students, we have pilot tested a half-day intensive workshop curriculum for residents that focuses on sexual communication skills and management of sexual problems. Unlike our medical school program, this residency course was offered on an elective, one-day basis. The current report describes the successful implementation of our pilot program with 46 medical residents from subspecialty and primary care residency programs. Before the workshop, 22 (48%) residents indicated that they were uncomfortable with open discussion of sexual issues and would not feel comfortable in addressing the topic with their patients. A number of factors were identified as barriers to communication, including lack of time, inadequate training, and personal discomfort. After the workshop, the participants rated themselves as more comfortable with the topic and as more likely to address sexual issues with their patients. The participants evaluated the workshop positively overall and responded well to the interactive format and audience-response components. Most of the participants showed interest and willingness to participate in further training in sexual medicine skills. Our program offers a model for training of residents in communication skills and management of sexual problems. The difficulties in implementation and overcoming institutional barriers to curriculum reform are addressed.

Investing time in health: do socioeconomically disadvantaged patients spend more or less extra time on diabetes self‐care?

BACKGROUND Research on self-care for chronic disease has not examined time requirements. Translating Research into Action for Diabetes (TRIAD), a multi-site study of managed care patients with diabetes, is among the first to assess self-care time. OBJECTIVE To examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes. DATA Eleven thousand nine hundred and twenty-seven patient surveys from 2000 to 2001. METHODS Bayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics. RESULTS Proportions of patients spending no extra time on foot care, shopping/cooking, and exercise were, respectively, 37, 52, and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about 3 min more per day. DISCUSSION Extra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.

The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study.

Objective:We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care. Research Design and Methods:Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry. Results:Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with <10% of black participants enrolled in provider groups in the highest-intensity quintile for physician feedback and <10% of both black and Asian/Pacific Islander participants enrolled in groups in the highest-intensity quintile for diabetes registry use. Although disparities in care were confirmed, particularly for black relative to white subjects, we did not find a consistent pattern of disparity attenuation with increasing implementation intensity for either processes of care or medication management of intermediate outcomes. Conclusions:For the most part, high-intensity implementation of a diabetes registry, physician feedback, or physician reminders, 3 clinical care strategies similar to those used in many health care settings, are not associated with attenuation of known disparities of diabetes care in managed care.

Hypertension in ethnic populations: tailoring treatments.

The Hispanic population in the United States comprises different and distinct cultures and genetic backgrounds. Most of the data on hypertension in this community are specific to Mexican Americans, in whom studies consistently show a lower prevalence of the disease compared with non-Hispanic whites and blacks. Mexican Americans have lower levels of awareness of hypertension, and fewer of them demonstrate adequate control of blood pressure compared with whites and blacks. Mexican Americans have a higher prevalence of cardiovascular risk factors other than hypertension, such as hypercholesterolemia, altered glucose metabolism, type 2 diabetes mellitus, and obesity (the metabolic syndrome), compared with whites and blacks. Hispanic Americans of Caribbean descent have a prevalence of hypertension similar to that in the black community. The reasons for the lack of awareness of hypertension in the Hispanic community and for the low rates of control with antihypertensive drugs are discussed.

Hypertension in african americans aged 60 to 79 years: statement from the international society of hypertension in blacks.

A 2014 hypertension guideline raised goal systolic blood pressure (SBP) from <140 mm Hg to <150 mm Hg for adults 60 years and older without diabetes mellitus (DM) or chronic kidney disease (CKD). The authors aimed to define the status of hypertension in black adults 60 to 79 years from the National Health and Nutrition Examination Survey 2005–2012 and provide practical guidance. Black patients were more often aware and treated (P≤.005) for hypertension than whites and had higher rates of DM/CKD (P<.001), similar control to <140/<90 mm Hg with DM/CKD (P=.59), and lower control without DM/CKD (<140/<90 mm Hg and <150/<90 mm Hg, P≤.01). Limited awareness (<30%) and infrequent health care (>30% 0–1 health‐care visits per year) occurred in untreated black and white hypertensive patients without DM/CKD and BP ≥140/<90 mm Hg. The literature suggests benefits of treated SBP <140 mm Hg in adults 60 to 79 years without DM/CKD. The International Society of Hypertension in Blacks recommends: (1) continuing efforts to achieve BP <140/<90 mm Hg in those with DM/CK, and (2) identifying hypertensive patients without DM/CKD and BP ≥140/<90 mm Hg and treat to an SBP <140 mm Hg in black adults 60–79 years.

The Dipeptidyl Peptidase (DPP)-4 Inhibitors for Type 2 Diabetes Mellitus in Challenging Patient Groups

Treating hyperglycemia is a critical aspect of managing type 2 diabetes mellitus (T2DM), but can be especially challenging in patients from vulnerable groups such as those with chronic kidney disease, African Americans, and older people. The dipeptidyl peptidase (DPP)-4 inhibitors are relatively new oral antidiabetes drugs that have been incorporated into treatment algorithms over the past few years and have also been studied in these vulnerable patients. Clinical trials with DPP-4 inhibitors have now been reported for all these patient groups and have demonstrated significant improvements in measures of hyperglycemia, with a good safety profile. Based on the current evidence, it appears that the DPP-4 inhibitors are worthy of consideration not only for the most straightforward patients with T2DM, but also for these vulnerable patients.

Management of Cardiovascular Disease by Primary Care Physicians in France: Lessons from the Seine

The paper by Schuster and colleagues 1 in this issue of the Journal raises provocative questions. ‘‘The French Paradox’’—so named because of the surprisingly low rate of cardiovascular disease in France compared with other European countries and the United States, and thought due to red wine consumption or other factors—has been the focus of almost endless debate. What this survey suggests are other variables that US physicians, insurers, and health systems should consider. A picture emerges of French physicians spending more time with patients, relying more regularly on electronic health records (EHRs), using evidenced-based guidelines, and, based on questions pertaining to levels of frustration, having more ‘‘fun’’ in the practice of medicine. Clearly much—if not all—of this is directed by the state-run health system. Should we be surprised that there may be a connection between time spent with patients, use of EHRs, and improved outcomes? Physicians would say, ‘‘hardly.’’ More interesting is greater reliance on lifestyle ⁄counseling and less on medication, despite no added expense to patients. This may validate many study findings, such as those of the Diabetes Prevention Program, which found that lifestyle changes were more effective than medication to reduce the future risk of diabetes. Another interesting observation by the authors is that French physicians probably engage in a more intense interaction with their patients related to cardiovascular disease risk factors. Is this related to having more time with patients, or something else? Perhaps French physicians have longer, more established patient relationships and are more comfortable with intense interactions. Thus, the provocative questions include: do we over-rely on medication vs lifestyle counseling, will our investment in EHRs not only reduce waste (overutilization) but also improve outcomes, and is there a link between physician satisfaction and patient outcomes? As the authors state, this is one of those studies that may raise more questions than answers. Finally, let’s assume, even with limitations, that these findings are true. What can we expect with health care reform and the issues raised by Schuster and his associates? Sadly, given the great imbalance in supply vs demand of primary care physicians and millions of patients who will enter the health care system with some form of insurance, our ability to increase time with lifestyle counseling will not only decrease but will be further constrained. Physician satisfaction is already low and, with reimbursement changes, are likely to further drop. There are incentives to more widely use EHRs. Taken From Medical and Academic Affairs, Jersey Shore University Medical Center, Neptune, NJ; and Vice-President of the International Society on Hypertension in Blacks Address for correspondence: David S. Kountz, MD, MBA, Medical and Academic Affairs, Jersey Shore University Medical Center, 1945 Rt. 33, Neptune, NJ 07754 E-mail: kdountz@meridianhealth.com Manuscript received September 29, 2010; revised October 15, 2010; accepted October 15, 2010