Nancy Pandhi

Undiagnosed hypertension among young adults with regular primary care use.

Objective: Young adults meeting hypertension diagnostic criteria have a lower prevalence of a hypertension diagnosis than middle-aged and older adults. The purpose of this study was to compare the rates of a new hypertension diagnosis for different age groups and identify predictors of delays in the initial diagnosis among young adults who regularly use primary care. Methods: A 4-year retrospective analysis included 14 970 patients, at least 18 years old, who met clinical criteria for an initial hypertension diagnosis in a large, Midwestern, academic practice from 2008 to 2011. Patients with a previous hypertension diagnosis or prior antihypertensive medication prescription were excluded. The probability of diagnosis at specific time points was estimated by Kaplan–Meier analysis. Cox proportional hazard models (hazard ratio; 95% confidence interval) were fit to identify predictors of delays to an initial diagnosis, with a subsequent subset analysis for young adults (18–39 years old). Results: After 4 years, 56% of 18–24-year-olds received a diagnosis compared with 62% (25–31-year-olds), 68% (32–39-year-olds), and more than 70% (≥40-year-olds). After adjustment, 18–31-year-olds had a 33% slower rate of receiving a diagnosis (18–24 years hazard ratio 0.66, 0.53–0.83; 25–31 years hazard ratio 0.68, 0.58–0.79) compared with adults at least 60 years. Other predictors of a slower diagnosis rate among young adults were current tobacco use, white ethnicity, and non-English primary language. Young adults with diabetes, higher blood pressures, or a female provider had a faster diagnosis rate. Conclusion: Provider and patient factors are critical determinants of poor hypertension diagnosis rates among young adults with regular primary care use.

The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs.

OBJECTIVES: To examine 1‐year mortality and healthcare payments of stroke patients experiencing zero, one and two or more bounce‐backs within 30 days of discharge.

Bouncing-Back: Rehospitalization in Patients with Complicated Transitions in the First Thirty Days After Hospital Discharge for Acute Stroke

SUMMARY Background: “Bounce-backs” (movements from a less intensive to a more intensive care setting) soon after hospital discharge are common, but reasons for bouncing-back remain unknown. Objective: To examine how the primary diagnosis for first rehospitalization relates to thirty-day bounce-back number and initial discharge destination in acute stroke. Population: Administrative data from 5,250 Medicare beneficiaries > 65 years discharged with acute ischemic stroke in 1998–2000 to a rehabilitation center, skilled nursing facility or home with home health care and with at least one thirty day rehospitalization. Analysis: Probability of thirty-day bounce-back was calculated using multivariate models. Results: Infections and aspiration pneumonitis were the most common reasons for rehospitalization, regardless of initial discharge site. Conclusions: Efforts addressing aspirations and infections, the preventable complications of immobility, will be critical in decreasing acute stroke bounce-backs.

Impact of rheumatoid arthritis on receiving a diagnosis of hypertension among patients with regular primary care.

Despite numerous studies reporting increased cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA), the impact of RA on managing modifiable CVD risk factors remains understudied. We tested the hypothesis that RA is a risk factor for not receiving a hypertension diagnosis.

Preventive service gains from first contact access in the primary care home.

Background:The patient-centered medical home (PCMH) concept recently has garnered national attention as a means of improving the quality of primary care. Preventive services are one area in which the use of a PCMH is hoped to achieve gains, though there has been limited exploration of PCMH characteristics that can assist with practice redesign. The purpose of this study was to examine whether first-contact access characteristics of a medical home (eg, availability of appointments or advice by telephone) confer additional benefit in the receipt of preventive services for individuals who already have a longitudinal relationship with a primary care physician at a site of care. Methods:This was a secondary analysis examining data from 5507 insured adults with a usual physician who participated in the 2003 to 2006 round of the Wisconsin Longitudinal Study. Using logistic regression, we calculated the odds of receiving each preventive service, comparing individuals who had first-contact access with those without first-contact access. Results:Eighteen percent of the sample received care with first-contact access. In multivariable analyses, after adjustment, individuals who had first-contact access had higher odds of having received a prostate examination (odds ratio [OR], 1.62; 95% CI, 1.20–2.18), a flu shot (OR, 1.36; 95% CI, 1.01–1.82), and a cholesterol test (OR, 1.36; 95% CI, 1.01–1.82) during the past year. There was no significant difference in receipt of mammograms (OR, 1.23; 95% CI, 0.94–1.61). Conclusions:In the primary care home, first-contact accessibility adds benefit, beyond continuity of care with a physician, in improving receipt of preventive services. Amid increasing primary care demands and finite resources available to translate the PCMH into clinic settings, there is a need for further studies of the interplay between specific PCMH principles and how they perform in practice.

Monitoring diabetes in patients with and without rheumatoid arthritis: a Medicare study

IntroductionDiabetes mellitus is a key predictor of mortality in rheumatoid arthritis (RA) patients. Both RA and diabetes increase the risk of cardiovascular disease (CVD), yet understanding of how comorbid RA impacts the receipt of guideline-based diabetes care is limited. The purpose of this study was to examine how the presence of RA affected hemoglobin A1C (A1c) and lipid measurement in older adults with diabetes.MethodsUsing a retrospective cohort approach, we identified beneficiaries ≥65 years old with diabetes from a 5% random national sample of 2004 to 2005 Medicare patients (N = 256,331), then examined whether these patients had comorbid RA and whether they received guideline recommended A1c and lipid testing in 2006. Multivariate logistic regression was used to examine the effect of RA on receiving guideline recommended testing, adjusting for baseline sociodemographics, comorbidities and health care utilization.ResultsTwo percent of diabetes patients had comorbid RA (N = 5,572). Diabetes patients with comorbid RA were more likely than those without RA to have baseline cardiovascular disease (such as 17% more congestive heart failure), diabetes-related complications including kidney disease (19% higher), lower extremity ulcers (77% higher) and peripheral vascular disease (32% higher). In adjusted models, diabetes patients with RA were less likely to receive recommended A1c testing (odds ratio (OR) 0.84, CI 0.80 to 0.89) than those without RA, but were slightly more likely to receive lipid testing (OR 1.08, CI 1.01 to 1.16).ConclusionsIn older adults with diabetes, the presence of comorbid RA predicted lower rates of A1c testing but slightly improved lipid testing. Future research should examine strategies to improve A1c testing in patients with diabetes and RA, in light of increased CVD and microvascular risks in patients with both conditions.

The relationship of individual comorbid chronic conditions to diabetes care quality

Objective Multimorbidity affects 26 million persons with diabetes, and care for comorbid chronic conditions may impact diabetes care quality. The aim of this study was to determine which chronic conditions were related to lack of achievement or achievement of diabetes care quality goals to determine potential targets for future interventions. Research design and methods This is an exploratory retrospective analysis of electronic health record data for 23 430 adults, aged 18–75, with diabetes who were seen at seven Midwestern US health systems. The main outcome measures were achievement of six diabetes quality metrics in the reporting year, 2011 (glycated haemoglobin (HbA1c) control and testing, low-density lipoprotein control and testing, blood pressure control, kidney testing). Explanatory variables were 62 chronic condition indicators. Analyses were adjusted for baseline patient sociodemographic and healthcare utilization factors. Results The 62 chronic conditions varied in their relationships to diabetes care goal achievement for specific care goals. Congestive heart failure was related to lack of achievement of cholesterol management goals. Obesity was related to lack of HbA1c and BP control. Mental health conditions were related to both lack of achievement and achievement of different care goals. Three conditions were related to lack of cholesterol testing, including congestive heart failure and substance-use disorders. Of 17 conditions related to achieving control goals, 16 were related to achieving HbA1c control. One-half of the comorbid conditions did not predict diabetes care quality. Conclusions Future interventions could target patients at risk for not achieving diabetes care for specific care goals based on their individual comorbidities.

Discharge Destination's Effect on Bounce-Back Risk in Black, White, and Hispanic Acute Ischemic Stroke Patients

OBJECTIVE To determine whether racial and ethnic effects on bounce-back risk (ie, movement to settings of higher care intensity within 30 d of hospital discharge) in acute stroke patients vary depending on initial posthospital discharge destination. DESIGN Retrospective analysis of administrative data. SETTING Four hundred twenty-two hospitals, southern/eastern United States. PARTICIPANTS All Medicare beneficiaries 65 years or more with hospitalization for acute ischemic stroke within one of the 422 target hospitals during the years 1999 or 2000 (N=63,679). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Adjusted predicted probabilities for discharge to and for bouncing back from each initial discharge site (ie, home, home with home health care, skilled nursing facility [SNF], or rehabilitation center) by race (ie, black, white, and Hispanic). Models included sociodemographics, comorbidities, stroke severity, and length of stay. RESULTS Blacks and Hispanics were significantly more likely to be discharged to home health care (blacks=21% [95% confidence interval (CI), 19.9-22.8], Hispanic=19% [17.1-21.7] vs whites=16% [15.5-16.8]) and less likely to be discharged to SNFs (blacks=26% [95% CI, 23.6-29.3], Hispanics=28% [25.4-31.6] vs whites=33% [31.8-35.1]) than whites. However, blacks and Hispanics were significantly more likely to bounce back when discharged to SNFs than whites (blacks=26% [95% CI, 24.2-28.6], Hispanics=28% [24-32.6] vs whites=21% [20.3-21.9]). Hispanics had a lower risk of bouncing back when discharged home than either blacks or whites (Hispanics=14% [95% CI, 11.3-17] vs blacks=20% [18.4-22.2], whites=18% [16.8-18.3]). Patients discharged to home health care or rehabilitation centers demonstrated no significant differences in bounce-back risk. CONCLUSIONS Racial/ethnic bounce-back risk differs depending on initial discharge destination. Additional research is needed to fully understand this variation in effect.

Association of anxiety and depression with hypertension control: a US multidisciplinary group practice observational study.

Objective: The presence of a mental health disorder with hypertension is associated with higher cardiovascular disease mortality than hypertension alone. Although earlier detection of hypertension has been demonstrated in patients with anxiety and depression, the relationship of mental health disorders to hypertension control is unknown. Our objective was to evaluate rates and predictors of incident hypertension control among patients with anxiety and/or depression compared with patients without either mental health diagnosis. Methods: A 4-year retrospective analysis included 4362 patients, at least 18 years old, who received primary care in a large academic group practice from 2008 to 2011. Patients met The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure criteria and had a hypertension diagnosis. Kaplan–Meier analysis estimated the probability of achieving control for patients with and without anxiety and/or depression. Cox proportional hazard models were fit to identify predictors of time to control. Results: Overall, 13% (n = 573) had a baseline diagnosis of anxiety and/or depression. Those with anxiety and/or depression demonstrated more primary care and specialty visits than those without either condition. After adjustment, patients with anxiety and/or depression had faster rates of hypertension control (hazard ratio [HR] 1.22; 1.07–1.39] than patients without either diagnosis. Other associations of faster hypertension control included female gender (HR 1.32; 1.20–1.44), absence of tobacco use (HR 1.17; 1.03–1.33), Medicaid use (HR 1.27; 1.09–1.49), and a higher Adjusted Clinical Group Risk Score (HR 1.13; 1.10–1.17), a measure of healthcare utilization. Conclusion: Greater healthcare utilization among patients with anxiety and/or depression may contribute to faster hypertension control.

Implementation Science Workshop: Engaging Patients in Team-Based Practice Redesign — Critical Reflections on Program Design

Center for Patient Partnerships, University of Wisconsin, Madison, WI, USA; University of Wisconsin Law School, Madison, WI, USA; University of Wisconsin Medical Foundation, Madison, WI, USA; Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital, Boston, MA, USA.