Paul L. Hebert

Barriers to Buying Healthy Foods for People With Diabetes: Evidence of Environmental Disparities

OBJECTIVESnA community coalition compared the availability and cost of diabetes-healthy foods in a racial/ethnic minority neighborhood in East Harlem, with those in the adjacent, largely White and affluent Upper East Side in New York City.nnnMETHODSnWe documented which of 173 East Harlem and 152 Upper East Side grocery stores stocked 5 recommended foods.nnnRESULTSnOverall, 18% of East Harlem stores stocked recommended foods, compared with 58% of stores in the Upper East Side (P <.0001). Only 9% of East Harlem bodegas (neighborhood stores) carried all items (vs 48% of Upper East Side bodegas), though East Harlem had more bodegas. East Harlem residents were more likely than Upper East Side residents (50% vs 24%) to have stores on their block that did not stock recommended foods and less likely (26% vs 30%) to have stores on their block that stocked recommended foods.nnnCONCLUSIONSnA greater effort needs to be made to make available stores that carry diabetes-healthy foods.

Effects of Nurse Management on the Quality of Heart Failure Care in Minority Communities: A Randomized Trial

Context People with chronic conditions may need tailored, practical help for managing their conditions. Contribution This 12-month trial of assistance with managing systolic- dysfunction heart failure randomly assigned 406 ethnically diverse adults from Harlem, New York, to usual care or nurse management. Nurses counseled nurse management patients about sodium intake, fluid buildup, medication adherence, and self-management of symptoms; served as a bridge between patients and physicians; and regularly called patients to discuss problems. Compared with usual care patients, nurse management patients had fewer hospitalizations and better functioning. Implications Nurse management can improve some outcomes in ethnically diverse patients with systolic-dysfunction heart failure in ambulatory practices. The Editors Heart failure disproportionately affects black and elderly people and is a leading cause of hospitalization among people 65 years of age or older (1, 2). Although effective therapies can improve functioning and survival in patients with systolic dysfunction, many patients may not be receiving the full benefit of existing knowledge (35). Patients play a critical role in managing a chronic condition, such as heart failure. Patients may not realize that specific symptoms are related to heart failure or that adhering to medications and diet can reduce symptoms and life-threatening episodes (6). Evidence-based guidelines for systolic dysfunction recommend that physicians not only offer patients effective therapies but also teach them the importance of adherence and self-monitoring (3, 4). Clinicians have fallen short in prescribing angiotensin-converting enzyme inhibitors and -blockers for patients with systolic dysfunction (5, 7, 8). When prescribed, the doses have often been lower than those proven to convey greater benefits (3, 9). Clinicians have also documented counseling only a fraction of patients with heart failure about self-management (10, 11). System-related factors may also influence patients ability to obtain quality care (12, 13). Systematic reviews of clinical behavior change have suggested that interventions targeted to specific problems are more likely to be successful (14, 15). On the basis of shortfalls identified in patient self-management and clinical care in Harlem, New York, a predominately nonwhite area, we tailored a nurse management intervention to address documented problems and evaluated its effectiveness in a randomized, controlled trial. Our trial among primarily minority patients addresses important gaps in the literature. We targeted problems documented among patients with heart failure in Harlem, enrolled patients from ambulatory care practices, randomly assigned patients to either nurse management or usual care, and evaluated the patients subsequent health-related outcomes. We hypothesized that patients in the focused nurse management program would have fewer hospitalizations and report better functioning than patients in usual care. Methods Development of the Intervention During interviews with patients with heart failure at Mount Sinai Hospital, New York, New York, patients reported inadequate understanding of heart failure and their role in managing it (6). Less than half of patients followed a very-low-salt diet, and only about one quarter weighed themselves daily. Regarding clinical management, medical records noted prescriptions for an angiotensin-converting enzyme inhibitor or hydralazinedinitrate combination in 82% of 322 consecutive black patients with documented systolic dysfunction who were scheduled for visits at the general medicine clinic at Harlem Hospital from February 1995 through February 1997. The prescribed doses, however, equaled or exceeded those found to be efficacious in clinical trials in only 26% of these patients (3). In designing a nurse management intervention to address these problems, we built on a Stanford University program that evaluated primarily privately insured patients at Kaiser Permanente in northern California (16, 17). We adapted their questionnaire on the frequency of foods eaten to incorporate those that are common among African-American and Hispanic people in Harlem. Settings and Recruitment All 4 hospitals in Harlem, the areas major providers, collaborated in the trial: 1 large private academic medical center (1171 beds), 2 medium-sized municipal hospitals (286 beds and 363 beds), and 1 smaller private community hospital (200 beds). In 2000, these hospitals had 521, 267, 218, and 168 discharges for the heart failure diagnosis-related group (code 127), respectively. All are not-for-profit institutions. The trial had the following inclusion criteria: adults 18 years of age or older; systolic dysfunction documented on a cardiac test (echocardiography, radionuclide ventriculography, myocardial stress sestamibi or thallium stress testing, or left-heart catheterization); English-language or Spanish-language speakers; community-dwelling at enrollment; and current patient in a general medicine, geriatrics, or cardiology clinic or office at a participating site. Exclusion criteria were medical conditions that prevented interaction with the nurse, including blindness, deafness, or cognitive impairment; medical conditions requiring individualized management that might differ from standard protocol, namely pregnancy, renal dialysis, or terminal illness; or procedures that corrected systolic dysfunction, such as heart transplantation. Of the 216 clinicians (209 physicians and 7 physicians assistants or nurse practitioners) in participating practices, 1 clinician declined permission to recruit his patients. The institutional review boards for each site approved the study. We identified patients with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and diagnosis-related group codes on outpatient or inpatient billings for heart failure, March 1999 through February 2001, who had at least 1 clinician visit to a participating practice and impaired systolic dysfunction. We defined impaired systolic dysfunction as a left ventricular ejection fraction less than 0.40 or moderately or severely reduced systolic dysfunction on echocardiography, radionuclide ventriculography, myocardial stress sestamibi or thallium stress testing, or left-heart catheterization. We obtained clinicians permission to recruit specific patients and sent each approved patient a letter from the sites physician coordinator. Bilingual recruiters telephoned eligible patients or approached them at scheduled clinician appointments. The recruiter confirmed each patients eligibility, obtained written informed consent to participate in the study, conducted the baseline survey, and telephoned the project manager for the treatment group assignment. The recruiter conveyed the assignment to the patient and, for each nurse management patient, scheduled the in-person appointment with a nurse. We provided telephone service for 3 patients who did not have it so we could telephone patients in both treatment groups every 3 months for data on end points and so nurse management patients could participate in the intervention. Randomization and Treatment Groups The projects statistician used a computer-generated, random-number sequence without blocking or stratification to centrally determine randomization assignments and concealed treatment group assignments in sealed, opaque envelopes. Usual care patients received federal consumer guidelines for managing systolic dysfunction but no other intervention (18). In the nurse management intervention, 1 of 3 trained registered nurses met once with each patient (Table 1). In counseling the patient, the nurse stressed the relationship among sodium intake; fluid buildup; and symptoms, such as shortness of breath. Nurses mailed patients the reports from the food-frequency questionnaire after each administration. The nurse also served as a bridge between the patient and the clinician (Table 1). A local clinical advisory committee implemented national evidence-based guidelines, and a committee of key clinicians from participating sites approved the protocol (3, 4). Nurses contacted patients clinicians to discuss specific medications and arranged any prescription changes and examinations ordered (Table 1). An internist monitored the nurses work, initially in weekly and then in biweekly meetings, and a cardiologist provided oversight and substituted for the internist at regular meetings, as necessary. Table 1. Components of Nurse Management* One nurse who was bilingual in English and Spanish delivered the intervention primarily at the 2 municipal hospitals, a second bilingual nurse delivered the intervention primarily at the small community hospital, and the second and a third English-languagespeaking nurse delivered the intervention primarily at the academic center. All 3 nurses covered each other, especially for the follow-up telephone calls. Outcomes and Measurement To measure hospitalizations, we used billing data from the 4 participating hospitals. At quarterly telephone surveys, interviewers who were blinded to treatment assignment asked patients about hospitalizations at nonparticipating hospitals; however, we present the analysis of billing data because they measure hospitalizations independent of possibly socially acceptable responses or survey nonresponse of the patients. For functional status, we used the generic Short Form-12 (SF-12) physical component score and the condition-specific Minnesota Living with Heart Failure (MLHF) Questionnaire, with both scales administered at the quarterly interviews. We measured deaths recorded in the National Death Index plus deaths reported by patients families for patients with no subsequent billings. Since both nurse management and usual care involved only services delivered in routine practice, the study did not monitor adverse effects. As required by the academic

Reducing Excessive Medication Administration in Hospitalized Adults With Renal Dysfunction

Medication errors are common and harm hospitalized patients. The authors designed and implemented an automated system to complement an existing computerized order entry system by detecting the administration of excessive doses of medication to adult in-patients with renal insufficiency. Its impact, in combination with feedback to prescribers, was evaluated in 3 participating nursing units and compared with the remainder of a tertiary care academic medical center. The baseline rate of excessive dosing was 23.2% of administered medications requiring adjustment for renal insufficiency given to patients with renal impairment on the participating units and 23.6% in the rest of the hospital. The rate fell to 17.3% with nurse feedback and 16.8% with pharmacist feedback in the participating units ( P < .05 for each, relative to baseline). The rates of excessive dosing for the same time periods were 26.1% and 24.8% in the rest of the hospital. Automated detection and routine feedback can reduce the rate of excessive administration of medication in hospitalized adults with renal insufficiency.

Explaining trends in hospitalizations for pneumonia and influenza in the elderly.

From 1987–99, influenza and pneumococcal vaccination rates among elderly Medicare beneficiaries increased by 300 percent and 500 percent, respectively. Despite these gains, annual rates of hospitalizations for pneumonia and influenza (P&I) have not decreased; rather, they have increased steadily. The authors investigate whether this paradoxical increase in hospitalization rates reflects an increasing burden of P&I or the effects of a changing healthcare environment. They find that from 1987–99, P&I hospitalizations per one thousand beneficiaries increased from 15.1 to 23.4. Of this increase, 23 percent was due to an aging Medicare population, 2.4 percent was due to increased rates of rehospitalization, and at most 5 percent was due to upcoding. There was no evidence that physicians were increasingly admitting patients with less complicated cases of P&I. The changing healthcare environment only partially explained the paradoxical increase in P&I hospitalizations. P&I appears to be an increasing burden to the elderly, despite increased vaccination rates.

The success of recruiting minorities, women, and elderly into a randomized controlled effectiveness trial

BACKGROUNDnHeart failure, a leading cause of hospitalization among elderly people, disproportionately afflicts African-American and other non-White populations. Studies of health care interventions often do not include these groups in proportion to numbers in the patient population. Our objective was to assess whether a randomized controlled effectiveness trial enrolled patients by ethnicity/race, gender, and age in proportion to those eligible.nnnMETHODSnWe conducted a randomized controlled trial comparing nurse management and usual care among ambulatory heart failure patients at the four hospitals in East and Central Harlem, New York. We incorporated culturally sensitive and age-appropriate strategies to enroll a demographically representative group into the trial. Recruitment proceeded in several steps: identifying patients with billing code and visit criteria, documenting systolic dysfunction, obtaining clinician permission and correct addresses, contacting patients, and enrolling eligible patients. We assessed differences by ethnicity/race and gender at successive steps in the recruitment process, and differences between enrollees and refusals regarding overall health, evaluation of medical care, and difficulty receiving care.nnnRESULTSnWe enrolled 406 ambulatory patients by ethnicity/race and gender in proportion to the numbers eligible to be contacted (46% African-American/Black, 33% Hispanic, and 47% female). Among patients contacted, however, those 18 through 74 years were 2.0 to 3.3 times more likely than those > or = 75 years to enroll (p < 0.001).nnnCONCLUSIONSnThe recruitment strategy successfully enrolled patients by ethnicity/race, gender, and age through 74 years, but not those > or = 75 years. Registries of patients who refuse to enroll in trials could provide guidance for clinical and public policy.

Hypertension Management in Minority Communities: A Clinician Survey

BACKGROUNDRates of blood pressure (BP) control are lower in minority populations compared to whites.OBJECTIVEAs part of a project to decrease health-related disparities among ethnic groups, we sought to evaluate the knowledge, attitudes, and management practices of clinicians caring for hypertensive patients in a predominantly minority community.DESIGN/PARTICIPANTSWe developed clinical vignettes of hypertensive patients that varied by comorbidity (type II diabetes mellitus, chronic renal insufficiency, coronary artery disease, or isolated systolic hypertension alone). We randomly assigned patient characteristics, e.g., gender, age, race/ethnicity, to each vignette. We surveyed clinicians in ambulatory clinics of the 4 hospitals in East/Central Harlem, NY.MEASUREMENTSThe analysis used national guidelines to assess the appropriateness of clinicians’ stated target BP levels. We also assessed clinicians’ attitudes about the likelihood of each patient to achieve adequate BP control, adhere to medications, and return for follow-up.RESULTSClinicians’ target BPs were within 2xa0mm Hg of the recommendations 9% of the time for renal disease patients, 86% for diabetes, 94% for isolated systolic hypertension, and 99% for coronary disease. BP targets did not vary by patient or clinician characteristics. Clinicians rated African-American patients 8.4% (pu2009=u2009.004) less likely and non-English speaking Hispanic patients 8.1% (pu2009=u2009.051) less likely than white patients to achieve/maintain BP control.CONCLUSIONSClinicians demonstrated adequate knowledge of recommended BP targets, except for patients with renal disease. Clinicians did not vary management by patients’ sociodemographics but thought African-American, non-English-speaking Hispanic and unemployed patients were less likely to achieve BP control than their white counterparts.

Challenges Facing Nurse-Led Disease Management for Heart Failure

The positive results of several randomized controlled trials of nurse-led disease management (DM) for heart failure have led to considerable growth in the use of DM programs in such patients. However, many aspects of the protocols used in randomized trials of DM for heart failure have differed, and there are still significant gaps in our knowledge of what makes DM work and for whom. Four important unresolved issues are: (i) what components of multifaceted DM protocols for heart failure are effective; (ii) whether a face-to-face meeting with the nurse is necessary for successful DM; (iii) what type of patients benefit from DM; and (iv) who should provide and pay for nurse-led DM.Our understanding of why nurse-led DM works would be enhanced if researchers systematically described each component of the intervention, measured the patient or clinician behavior that each component was designed to modify, and reported the trial’s success or failure at achieving that modification. Almost all randomized trials to-date have recruited hospitalized patients at relatively high risk of decompensation and have provided them with face-to-face contact with the DM team. More research is needed to document the effectiveness of DM protocols that use purely telephonic contact with patients, and those that recruit lower-risk patients from ambulatory settings. Finally, instead of assessing whether DM reduces costs or yields an adequate return on investment, more emphasis should be placed on cost-effectiveness research, which assesses whether DM improves patient health-related quality of life for a reasonable cost. Research along these lines will fill the gaps in our knowledge regarding the utility of DM for heart failure, and will contribute to making nurse-led DM for heart failure more effective, efficient, and commonplace.

Response to Gender and Blood Pressure Control

We thank Barrios et al1 for their interest in our recent publication. Our work identified gender disparities in blood pressure control and receipt of recommended preventive therapies in ambulatory practices across the Unites States.2 In a sample of 12 064 visits (7786 women and 4278 men), women were less likely than men to meet blood pressure control targets, especially older women aged 65 to 80 years, and to receive recommended therapies, such as aspirin and β-blockers, for the …