Randy Wexler

Heart rate control with adrenergic blockade: clinical outcomes in cardiovascular medicine.

The sympathetic nervous system is involved in regulating various cardiovascular parameters including heart rate (HR) and HR variability. Aberrant sympathetic nervous system expression may result in elevated HR or decreased HR variability, and both are independent risk factors for development of cardiovascular disease, including heart failure, myocardial infarction, and hypertension. Epidemiologic studies have established that impaired HR control is linked to increased cardiovascular morbidity and mortality. One successful way of decreasing HR and cardiovascular mortality has been by utilizing β-blockers, because their ability to alter cell signaling at the receptor level has been shown to mitigate the pathogenic effects of sympathetic nervous system hyperactivation. Numerous clinical studies have demonstrated that β-blocker-mediated HR control improvements are associated with decreased mortality in postinfarct and heart failure patients. Although improved HR control benefits have yet to be established in hypertension, both traditional and vasodilating β-blockers exert positive HR control effects in this patient population. However, differences exist between traditional and vasodilating β-blockers; the latter reduce peripheral vascular resistance and exert neutral or positive effects on important metabolic parameters. Clinical evidence suggests that attainment of HR control is an important treatment objective for patients with cardiovascular conditions, and vasodilating β-blocker efficacy may aid in accomplishing improved outcomes.

Physician reported perception in the treatment of high blood pressure does not correspond to practice

BackgroundHigh blood pressure is a significant health problem world-wide. Physician factors play a significant role in the suboptimal control of hypertension in the United States. We sought to better understand primary care physicians opinions regarding use of hypertension guidelines, patient and physician related barriers to treatment and physician treatment decision making in the management of hypertension as part of a first step in developing research tools and interventions designed to address these issues.MethodsAn IRB approved survey pertaining to physician opinion regarding the treatment of hypertension. Items consisted of questions regarding: 1) knowledge of hypertension treatment guidelines; 2) barriers to hypertension control (physician vs. patient); and 3) self-estimation of physician treatment of hypertension. Descriptive Statistics were used to describe results.ResultsAll physicians were board certified in family or general internal medicine (n = 28). Practices were located in urban (n = 12), suburban (n = 14) and inner city locations (n = 1). All physicians felt they did a good job of treating hypertension. Most physicians felt the biggest barrier to hypertension control was patient non-compliance. Half of physicians would fail to intensify treatment for hypertension when blood pressure was above recommended levels for all disease states studied (essential hypertension, heart disease, diabetes, and renal disease).ConclusionPhysician ability to assess personal performance in the treatment of hypertension and physician opinion that patient noncompliance is the greatest barrier to optimal hypertension control is contradictory to reported practice behavior. Optimal blood pressure control requires increased physician understanding on the evaluation and management of blood pressure. These data provide crucial formative data to enhance the content validity of physician education efforts currently underway to improve the treatment of blood pressure in the primary care setting.

Lack of private health insurance is associated with higher mortality from cancer and other chronic diseases, poor diet quality, and inflammatory biomarkers in the United States.

OBJECTIVE The lack of health insurance reduces access to care and often results in poorer health outcomes. The present study simultaneously assessed the effects of health insurance on cancer and chronic disease mortality, as well as the inter-relationships with diet, obesity, smoking, and inflammatory biomarkers. We hypothesized that public/no insurance versus private insurance would result in increased cancer/chronic disease mortality due to the increased prevalence of inflammation-related lifestyle factors in the underinsured population. METHODS Data from the Third National Health and Nutrition Examination Survey participants (NHANES III;1988-1994) were prospectively examined to assess the effects of public/no insurance versus private insurance and inflammation-related lifestyle factors on mortality risk from cancer, all causes, cardiovascular disease (CVD) and diabetes. Cox proportional hazards regression was performed to assess these relationships. RESULTS Multivariate regression analyses revealed substantially greater risks of mortality ranging from 35% to 245% for public/no insurance versus private insurance for cancer (HR=1.35; 95% CI=1.09,1.66), all causes (HR=1.54; 95% CI=1.39,1.70), CVD (HR=1.62; 95% CI=1.38,1.90) and diabetes (HR=2.45; 95% CI=1.45,4.14). Elevated CRP, smoking, reduced diet quality and higher BMI were more prevalent in those with public insurance, and were also associated with increased risks of cancer/chronic disease mortality. DISCUSSION Insurance status was strongly associated with cancer/chronic disease mortality after adjusting for lifestyle factors. The results suggest that inadequate health insurance coverage results in a substantially greater need for preventive strategies that focus on tobacco control, obesity, and improved dietary quality. These efforts should be incorporated into comprehensive insurance coverage programs for all Americans.

Primary Care Access Barriers as Reported by Nonurgent Emergency Department Users Implications for the US Primary Care Infrastructure

The objective was to explore variation by insurance status in patient-reported barriers to accessing primary care. The authors fielded a brief, anonymous, voluntary survey of nonurgent emergency department (ED) visits at a large academic medical center and conducted descriptive analysis and thematic coding of 349 open-ended survey responses. The privately insured predominantly reported primary care infrastructure barriers—wait time in clinic and for an appointment, constraints related to conventional business hours, and difficulty finding a primary care provider (because of geography or lack of new patient openings). Half of those insured by Medicaid and/or Medicare also reported these infrastructure barriers. In contrast, the uninsured predominantly reported insurance, income, and transportation barriers. Given that insured nonurgent ED users frequently report infrastructure barriers, these should be the focus of patient-level interventions to reduce nonurgent ED use and of health system-level policies to enhance the capacity of the US primary care infrastructure.

Racial Differences in Barriers to Blood Pressure Control in a Family Practice Setting

Objective: Hypertension prevalence in the African American community is greater than in all other ethnic groups. Cultural perceptions of health and disease introduce barriers to providing effective care. The purpose of this study was to identify racial differences in the perceived causes of hypertension, current behaviors performed to control blood pressure, and perceived barriers to preventing or treating hypertension. Methods: A self-administered survey of patients seen for medical care in a primary care network was conducted. The survey was developed to measure perceptions of hypertension etiology and treatments. Data from African American (n = 69) and Caucasian (n = 218) respondents were used to assess racial differences in perceptions of blood pressure control. Results: About half of respondents knew their current blood pressures. African American patients were significantly less likely to believe that hypertension was caused by a lack of exercise and obesity. Significantly more Caucasians were less likely to report cutting down on table salt and taking prescription medications for blood pressure control. Both African Americans and Caucasians believed that sodium reduction was the most easily changed behavior to control their blood pressure, while both groups identified weight loss as being the most difficult. Conclusion: Racial differences exist in the perceived causes and treatments of high blood pressure, indicating a need for further patient education. When treating and counseling patients, physicians and support staff members must be sensitive to racial diversity and strive to offer culturally relevant solutions, especially for behaviors perceived as most difficult to change.

Letter by Wexler and Feldman Regarding Article, “Ethnic and Gender Differences in Ambulatory Blood Pressure Trajectories: Results From a 15-Year Longitudinal Study in Youth and Adults”

To the Editor: The research presented by Wang et al1 is an important contribution toward understanding and reducing disparities in health care in general and hypertension in particular. Although we agree with their conclusion that “further work will be needed to determine specific risk factors, both genetic and environmental,” we hope we will not forget that the explanation of …

Terminology Matters: Patient Understanding of “Opioids” and “Narcotics”

Background:  The terms “opioid” and “narcotic” are often used interchangeably by healthcare providers. The purpose of this study was to compare understanding “narcotics” vs. “opioids.”

Target Blood Pressure Level Before Antihypertensive Class to Improve Outcomes More Quickly in Uncomplicated Hypertension

To the Editor: The article by Ma et al,1 regarding changes in antihypertensive prescribing during US outpatient visits for uncomplicated hypertension, provides important information on the prescribing patterns and use of guideline recommendations for the treatment of hypertension in the United States. However, although the ongoing debate as to which class of antihypertensive to prescribe, especially in patients with uncomplicated hypertension, continues unabated, the importance of blood pressure reduction is too …

SHAPING HEALTH-RELATED POLICY IN THE UNITED STATES: 1 FAMILY PHYSICIAN AT A TIME

The Affordable Care Act will profoundly influence health care delivery in the United States. Here, Dr Randy Wexler, an Associate Professor of Family Medicine at The Ohio State University, describes his health policy interests and activities. Through the years, Dr Wexler has worked with local-, state-, and federal-level policy makers. We hope that by sharing his experiences, family physicians will become interested in and prompted to be more involved in shaping health-related policy related to the delivery of primary care. As a busy family physician, how did you become interested and involved in health-related policy activities? My interest in policy issues really evolved out of my frustration with the overall health care system. During my family medicine residency training I began attending my local Ohio Academy of Family Physicians affiliate and things just evolved from there. I think all family physicians must be engaged in health policy-related activities in some manner. You have to make the time to be involved. So many of the decisions made by state and federal agencies impact how family physicians not only practice, but also the manner in which we deliver care. To not engage in any form, even just a little, allows others to determine how we practice. It is just like the old saying, “you can pay (a little time) now or pay (a lot of time) later.” A family physician is seeking to be involved in health-related policy efforts. What advice could you provide him/her in getting started? Fortunately, there are many ways to get involved. At the local level one can engage with their state American Academy of Family Physicians affiliate. To impact federal issues the American Academy of Family Physicians (AAFP) has many options. For example, the Family Medicine Political Action Committee (FamMedPAC) advocates for family medicine in Washington, DC. Information about FamMedPAC is available at http://www.aafp.org/online/en/home/policy/fammedpac.html?navid=fammedpac. The AAFP also has a “Speak Out” Web site (http://capitol.aafp.org/aafp/home/) that encourages family physicians to contact their members of Congress and provides a comprehensive list of sample talking points on pertinent issues. Finally, one can call the office of their General Assembly or member of Congress and request an appointment. Often you will meet with an aide, but aides are the sergeants of government and good relationships to establish. While most meetings will be just 15 or 30 minutes, it is always beneficial to place a follow-up phone call a few days after each meeting. Building relationships with elected officials is the key to establishing a voice for family medicine. As a whole, NAPCRG advocates for increased primary care research funding. Again, how do you suggest family physicians lead this effort? The most important thing NAPCRG can do is educate policy makers on the importance of primary care research and the impact such research can have on the nation. The late Dr Barbara Starfield and colleagues demonstrated that primary care services reduce both morbidity and mortality, whether primary care is characterized by primary care provider supply, source of primary care, or which components of primary care are utilized.1 Further, they found that primary care—in comparison to specialty care—results in not only equitable distribution of health resources and improved outcomes, but also reduced costs. Primary care research is well suited for evaluation and interpretation of “real-world” problems and can focus improvements on managing health services toward more efficient and higher quality care. Primary care research can be especially relevant in addressing new and emerging issues, in addition to the consideration of questions such as “how the provision of care can be improved.”2 Furthermore, primary care is ideally positioned to deal with issues related to disparities in health care delivery by addressing areas necessary to resolve such inequities. Rust and Cooper3 argue that we must: (1) conduct research in real-world, high-disparity primary care settings; (2) develop community partnerships; (3) address the complex mix of disparities in chronic disease risk factors and outcomes; (4) focus efforts on the triangulation of patient, community, and provider; and (5) test dynamic, constantly improving interventions. Research in primary care is ideal for addressing such needs and inequities fomented by the current health care system.

Letter by Wexler and Feldman Regarding Article, “Socioeconomic Position, Race/Ethnicity, and Inflammation in the Multi-Ethnic Study of Atherosclerosis”

We read with great interest the research by Ranjit et al1 in the November 20, 2007, issue of Circulation . The link between socioeconomic position (SEP) and cardiovascular disease (CVD), especially in blacks, is well documented.2,3 As discussed by Ranjit et al,1 what is less clear is whether inflammation is linked to SEP and CVD. Should it become possible to explain the linkage between SEP, CVD, and inflammation, it would then theoretically become possible to target multipart interventions designed to address these various factors. Ranjit et al1 …