Suzanne Hughes

The use of non face-to-face communication to enhance preventive strategies.

Multiple studies have demonstrated disappointingly low rates of persistence with therapies recommended to reduce cardiovascular risk. Non face-to-face communication has been employed as a strategy to increase the rate of adherence with both pharmacologic and lifestyle modification risk-reduction measures. In addition to the impact on adherence, these interventions have the potential to affect intermediate measures, such as increased access to care, increased patient satisfaction, and decreased resource utilization. Improvement in clinical outcomes is the ultimate measure of success of this intervention.

Novel cardiovascular risk factors.

In addition to the well-established cardiovascular risk factors of elevated total and low-density lipoprotein cholesterol, hypertension, and cigarette smoking, multiple additional factors are suspected culprits in both the development and progression of atherothrombosis. It is key for the clinician to critically review research findings utilizing an organized framework in order to credibly advise the patient with cardiovascular disease or at risk for its development. The current evidence and recommendations regarding the following “novel” or “emerging” risk factors will be reviewed: lipoprotein(a), hyperhomocysteinemia, C-reactive protein, infectious processes, fibrinogen, and microalbuminuria.

Preparing nurses for leadership roles in cardiovascular disease prevention

Cardiovascular disease (CVD) is a critical global health issue, and cardiovascular nurses play a vital role in decreasing the global burden and contributing to improving outcomes in individuals and communities. Cardiovascular nurses require the knowledge, skills, and resources that will enable them to function as leaders in CVD. This article addresses the education, training, and strategies that are needed to prepare nurses for leadership roles in preventing and managing CVD. Building on the World Health Organization core competencies for 21st-century health care workers, the specific competencies of cardiovascular nurses working in prevention are outlined. These can be further strengthened by investing in the development of cultural, system change and leadership competencies. Mentorship is proposed as a powerful strategy for promoting the cardiovascular nursing role and equipping individual nurses to contribute meaningfully to health system reform and community engagement in CVD risk reduction.

Improving cardiovascular health in women: an opportunity for nursing.

145 Cardiovascular disease (CVD) accounts for 43% of the annual mortality in American women, well ahead of the 22% caused by all forms of cancer. Mortality rates from CVD in males have decreased over the past 20 years, but the statistics do not follow the same downward trajectory for women. In fact, CVD deaths in women now comprise more than 52% of the annual deaths from CVD.1 Surveys indicate that most women believe that breast cancer is their greatest health threat.2 In reality, a woman is more than 8 times as likely to die from heart disease as from breast cancer. Although early detection greatly improves outcomes, sadly, breast cancer is thus far not preventable. This is in stark contrast to the plethora of evidence-based strategies for cardiovascular risk reduction. The first step toward reduction of CVD in women is to raise awareness about the magnitude of the problem. Awareness-raising campaigns have been at the forefront of the agendas for both the National Institutes of Health (NIH) and the American Heart Association (AHA). These efforts are directed toward putting to rest the myth that heart disease is some-

Are you assessing the communication "vital sign"? Improving communication with our low-health-literacy patients.

Approximately one-half of American adults lack the health literacy and numeracy skills necessary to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Health literacy is a shared function of social and individual factors, and health literacy skills are mediated by education, culture, and language. Patients with low health literacy have difficulty processing items that affect cardiovascular disease management activities such as locating or accessing health care, understanding educational materials, reading appointment reminders, reading medication and nutrition labels, and understanding the consequences of unhealthy behaviors and environmental exposures. They may also experience difficulties in communication with their health care provider. Those with low health literacy are 1.5 to 3 times more likely to experience adverse health outcomes. Individuals with inadequate health literacy and chronic conditions such as cardiovascular disease are at increased risk for poor care and outcomes including lack of knowledge about disease, poor self-care, increased hospital admissions, increased mortality, and higher health care costs. Despite the high prevalence and serious consequences of inadequate health literacy, too often clinicians fail to recognize its presence. Many clinicians are unaware that this problem exists or simply do not ask about it. Moreover, because individuals with low health literacy are often embarrassed or ashamed to admit they have difficulty understanding health information and instructions, they may be using wellestablished coping mechanisms that effectively mask their problem. Patients with low literacy do not fit a specific stereotype. Although a disproportionate number of ethnic minorities, immigrants, and older adults have problems with health literacy, according to a national study, individuals with limited literacy are born in the United States (75%), are white (50%), hold fullor part-time job (40%), and have finished high school (25%). Contributing to the problem is the fact that clinicians often lack the knowledge and/or resources, including time and tools, to assess the level of health literacy and respond appropriately. Simple screening approaches and other resources and tools to improve communication with our low-literacy patients are available, and broad dissemination of these resources is needed. The following are ‘‘red flags’’ that may suggest problems with health literacy:

Progress in prevention: motivating our patients to adopt and maintain healthy lifestyles.

One in 3 American adults has cardiovascular disease (CVD) and CVD is the leading cause of death in the United States. As cardiovascular nurses, we spend a great deal of time promoting awareness of and adherence to national guidelines for primary prevention of CVD and stroke and secondary prevention for patients with coronary and other vascular disease. We diligently encourage individuals to reduce their CVD risk by modifying their lifestyles through tobacco cessation; weight control; increased physical activity; alcohol moderation; reduction of dietary sodium, saturated fats, trans-fatty acids, and cholesterol; and increased consumption of fresh fruits, vegetables, fiber, low-fat dairy products, and omega-3 fatty acids. Even modest sustained lifestyle changes can substantially reduce CVD morbidity and mortality. Furthermore, because many of the beneficial effects of lifestyle changes accrue over time, long-term adherence maximizes individual and population benefits. However, the adoption and maintenance of new CVD risk-reducing behaviors pose seemingly insurmountable challenges for many individuals. In addition, health professionals often lack adequate skills for effective lifestyle modification counseling. It is increasingly recognized that patient education is necessary but insufficient to motivate CVD riskreducing behaviors for most individuals. Behavior change theories and models have evolved, moving health education interventions away from the traditional informationbased and advice-giving model to one that embraces and addresses the complex interaction of motivations, cues to action, perception of benefits and consequences, environmental and cultural influences, expectancies, self-efficacy, state of readiness to change, ambivalence, and implementation intentions. Nevertheless, as health professionals, we often assume an approach that is authoritarian, paternalistic, confrontational, forceful, or guilt inducing. There is evidence that such attitudes will not only limit progress, but actually are correlated with negative behavioral and clinical outcomes. Additionally, a negative cycle can be initiated, as indicated by a study where higher patient resistance to quitting smoking led to an increase in confrontational and other negative behaviors in health professionals attempting to promote behavior change. Motivational interviewing (MI) is an evidence-based approach which provides some very useful tools for health professionals who are striving to promote behavior change. Motivational interviewing is a collaborative, directive, individual-centered counseling style for eliciting behavior change with a central purpose of helping individuals to explore and resolve their ambivalence (ie, lack of readiness to change their behavior). It is called interviewing because it involves careful listening and strategic questioning rather than teaching to help people overcome their ambivalence to change. As a brief introduction, the 7 key principles that characterize the nature of motivational interviewing include the following:

Progress in prevention: prevention of cardiovascular disease a life course ecological perspective.

The central role of health behaviors and therapeutic lifestyle change in cardiovascular health promotion and risk reduction across the life course of individuals and populations has been firmly established. Reflecting on the evidence accumulated over the past several decades, guidelines for primary and secondary prevention of cardiovascular disease (CVD) emphasize the critical and essential role of healthy lifestyle behaviors. Recent recommendations for children, adolescents, and adults also underscore the important role of environments/ contexts in which health behaviors develop and are maintained or modified. Interdisciplinary organizations, consensus reports from expert panels, and a recent National Institutes of Health event call attention to multilevel environmental factors as important determinants of healthy lifestyle behaviors. Paradigms for conceptualizing, investigating, and practicing behavior change, with individuals and other units of intervention, increasingly emphasize social-ecological life course approaches. Clearly, patterns of CVD health behaviors develop early in childhood, affect atherosclerotic CVD processes, and are influenced over time by families, schools, communities, the media, and broader social-cultural and environmental factors. The epidemic of childhood obesity, a major challenge to the health of the public, has drawn our attention to the powerful impact of these potentially modifiable influences on health behaviors and health. In the setting of obesity, specifically, the multilevel contextual factors that influence adverse patterns of dietary intake and physical activityVrecognized behavioral determinants of energy balanceVhave been emphasized. The terms obesogenic and toxic have emerged to characterize environments that promote overweight and obesity. It is recognized that the relative importance of specific environmental/ contextual influences on health behaviors relevant to weight management (and other CVD health behaviors) will vary from early childhood to older adult life. For example, schools, including preschool and after school programs, have been targeted as important venues for promoting healthy patterns of dietary intake and physical activity for preschoolers, schoolaged children, and adolescents. Some broader level environmental factors, however, are important and applicable across developmental stages. Exemplified in recent evidence-based reports from the Institute of Medicine and in the literature of social epidemiology, the media, physical (built) environments, and the socioeconomicpolitical milieu influence health behaviors and health across the life course of individuals and diverse populations. Taken together, the evidence compels us, as providers and consumers of preventive healthcare, to attend to and address these environmental/ contextual factors, also referred to as the social-ecological determinants of health. As members of the community of cardiovascular healthcare professionals, we are reminded to value the complementary and potentially synergistic individual/clinical and public health approaches to CVD prevention. Social-ecological life course perspectives are highly relevant to both. On an individual/clinical level, this perspective encourages us to assess and manage risk behaviors and other CVD factors with considerable emphasis on those contexts and environments relevant to the individual. Addressed in

News from the field of women's heart health.

Over the past few years, February has become the month when we pay particular attention to heart health in women. Since the respective launches of the National Heart, Lung, and Blood Institute’s ‘‘Heart Truth’’ campaign and the American Heart Association’s ‘‘Go Red for Women,’’ the topic of heart disease in women has received attention in the professional literature and in the lay press. Newly published research, surveys, and guidelines can provide important talking points for clinicians with educational efforts in the clinical and community settings. The observance of ‘‘National Wear Red Day’’ Day on February 3 provides an appropriate time to reflect on the latest information.

Counseling patients for lifestyle change: making a 15-minute office visit work.

Lifestyle counseling is an intervention that can improve chronic disease management as well as patient and provider satisfaction. Patients and providers are often frustrated with difficulties faced in the implementation and maintenance of lifestyle change. Can we change this paradigm? Are there new strategies that work and can be implemented in a typical office visit? The medical literature confirms the effectiveness of lifestyle interventions and recommends that lifestyle counseling be considered as a cornerstone of care. Here we present a case study of a midlife woman to show how motivational interviewing can be used to help her identify and meet her health goals.

Progress in prevention: Accountable care and cardiovascular nursing

History was made on March 23, 2010, when President Obama signed into law the Patient Protection and Affordable Care Act, which (1) extends health care coverage to 32 million people in the United States who are currently uninsured and (2) begins to reform our health care delivery system toward a model that is accountable and coordinated. This historic legislation begins to address multiple fundamental problems with our current health care (or more accurately, our Bsick-care[) system. The Institute of Medicine, in its landmark report, Crossing the Quality Chasm, identified 6 dimensions for quality improvement in our health care system: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The newly appointed director of the Centers for Medicare & Medicaid Services, Dr Donald Berwick, has identified the Btriple aim,[ 3 simultaneous targets as a means of improving the US health care system: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. What are those fundamental problems that face patients accessing our current system? Although the United States undoubtedly has among the world’s best health care providers and health care institutions, the US medical system falls short in delivering the safest and most reliable high-quality care. Despite the resources we have, there remain far too many unplanned hospital admissions (and readmissions). There is an unacceptably high rate of medical errors and health careYassociated infections. Our current health care delivery system is organized around episodic care for acute illnesses, without a coordinated approach to primary and secondary prevention of chronic diseases, such as diabetes, coronary heart disease, and heart failure. It is estimated that health care costs for chronic disease treatment account for more than 75% of national health expenditures. Aging of the population, the high prevalence of chronic diseases, such as diabetes, arthritis, and cardiovascular disease, along with the overweight and obesity epidemic will continue this trend. A central issue for consideration in current health reform discussions is how we can simultaneously contain rising health care costs while achieving quality health care outcomes. One strategy to accomplish these seemingly disparate objectives is the creation of accountable care organizations (ACOs). Under the Patient Protection and Affordable Care Act, the Department of Health and Human Services by 2012 must establish a BMedicare Shared Savings Program[ that allows groups of providers who meet certain statutory criteria to be recognized as ACOs. Eligible ACOs would be groups of providers and suppliers that have an established mechanism for joint decision making, including practitioners in group practices, networks of practices, partnerships or joint ventures between hospitals and practitioners, and hospitals employing practitioners. At the time of this writing, the National Committee for Quality Assurance had issued draft criteria and solicited public comment for ACOs. Final iteration is pending. In general, an ACO is defined as an entity or organizational structure that integrates providers along the care delivery continuum and rewards providers based on