Thomas D. MacKenzie

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)

Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

A canadian survey of prophylactic antibiotic use among hip-fracture patients

OBJECTIVE To study how surgical prophylactic antibiotics (SPAs) were utilized in the perioperative management of surgery for hip fractures. DESIGN Retrospective chart review of randomly selected medical records. SETTING Twenty-two hospitals (teaching, nonteaching, community, and large urban referral centers) from across Canada. PATIENTS Patients admitted in 1990 with a diagnosis of hip fracture. METHODS Complete medical records of 438 patients were examined; 352 cases who underwent surgical repair of a fractured hip with insertion of prosthetic material were included in analysis. Perioperative SPA use was assessed by abstracting the agent(s) chosen, dosages, time given with respect to the incision, and duration of postoperative use. Fourteen patient and process-of-care variables related to SPA were examined. RESULTS 247 (70%) of 352 cases did not receive a dose of SPA 2 hours preoperatively. Ten percent of preoperative SPA was administered either too early or during the procedure. In 91 (39%) of 231 cases receiving SPA, the first dose was not administered until the end of the procedure. Preoperative SPA consisted of a parenteral first-generation cephalosporin for 94% of cases. SPAs were continued more than 24 hours postoperatively in 78% of cases. Lack of a written order for SPA, being a nonteaching hospital, and shorter duration of surgical procedure were predictive of failure to receive SPA in an effective manner. CONCLUSIONS Most hip-fracture-surgery patients did not receive effective antibiotic prophylaxis as required to prevent serious wound infections. This important variable can be included for surveillance, so that corrective measures can be taken to assure effective prophylactic antibiotic administration.

Effects of Clinical Pathways for Common Outpatient Infections on Antibiotic Prescribing

BACKGROUND Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. METHODS Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period. RESULTS In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P<.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P<.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P<.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group. CONCLUSIONS This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.

Evidence-Based Guideline for the Management of High Blood Pressure in Adults

Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients.

Rapid response activation (RRA), triggered chiefly by surpassing threshold vital sign abnormalities (TVSAs), is designed to intervene at the earliest point in a patient’s deteriorating course. The authors aimed to quantify the incidence of TVSA among patients hospitalized on acute care units in a hospital that uses rapid response. During the course of 6 months, the authors compared adverse events (mortality, unexpected intensive care unit [ICU] transfers, and cardiopulmonary arrest) and TVSA among patients who triggered an RRA, patients with TVSAs and no RRA, and all other patients. At least 1 TVSA was recorded in 31.9% of stays and 12.2% of patient-days. RRA patients were more likely (22.5%) than other TVSA patients (7.9%) and other patients (1.8%) to have an adverse event (P < .01). Incidence varied by vital sign. During the investigation, only 2.5% of TVSA opportunities triggered an RRA. As systems engage electronic workflows, automatically triggering RRAs based solely on TVSAs could place a tremendous burden on systems.

Design of a nurse-run, telephone-based intervention to improve lipids in diabetics.

This randomized, controlled trial tested the effectiveness of a nurse-run, telephone-based intervention to improve lipid control in patients with diabetes. Our patient population is predominantly low-income and Latino. Using our diabetes registry, we randomly assigned 381 patients to continue with their usual care and 381 to participate in our nurse-run program. Three registered nurses learned algorithms for diabetes care. These algorithms address management of lipids, glycemic control, blood pressure, nephropathy, aspirin use, eye screening, pneumovax and influenza vaccines, obesity, and cigarette smoking. The nurses were also trained in motivational interviewing techniques and facilitation of patient self-management. The primary goal was to improve lipid control in our diabetic population. Secondary outcomes address blood pressure control, glycemic control, renal function, and medication adherence. In addition, a cost-effective analysis is being performed. This article summarizes the design of the intervention.

Using Antibiograms to Improve Antibiotic Prescribing in Skilled Nursing Facilities

BACKGROUND Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown. OBJECTIVE To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing. DESIGN AND SETTING Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs. METHODS Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities. RESULTS We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]). CONCLUSIONS Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

The impact of tailored diabetes registry report cards on measures of disease control: a nested randomized trial

BackgroundMost studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback.Methods5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews.ResultsMany providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources.ConclusionsPatient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts.Trial RegistrationClinicalTrials.gov: NCT00827710

ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group

Background: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. Objectives: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. Methods: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. Results: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). Conclusion: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

Diabetes Population Management by Telephone Visits

INTRODUCTION Little has been published on the impact of telephone visits on diabetes outcome performance. RESEARCH DESIGN AND METHODS An attending and resident physician prioritized telephone visits based on glycemic, blood pressure, and lipid performance. The resident and attending panel was compared with all other diabetic patients at the clinic for baseline and end-intervention performance. RESULTS The intervention patients had an absolute percentage of increase versus control patients of 14.9 (p<0.01), 13.9 (p<0.01), and 8.3 (p=0.01) for HbA1c <9%, low-density lipoprotein <100 mg/dL, and blood pressure <130/80 mm Hg, respectively. CONCLUSIONS This pilot study suggests that provider-driven telephone visits may be a means for healthcare systems to improve chronic disease outcomes as they transition to new paradigms of chronic care delivery. LIMITATIONS This study was neither randomized nor blinded, was susceptible to an interventionist effect, and did not analyze for differences in baseline medication use.