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OBJECTIVE: The purpose of this study was to evaluate the effectiveness of an interdisciplinary diabetes team model of care in assisting patients to achieve improved glucose control in a primary care rural setting. METHODS: A family medicine clinic at a rural university medical center developed an interdisciplinary diabetes team clinic composed of a certified diabetes educator/dietitian, a case manager, a pharmacist, nursing staff, a family medicine resident, a psychologist, and a board-certified family medicine attending physician. Patients were referred if their hemoglobin A1c (HbA1c) was ≥9% (75 mmol/mol); patients were seen for an initial consultation and for additional visits as needed. RESULTS: A total of 94 patients attended an initial visit and at least 1 follow-up within 6 months. Mean age was 57 ± 13 years, and 54% were female. Median time from the initial intensive diabetes clinic visit to a follow-up visit was 2.8 months. There was a significant reduction in median HbA1c percentage from 10.25% (88.5 mmol/mol) ± 1.4% (range 73–104 mmol/mol) at the initial intensive diabetes clinic visit to 8.7% (72 mmol/mol) ± 1.8% (range 52–92 mmol/mol) at a 1- to 6-month follow-up (z = −7.161, P < 0.001) and a significant difference between baseline HbA1c (10.25% [88.5 mmol/mol] ± 1.4% [range 73–104 mmol/mol]) and latest HBA1c (1–18 months later) 8.4% (68 mmol/mol) ± 2.2% (range 44–92 mmol/mol; z = −7.022, P < 0.001). Overall, 86% of patients had a lower HbA1c at follow-up, and 33% had an HbA1c 0.05). CONCLUSIONS: An interdisciplinary team approach to glycemic control can achieve significant reductions in HbA1c in the rural primary care setting.

Objectives Practice-based research networks (PBRNs) have been described as new clinical laboratories for primary care research and dissemination. PBRNs, however, have struggled to disseminate research results in a meaningful way to participating providers and clinics. Methods The Central Appalachia Inter-Professional Pain Education Collaborative was developed to work with PBRN clinics using quality improvement methods, deliver statewide continuing education activities to address the issue of opioid use in patients with chronic pain, and develop a multimodal mechanism to disseminate project results to clinics and participating providers. Results Successful change in the delivery of chronic pain care was dependent on the clinic's commitment to a team-based, patient-centered approach. Statistically significant improvements were shown in 10 of 16 process measures, and 80% of the participants agreed that the quality improvement process activity increased their knowledge and would improve their performance in managing patients with chronic pain, as well as patient outcomes in their practice. Conclusions The Central Appalachia Inter-Professional Pain Education Collaborative project used an extensive and innovative dissemination plan under the rubric of "continual dissemination." Unlike traditional dissemination efforts that focus on summary presentations, this initiative used a continual dissemination approach that updated participants quarterly through multiple means throughout the project, which improved engagement in the project.

OBJECTIVES The objective of this study was to assess the cardiovascular health status of baby boomers with diabetes mellitus (DM) in comparison to the same-age population with DM 10 years previously. METHODS The study was conducted in baby boomers with DM using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012 compared with NHANES 1999-2002. Cardiovascular health metrics were derived from the American Heart Association's Life's Simple 7. The primary outcome was the comparison of the proportion of individuals with each characteristic, including healthy diet, healthy weight, not smoking, exercising regularly, and maintaining an optimal level of glycated hemoglobin (HbA1C), cholesterol, and blood pressure. RESULTS Current baby boomers with DM (NHANES 2009-2012) had more obesity (70.9% vs 58.8%; P = 0.009) and a lower proportion of ideal physical activity (20.9% vs 31.7%; P = 0.01) than people of the same age 10 years ago; fewer than 1% adhere to an ideal healthy diet. Current baby boomers more often had ideal cholesterol (59.4% vs 47.2; P = 0.01) and reached an ideal HbA1C (51.0% vs 43.4%; P = 0.047). Blood pressure control, adherence to ideal diet, and smoking rates were not significantly different from 10 years ago. In logistic regression analyses controlling for likely confounders, baby boomers persisted in having more obesity and exercising less often, and reaching an ideal cholesterol level more often (P < 0.01). CONCLUSIONS Although improving in cholesterol and HbA1C, baby boomers demonstrated worsening in several key cardiovascular health indicators, particularly obesity and physical activity.

OBJECTIVES The dietary habits of baby boomers (people born between 1946 and 1964) undoubtedly will have a substantial impact on their future health; however, dietary information regarding the intake of key chronic disease-related nutrients is lacking for this generation. The objective of this study was to compare the dietary intake of key chronic disease-related nutrients of the baby boomer generation with the previous generation of middle-aged adults. METHODS National cross-sectional study comparison analyzing data from the National Health and Nutrition Examination Survey (NHANES) including NHANES III (1988-1994) and the NHANES for 2007-2010, focused on adult respondents ages 46 to 64 years who were not institutionalized at the time of each survey. The two cohorts were compared with regard to dietary intake of key nutritional components. The main outcome measures were intake of total calories, sodium, cholesterol, fat, fruits, vegetables, vitamin C, water, and fiber. RESULTS The baby boomers' average daily intake of nutrients exceeded that of the previous generation of middle-aged adults for total calories (2118/1999), total fat (82/76 g), sodium (3513/3291 mg), and cholesterol (294/262 g; all P < 0.001). The intake of vitamin C (105/89 g), water (1208/1001 g), and vegetables (199/229 g) was less than that of the previous generation (P < 0.001), and the dietary intake of fruit and fiber was unchanged. In regression analyses, dietary changes remained significant after controlling for age, race, sex, and socioeconomic status (all P < 0.01). CONCLUSIONS The study findings document higher dietary intake of key chronic disease-related nutrients along with reduced vegetable intake among baby boomers compared with the previous generation of middle-aged adults. These findings are indicative of a diet that may contribute to increased rates of chronic disease among individuals in this age group.

The objective of this study was to compare rates of use of medications for diabetes, hypertension, and hypercholesterolemia between 1988-1994 and 2001-2006 and determine whether increased medication use may be partly attributable to nonadherence to healthy lifestyle habits. This study analyzed and compared data from two different time periods in the National Health and Nutrition Examination Survey (NHANES). Disease prevalence rates increased 23% (P < 0.01), and medication use increased 121% (P < 0.05) over the study's period. Diabetes medication use increased from 5.3% to 8.7%, antihypertension medication from 23.0% to 32.4%, and cholesterol-lowering medication from 4.5% to 16.7% (all P < 0.05). By race, diabetes medication use increased most among Hispanics (7.2% to 13.2%), antihypertension use increased most among non-Hispanic blacks (30.8% and 39.6%), and cholesterol medication increased most in non-Hispanic whites (4.9% to 17.8%) (all P < 0.05). Greater adherence to healthy lifestyle habits was associated with less use of medication (P < 0.01). Medication use for diabetes, hypertension, and hypercholesterolemia has increased between 1988-1994 and 2001-2006 and is greater in people with fewer healthy lifestyle habits.

Recent evidence supports an association between elevation of inflammatory markers, such as C-reactive protein, and subsequent cardiovascular disease risk. The American Heart Association released guidelines in 2003 to help clinicians know when to use such markers. Because inflammatory markers are associated with diabetes, obesity, and hypertension, knowledge of the role of such markers is extremely important for prevention and chronic disease management. Newer studies published after the guidelines, and another recent review provide further documentation of the growing role of inflammation in cardiovascular risk. Based on the available literature, this article reviews the new guidelines, more recent evidence since the guidelines, and forms recommendations for primary care clinical practice.

Background The purpose of this study was to determine which patient-related factors are most strongly associated with having uncontrolled hypertension among outpatients. Methods A sample of 300 outpatients with diagnosed hypertension from three different settings was reviewed, focusing on demographics, comorbidity, adherence, and treatment factors. Regression analyses were conducted to determine which factors were associated with poor BP control (> 140 mmHg systolic or > 90 mmHg diastolic). Results Those most strongly associated with blood pressure control were men (OR 2.04, 95% CI 1.17-3.55) living in a rural setting (OR 0.30, 95% CI 0.16-0.55). Age, race, total number of medicines, number of visits, and the number of comorbidities were not significantly associated with poor blood pressure control in this population. Conclusions Being urban and male are strongly associated with uncontrolled hypertension. Public health blood pressure control efforts in the Southeast region should be directed toward this population.

Background: Patients facing end-of-life issues have spiritual concerns that may have an impact on their medical decision-making. Methods: To determine whether physicians address spiritual concerns in this context, we reviewed the charts of 92 elderly hospitalized patients facing decisions regarding resuscitation status or feeding tube placement. Results: The average age of the participants was 72.4 years and 51% of them were female. Only 6.5% of the patients had spiritual histories documented in their charts; 29% had either a spiritual history or some mention of chaplain or psychiatrist involvement. Conclusion: Spiritual concerns of many patients facing end-of-life decisions are not being addressed.

Objectives Although conceptually there is agreement on how the Patient-Centered Medical Home (PCMH) should be organized, there is little information regarding which PCMH components are the most important to patients. Methods An anonymous, voluntary survey was administered to patients at three US academic medical centers. Questions sought opinions regarding the National Committee for Quality Assurance's key components and essential elements of the PCMH. Analysis of the survey responses was conducted using SAS version 9.1. Results A total of 780 surveys were returned. Patients expressed believing strongly that the ability to coordinate care, help patients to manage their own disease, and track laboratory results were the most important aspects of a PCMH office. There were no differences in response to the survey according to age, sex, race, or site. Patients listed care coordination, patient self-management, and improved access to care as the top priority attributes of a PCMH. Conclusions Patients were consistent in their opinions that care coordination, access, and patient self-management were the most important elements of a PCMH.

Background: The objective of this study was to explore physician and practice characteristics according to sex. Method: All graduates of a southeastern state's family practice residency programs were surveyed. Results: Seven hundred fourteen (53.5%; 79.7% men, 20.3% women) surveys were returned and analyzed. Practice arrangements and practice settings did not differ significantly between the two study groups. Male graduates saw a significantly higher percentage of geriatric patients (28.9% versus 24.7%; P = 0.008) and made significantly more nursing home visits (50.6% versus 35.5%; P = 0.002) and home visits (49.0% versus 33.8%; P = 0.001) than female graduates. With the exception of skin biopsies, a greater percentage of male physicians performed procedures than female physicians. Female graduates and male graduates had the same initial salary but had a significantly different current salary range. No significant differences were seen in personal or career satisfaction. Conclusion: Practice patterns of male and female physicians were generally similar. However, significant differences were noted in geriatric care, procedures, and salary.

The purpose of this study was to explore the relationship between religious affiliation and obstetric outcome. We reviewed 1,919 records of patients whose infants were born at a university medical center. Data obtained from maternal and newborn records included demographic information, prenatal history, labor and delivery records, and religious affiliation. Maternal complications and neonatal intensive care unit (NICU) admissions were lowest for mainline Christians (11%, 11%), intermediate for evangelical Christians (17%, 12%), and highest for patients with no religious preferences (21%, 18%). After controlling for possible confounders, the association of religious affiliation and lower NICU admission rates remained. Mainline Christians had a lower frequency of maternal complications. Patients with a religious affiliation had better obstetric outcome than those without. Most of the association seems to be due to a lower risk social profile, but a small positive influence of religion persisted.