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BACKGROUND:Ischemic stroke continues to be a leading cause of serious disability within the United States, affecting 795 000 people annually. Approximately 12% to 21% of post–ischemic stroke patients will be readmitted to the hospital within 30 days of discharge. Studies suggest that implementation of a follow-up appointment within 7 to 14 days of discharge improves 30-day readmission rates; however, implementation of these guidelines is uncommon, and follow-up visits within the recommended window are not often achieved. The purpose of this project was to evaluate the impact of an advanced practice registered nurse (APRN)-led stroke clinic on follow-up care for post–ischemic stroke patients. The aims were to improve time to follow-up visit and reduce 30-day unplanned readmissions. METHODS:A pre/post intervention design was used to evaluate the impact of a process to access the APRN-led stroke clinic. The intervention included a scheduling process redesign, and subsequent APRN and scheduler education. RESULTS:The time to clinic follow-up preintervention averaged 116.9 days, which significantly reduced to 33.6 days post intervention, P= .0001. Unplanned readmissions within 30 days declined from 11.5% to 9.9%; however, it was not statistically significant, P= .149. Age was not statistically different between preintervention and postintervention groups, P= .092, and other demographics were similar between the groups. CONCLUSION:An APRN-led clinic can improve follow-up care and may reduce unplanned 30-day readmissions for post–ischemic stroke patients. Further work is needed to determine the impact of alternative approaches such as telehealth.

Increased treatment complexity in patients with diabetes contributes to medication nonadherence. Patient portals that are accessible through electronic health records may offer improved patient-provider communication and better medication management in patients with diabetes and uncontrolled hypertension. We conducted a prospective, mixed-methods evaluation of the Duke PillBox application, a SMART-on-FHIR medication management application integrated into the electronic health record patient portal. Adults with active portal status, diabetes, and uncontrolled hypertension participated in a usability/feasibility survey and communicated with a pharmacist via the portal-based application who conducted medication reconciliation and discussed medication indications, side effects, and barriers to use with patients. Of the eligible patients (n = 285), 29 (10%) were interested, and 12 (8%) participated. Challenges to usability were due to the electronic health record–portal communication interface (91%), browser access and compatibility (55%), and persistent lists of unused medications in the electronic health record (27%). The findings of this study suggest that electronic health record–integrated medication applications are desirable as indicated in patient interactions at the outset and conclusion of the study. Persistent challenges included electronic health record integration, interoperability, user interface, and browser connectivity for both patients and providers.

With advances in heart failure (HF) treatment, patients are living longer, putting further emphasis on quality of life (QOL) and the role of palliative care principles in their care. Spirituality is a core domain of palliative care, best defined as a dynamic, multidimensional aspect of oneself for which 1 dimension is that of finding meaning and purpose. There are substantial data describing the role of spirituality in patients with cancer but a relative paucity of studies in HF. In this review article, we explore the current knowledge of spirituality in patients with HF; describe associations among spirituality, QOL, and HF outcomes; and propose clinical applications and future directions regarding spiritual care in this population. Studies suggest that spirituality serves as a potential target for palliative care interventions to improve QOL, caregiver support, and patient outcomes including rehospitalization and mortality. We suggest the development of a spirituality-screening tool, similar to the Patient Health Questionnaire-2 used to screen for depression, to identify patients with HF at risk for spiritual distress. Novel tools are soon to be validated by members of our group. Given spirituality in HF remains less well studied compared with other patient populations, further controlled trials and uniform measures of spirituality are needed to understand its impact better

Heart failure is the leading cause of hospitalizations and readmissions. Guideline-directed medical therapy is the cornerstone to improving outcomes, but less than 20% of patients with heart failure marked by reduced ejection fraction receive target doses. This report reviews the neurohormonal cascade that occurs in heart failure and the role of guideline-directed medical therapy based on the results of landmark trials. In addition, evidence-based strategies to up-titrate medications are described. Nurse practitioners are in an optimal situation to titrate guideline therapy with frequent follow-up and monitoring.

Background:Nurse graduates (NGs) are ill prepared when faced with patient death and dying, despite receiving educational preparation on end-of-life (EOL) care in their prelicensure nursing programs.Method:This qualitative descriptive study included a convenience sample of NGs (This qualitative descriptive study included a convenience sample of NGs (n= 20) who experienced a first adult patient death during their first 18 months of practice at a large teaching hospital with an extensive NG transition program, including preceptor-guided orientations, nurse internship programs, and nurse residency programs.Results:Six major themes described the NG experience: Navigating the Process, Not Prepared, Support, Missed Opportunities, Preparing NGs for Death and Dying, and Guiding NGs Through Practice. Critical gaps in preparation were evident across all themes.Conclusion:Results of this study suggest specific opportunities for improvement of NGs' readiness to effectively care for patients and families in EOL situations by increasing their exposure to death and dying experiences before graduation and during their first year of practice. Results of this study suggest specific opportunities for improvement of NGs' readiness to effectively care for patients and families in EOL situations by increasing their exposure to death and dying experiences before graduation and during their first year of practice. [[J Contin Educ Nurs. 2020;50(6):267–273.]

Supplemental Digital Content is available in the text.Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study (Data Supplement) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

Nursing relies on the evidence to support best practice, like other scientific professions. The benefits of nursing research and phases involved in research project are discussed.

Clinical decision support systems are used to ensure compliance with guidelines and can assist providers in improving quality of care. This quality improvement initiative was designed to evaluate the use of a clinical decision support system to improve specialist referral rate for patients with severe aortic stenosis. A clinical decision support system for cardiology and primary care providers was implemented to improve diagnosis of severe aortic stenosis. The ordering provider received an electronic medical record in-basket alert providing feedback and recommendations for referral to specialist for evaluation. The echocardiogram data were evaluated for change in specialist referral rate. Before clinical decision support system implementation, the referral rate was 72% for a 3-month period. All providers ordering echocardiograms received clinical decision support system notification if patient results met criteria based on valve severity (aortic valve area < 1.0 cm2, mean gradient ≥ 40 mm Hg, peak velocity ≥ 4.0 m/s). After implementation, clinical decision support system referral rate was 97.5%, a 24.6% increase in referral rates (P< .001). Low referral rates for patients with severe aortic stenosis are a recognized challenge. Utilizing the clinical decision support system to improve awareness of quality guidelines and recommendations was associated with increased adherence to referral guidelines by providers. This innovation is pertinent to practice and enhances the functionality of the electronic medical record by providing real-time feedback to providers to improve practice. Referral rates for patients with severe aortic stenosis can be improved with use of provider clinical decision support system.

This article reports the process of adapting a research intervention to improve medication adherence among cardiovascular disease patients and translating it into community-based clinical programs.Relatively few successful medication adherence interventions are translated into real-world clinical settings. The Prevention of Cardiovascular Outcomes in African Americans with Diabetes (CHANGE) intervention was originally conceived as a randomized controlled trial to improve cardiovascular disease-related medication adherence and health outcomes. The purpose of the study was to describe the translation of the CHANGE trial into two community-based clinical programs. CHANGE 2 was available to Medicaid patients with diabetes and hypertension whose primary care homes were part of a care management network in the Northern Piedmont region of North Carolina. CHANGE 3 was available to low-income patients receiving care in three geographical areas with multiple chronic conditions at low or moderate risk for developing cardiovascular disease. Adaptations were made to ensure fit with available organizational resources and the patient population’s health needs. Data available for evaluation are presented. For CHANGE 2, we evaluated improvement in A1c control using paired ttest. For both studies, we describe feasibility measured by percentage of patients who completed the curriculum. CHANGE 2 involved 125 participants. CHANGE 3 had 127 participants. In CHANGE 2, 69 participants had A1c measurements at baseline and 12-month follow-up; A1c improved from 8.4 to 7.8 (p= .008). In CHANGE 3, interventionists completed 47% (n= 45) of calls to enroll participants at the 4-month encounter, and among those eligible for a 12-month call (n= 52), 21% of 12-month calls were completed with participants. In CHANGE 2, 40% of participants (n = 50) completed all 12 encounters. Thoughtful adaptation is critical to translate clinical trials into community-based clinic settings. Successful implementation of adapted evidence-based interventions may be feasible and can positively affect patients’ disease control.

Recent studies have drawn attention to nonclinical factors to better understand disparities in the development, treatment and prognosis of patients with cardiovascular disease. However, there has been limited research describing the nonclinical characteristics of patients hospitalized for cardiovascular care.

Nursing professional development practitioners are in a key position to use tools that foster nurses’ interpretation of research findings for increased use of evidence in practice. An online course was developed to teach statistics as language. The feasibility and efficacy of this “Language of Data” program were examined in a pilot study with a convenience sample from inpatient settings. Recognition and interpretation of statistical symbols significantly improved after the intervention. Knowledge, confidence, and accuracy also improved. The Language of Data program may be used by nursing professional development practitioners to improve nurses’ adoption of evidence-based practice by furthering their ability to translate science.

Behavioral challenges are often present in human illness, so behavioral economics is increasingly being applied in healthcare settings to better understand why patients choose healthy or unhealthy behaviors. The application of behavioral economics to healthcare settings parallels recent shifts in policy and reimbursement structures that hold providers accountable for outcomes that are dependent on patient behaviors. Numerous studies have examined the application of behavioral economics principles to policy making and health behaviors, but there are limited data on applying these concepts to the management of chronic conditions, such as heart failure (HF). Given its increasing prevalence and high associated cost of care, HF is a paradigm case for studying novel approaches to improve health care; therefore, if we can better understand why patients with HF make the choices they do, then we may be more poised to help them manage their medications, influence daily behaviors, and encourage healthy decision making. In this article, we will give a brief explanation of the core behavioral economics concepts that apply to patients with HF. We will also examine how to craft these concepts into tools such as financial incentives and social networks that may improve the management of patients with HF. We believe that behavioral economics can help us understand barriers to change, encourage positive behaviors, and offer additional approaches to improving the outcomes of patients with HF.

Introduction:Fragmentation in heart failure (HF) care transitions occur disproportionately among those adversely affected by social drivers of health. Social network analysis (SNA) may provide new insights into barriers to equitable care. Purpose:To assess the nature and structure of clinician networks across health system settings of care during care transitions.Methods:An explanatory sequential mixed-methods design was used. We stratified a purposeful sample (n=11) from a cohort of adults (n=1269) first hospitalized for HF between 2016 and 2018 by race, Medicaid use, and Area Deprivation Index, adjusting for risk (3M Clinical Risk Groups Severity of Illness Score and Charlson Comorbidity Index). EHR clinical notes were used to construct patients' clinician networks 1-year before, during, and after the index hospitalization using patient-sharing (2-mode) SNA. Patients' clinician positional and structural network measures were integrated with qualitative analyses of clinical notes.Results:Socioeconomically advantaged patients used fewer acute care services and lived longer. They tended to have higher network density and clinicians more centrally located in the health system network earlier and across settings and frequent telephone notes between visits that indicated reciprocal communication patterns among patients and clinicians shown in contents. Close care relationships and early involvement of influential providers measured by high Eigenvector centrality may be vital for smooth care transitions.Conclusions:Barriers to care coordination may result from variability in clinician networks. Well-connected clinician teams and consistent and reciprocal communication between patients and outpatient care teams are associated with more effective care coordination. Patients with clinicians in central and bridge positions within a health system network may receive higher quality care due to greater social capital and influence.

Adherence to proven, effective medications remains low, resulting in high rates of clinical complications, hospital readmissions, and death. The use of technology to identify patients at risk and to target interventions for poor adherence has increased. This review focuses on research that tests these emerging technologies and evaluates the effect of technology-based adherence interventions on cardiovascular outcomes.

Background:Disparities in hypertension and cardiovascular outcomes among Black men in the US are influenced by social determinants of health (SDOH) and systemic inequity. Self-measured blood pressure (SMBP) monitoring programs may be an efficacious strategy to combat these disparities in the community setting. Leveraging the advantages of SMBP, however, requires improved understanding of barriers to engagement in this population.Methods:A total of 258 Black male patients of a Federally Qualified Health Center, with severe hypertension (>160mm Hg systolic or >100mm Hg diastolic) were eligible. Patients were called using the phone number(s) in the electronic health record (EHR), and callers documented brief summaries of the call. At least 3 attempts were made to offer a free BP cuff, and provide longitudinal SMBP education and heart-healthy lifestyle counseling. NVivo was used for coding and content analysis, employing mixed inductive and deductive approaches to identify barriers to engagement. Coding structure included ‘communication’ and ‘engagement’, stratified by positive and negative attributes.Results:Analysis of initial outreach data (n=172) highlighted themes of unfavorable engagement to include excessive burden from competing health priorities and socioeconomic stress, and communication themes included unreliable phone numbers in the EHR hindering contact, and skepticism/mistrust of the caller by those patients reached. (Table).Conclusion:Optimizing engagement in SMBP programs to address hypertension disparities remains challenging, however improved SDOH screening and resource connection, system practices in EHR integrity, and understanding of patient mistrust of the health system may be key considerations. Ongoing thematic analyses on sustained SMBP skill-building and patient trust in care navigation may provide further insight on strategies to improve racial disparities in cardiovascular health outcomes.

Introduction:Delirium is common in cardiac intensive care units due to illness related stress, polypharmacy, interventions, excessive light and noise, disorientation and sleep disruption. Delirium assessment is poor due to limited nursing knowledge and the lack of integrated features in electronic health platforms (EHR) to support accurate assessment and documentation.Hypothesis:We hypothesized that education on use of the Confusion Assessment Method for the ICU (CAM-ICU) and enhanced features in the EHR would improve the ability to detect delirium in our CTICU.Methods:We conducted a QI intervention using a PDSA approach and pre-post evaluation design. In the Planningphase audited 100 randomly selected charts to determine baseline documentation of delirium. We conducted a survey of nurses’ knowledge of delirium and documentation criteria and identified a knowledge deficit. In the Dophase, a multi-stage educational initiative was used to address delirium awareness, knowledge, and CAM-ICU documentation competency. Enhancements in the EHR were made to enable accurate assessment, documentation and scoring using embedded logic. Post-intervention audits (n=100) were performed.Results:Survey respondents (n=64) averaged 31 years old (SD 1.4) and had 6 years nursing experience on average (median=3, range <1-40). Nurses believed patients with delirium had longer ICU LOS and worse outcomes and patients would benefit from screening. Most lacked training in delirium screening (88.1%, n=58). Baseline documentation of at least one assessment of delirium was 44% (n=44) and post-intervention was 100% (p<0.001). Accuracy of CAM-ICU assessments at baseline was challenging to determine due to a single field (YES/NO/UTA) in the EHR, however, positivity of pre-intervention assessments was 1% (n=1) and post- intervention at least 1 positive CAM score was recorded in 33% (n=33) of patients (p<0.001).Conclusions:Findings suggest that a multi-stage educational intervention paired with EHR integrated scoring logic improves awareness, knowledge and documentation accuracy for delirium in the ICU, which may improve patient safety and ICU outcomes. Better assessment and documentation may improve patient safety and ICU outcomes.

Introduction:Use of guideline-directed medical therapy (GDMT) is suboptimal in practice and often better in patients enrolled in clinical trials. We sought to investigate whether care differed for patients with heart failure with reduced ejection fraction (HFrEF) recently enrolled in a pharmaceutical trial versus those in a pragmatic implementation study.Methods:DAPA-HF was a randomized trial of dapagliflozin versus placebo that included patients with HFrEF, and standard background GDMT was required unless contraindicated or not tolerated. CONNECT-HF was a site-level cluster randomized pragmatic trial that included patients discharged after admission for decompensated HFrEF, with the goal of improving GDMT at one year. Each study required patient informed consent. Medication use data includes the total population at the time of enrollment in DAPA-HF and at one year in CONNECT-HF.Results:CONNECT-HF enrolled U.S. patients who were younger, more likely female, and more often Black (Table 1). Patients in DAPA-HF had significantly higher use of all classes of GDMT at any dose and at ≥ 50% target dose (Figure 1). Unadjusted mortality was lower in DAPA-HF (Table 1).Conclusions:Use of GDMT was substantially better and mortality was lower in a traditional randomized trial than in a pragmatic implementation trial. Whether this is due to differences in the populations, site care teams, or intensity of care and monitoring is unknown. The protocol-driven aspects of traditional trials are worthy of further study to improve care provided in standard practice. These observations also support inclusion of patients in randomized trials given the excellent care and outcomes in that setting.

Background:Research on the patient experience during cardiac catheterization is lacking. Opportunity exists to improve the delivery of procedural sedation to positively impact patient’s report of pain, comfort and satisfaction. We aim to evaluate if the time interval between procedural sedation and subcutaneous lidocaine influences patient experience.Methods:We conducted a prospective, randomized controlled study to determine the effect of 2 time intervals (<6 minutes vs >7 minutes) on 1) total medication dosage, 2) patient-reported and observed pain and 3) patient satisfaction in 175 adults undergoing elective, outpatient cardiac cath from December 2020 to April 2021. Patient reported pain and satisfaction were assessed using the Procedural Sedation Assessment Survey. Observed pain was assessed using the Behavioral Pain Assessment Tool. Generalized linear mixed models were used to analyze the effect of time interval on total medication dose, pain and satisfaction.Results:Of 175 patients randomized, 9 were excluded and 5 withdrew. In the final sample (n=161), the mean age was 62 (SD 13.4), a majority were male (106, 66%), white (117, 74%), with a mean BMI of 28.5 (SD 5.6). Total procedural sedation did not differ between groups. Likewise, patient-reported pain and satisfaction and observed measures of pain did not differ, even after adjustment for age, sex, race, BMI, fellow involvement, vascular access and procedure type.A 3-way interaction was found between procedure type, group assignment, and reported pain during the procedure (p=0.03). Patients undergoing PCI, with intervals <6 minutes self-reported more intra-procedural pain, despite post hoc analysis showing patients undergoing PCI had higher total medication dosages of both fentanyl and midazolam (p<0.001 & p<0.001) in both groups.Conclusions:No differences were found between groups related to total medication dose, pain or satisfaction regardless of timing between sedation and lidocaine. However, the findings suggest that longer intervals may reduce reported pain among patients undergoing PCI. Further investigation of sedation timing during PCI is needed to potentially improve the patient experience.

Introduction:Rates of uncontrolled hypertension are higher in Black men than in the general population. Prior studies have shown that home self-monitoring of blood pressure (SMBP), in addition to clinical support and education, helps patients lower their blood pressure (BP). This study evaluated a SMBP program for Black men with hypertension at a Federally Qualified Health Center (FQHC).Hypothesis:We hypothesized that virtual outreach would increase SMBP adoption and lower BP among Black Men at a FQHC.Methods:Black men >18 years old with severe hypertension (>160 mmHg systolic or > 100 mmHg diastolic) were contacted by student volunteers and offered a free BP cuff with program enrollment. Students attempted >4 calls with each participant over the course of 2 plan-do-study-act (PDSA) cycles. Students provided BP education and asked participants to report SMBP readings. Univariate analyses were performed to explore the effect of our SMBP program on clinic BPs.Results:Of 258 eligible, 137 (53.1%) were successfully contacted and 82 (31.8%) received a BP cuff. By the end of PDSA cycle 2, 52 men (20.2%) had reported a BP reading to their student caller. For those who had an updated BP documented in the medical record after cycle 1, subsequent office systolic BP changed by an average of -24.9 (95% CI: -30.8, -19.0) mmHg for the 37 men who used their BP cuff (p<0.001) and by -21.4 (95% CI: -25.1, -16.8) mmHg for the 108 men who did not (p<0.001). The reduction in BP was larger for the group that used BP cuffs (difference -3.5 [95% CI: -12.1, 5.1] mmHg, p=0.35), but this change was not statistically significant.Conclusions:Creating partnerships via virtual communication between university students and community members led to adoption of SMBP among Black men. BP reduction trended greater in the group that began self-monitoring, but difficulty in follow-up and a small sample size limited statistical power.

Introduction:Re-hospitalization for patients with heart failure (HF) is a persistent challenge. Person-oriented analysis may highlight heterogeneities and inform strategies to avert acute-care utilization.Purpose:To evaluate how outpatient utilization and sociodemographic, health behavior, and clinical factors are associated with high acute-care utilization using trajectory modeling.Methods:This retrospective cohort study used group-based trajectory modeling to identify latent groups of emergency department (ED), inpatient, and outpatient utilization one year before and after the initial HF hospitalization in adults (n= 1269) who had the index hospitalization between January 2016 and December 2018. Factors associated with high acute-care utilization were assessed by multinomial logistic regression.Results:People with medium or high outpatient utilization (44.9%) versus those with low outpatient utilization (37.7%) were associated with higher acute-care utilization after controlling for other significant factors such as insurance and comorbidities. Patients had six distinct typologies of acute-care utilization (Figure 1). Four typologies (14.3%) with higher acute-care utilization (ED or inpatient or both) accounted for 52% and 33.0% of the total ED and inpatient encounters. However, the association between outpatient and higher acute-care utilization was not significant among people with fluctuating outpatient utilization (17.4%).Conclusions:A person-oriented approach characterizing heterogeneity in acute-care utilization complements the hospital-focused 30-day readmission metric by revealing patients’ unique changes in utilization over time. High-frequency outpatient care may indicate fragmented care. Developing tailored interventions in the outpatient setting to address the small subgroup of patients with consistently high ED or inpatient utilization may improve re-hospitalization for patients with HF.

Research begins with the patient. Nurses, as central figures in providing patient care, are increasingly being called upon to develop and lead initiatives that define what patient care is, and should become for the future. By participating in clinical practice work groups, leading patient care standards committees, and developing process improvement programs, nurses are using research to improve patient care. In this article, research strategies are presented that incorporate not only where to begin in the research process, but also the importance of incorporating teamwork and fun into the clinical research equation.

Advances in the understanding of ACS have occurred rapidly in the last 5 years and have changed dramatically the way patients are evaluated, diagnosed, and managed. Medical improvements in antiplatelet and antithrombin agents have created a new world of therapeutic options for patients with ACS. These advances promise better outcomes for patients who experience coronary events, including more rapid and effective diagnostics, improved myocardial reperfusion, and faster, more effective stabilization of the ruptured plaque surface, thereby deterring subsequent ischemic events. Nurses who care for patients with ACS have much to learn and look forward to in the coming years regarding the role of inflammatory mechanisms in ACS and the implications these mechanisms may have for cardiovascular patients.

Supplemental Digital Content is available in the text.Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.

Introduction:Severe hypertension (180+ systolic or 110+ diastolic) is associated with a two-fold increase in relative risk of death. Interventions to date fail achieve sustained improvement in blood pressure, particularly in regional areas of high social disparity.Hypothesis:A community-based intervention using a multidisciplinary outreach model in primary care (PC) will lower blood pressure (BP) in patients with severe hypertension.Methods:A quality improvement project was performed in three, 3-month Plan Do Study Act cycles. A team of PC providers, nurses, patient navigators, behavioral health staff and pharmacists at a Federally Qualified Health Center (FQHC) reached out to 235 adult patients with severe hypertension viatelephone, mail, and face-to-face.Results:Of the 235 patients, average age was 57 years (S.D.), 37% (n=87) were male, 80% (n=188) were Black and 45% (n=106) were uninsured. The majority of patients contacted (77%, n=181) attended a follow-up appointment within the 9-month project. A majority of patients (92%, n=167) ended the project with an improved systolic BP (average decrease 33 mmHg); and improved diastolic BP, (80%, n=146, average decrease 15 mmHg ). Many (29%, n=53) attained goal BP (<140/90mmHg) by their last visit. Medication possession ratio improved from 23% to 40% among patients reached by pharmacists (n=30). There were fewer deaths in those reached by the Severe Hypertension Outreach (SHO) team as compared to those not reached (n=1 vs 3).Conclusions:Multidisciplinary outreach and use of evidence-based guidelines (JNC 8) was associated with lower BPs in patients with severe hypertension. Further evaluation is needed to determine effect of outreach among hypertensive patients with comorbid substance abuse.

Introduction:Diabetes affects>29 million Americans and is the seventh-leading cause of death in the United States. The use of guideline-based therapies improves outcomes, but actual adoption in clinical practice varies.Hypothesis:We explored guideline adoption including medication initiation, patient education, and follow-up appointments for routine A1c testing in the first year following diabetes diagnosis across four socioeconomic strata.Methods:In this 5-year retrospective cohort study of a countywide population in the southeastern United States, we identified adults diagnosed with incident type 2 diabetes in 2009-2012 with follow-up through 2013. Guideline recommendations for medication initiation, patient education, and follow-up appointments for routine A1c testing were measured as binary endpoints. One-year clinical outcomes were measured.Results:Among 25,574 adults with diabetes, we identified 6.2% (n=1542) with incident type 2 diabetes. Of those, over half did not receive guideline recommended diabetes medications (57.5%), referral for diabetes education (16.4%), or follow-up appointments for A1c testing (42.4%). Implementation of guideline-based care did not differ by socioeconomic group (p=.164). Among those patients who did receive evidence-based treatment, A1c improved 2-2.5% in the first 100 days following diagnosis and was sustained at 12 months.Conclusions:Use of evidence-based medications, self-management education, follow-up appointments, and A1c testing was low across all four socioeconomic quartiles. Earlier implementation of evidence-based guidelines may improve population health, regardless of socioeconomic status.

Background:To reduce readmissions rates for patients admitted with acute myocardial infarction (AMI) or congestive heart failure (CHF), Duke University Hospital piloted a program in which patients were contacted by telephone within 72 hours of discharge and asked a set of structured questions believed to identify gaps in care to reduce the risk of readmission.