Search

Greater difficulty in controlling blood pressure (BP) and adverse lifestyle practices such as higher salt intake or less physical activity may account for some of the differences between BP control rates in Black vs White adults, thereby exposing Black adults to a higher risk of vascular events.To determine whether a lifestyle coaching intervention or an enhanced pharmacotherapy protocol is more effective than usual care in improving BP control rates in Black adults treated within an integrated health care delivery system.Shake, RattleRoll, a cluster randomized clinical trial, was conducted from June 5, 2013, to June 11, 2018, in a large integrated health care delivery system. Enrollment was completed during a 12-month period and interventions were implemented for 12 months. Follow-up lasted 48 months after enrollment. Panels of Black adult members of the health care delivery system with BP of at least 140/90 mm Hg from 98 adult primary care physicians were randomly assigned at the primary care physician level to usual care (UC group [n = 1129]), enhanced pharmacotherapy monitoring (EP group [n = 346]) of current BP management protocol, or diet and lifestyle coaching consisting of photographs, stories, and recipes, for example, that are appropriate for Black adults (LC group [n = 286]) focused on the Dietary Approaches to Stop Hypertension (DASH) diet. Data were analyzed from June 1, 2016, to March 25, 2022.The UC group received care per customary protocol. The EP group was contacted by a research nurse and/or a clinical pharmacist to discuss barriers to hypertension control, and drug therapy emphasized the use of thiazide diuretic intensification and addition of spironolactone as needed. The LC group received as many as 16 telephone sessions with a lifestyle coach and an emphasis on implementing reduction of sodium intake and the DASH diet.Intention-to-treat analysis of BP control rates at end of the 12-month intervention.Among the 1761 participants, the mean (SD) age was 61 (13) years, and 1214 (68.9%) were women. At the end of the 12-month intervention period, there was no significant difference in BP control rate among study groups (UC, 61.8% [95% CI, 58.8%-64.9%]; EP, 64.5% [95% CI, 59.0%-69.4%]; LC, 67.8% [95% CI, 62.1%-73.2%]; LC vs EP, P = .07). However, greater BP control was present in the LC group vs UC at 24 months (UC, 61.2% [95% CI, 57.3%-64.7%]; EP, 67.6% [95% CI, 61.9%-72.8%]; LC, 72.4% [95% CI, 66.9%-78.1%]; LC vs UC, P = .001), and 48 months (UC, 64.5% [95% CI, 61.6%-67.2%]; EP, 66.5% [95% CI, 61.3%-71.3%]; LC, 73.1% [95% CI, 67.6%-77.9%]; LC vs UC, P = .006) after enrollment. The contribution of BP medication adherence to explain group differences was inconclusive.In this cluster randomized clinical trial including Black adults with persistent uncontrolled hypertension, a 12-month LC intervention was more effective at controlling BP than UC at 24 and 48 months after enrollment. Further research is needed to explore the potential implementation of this intervention into clinical practice.ClinicalTrials.gov Identifier: NCT01892592.

Supplemental Digital Content is available in the text., Background and Purpose: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. Methods: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. Results: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92–104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130–136]; P

Objective Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)‐capable center is controversial. We sought to estimate the accuracy of field‐based identification of potential EST candidates in a hypothetical best‐of‐all‐worlds situation. Methods In Kaiser Permanente Northern California, all acute stroke patients arriving at its 21 stroke centers between 7:00 am and midnight from January 2016 to December 2019 were evaluated by teleneurologists on arrival. Initial National Institutes of Health Stroke Scale (NIHSS) score, presence of LVO, and referral for EST were obtained from standardized teleneurology notes. Factors associated with LVO were evaluated using generalized estimating equations accounting for clustering by facility. Results Among 13,377 patients brought in by EMS with potential stroke, 7168 (53.6%) were not candidates for acute stroke interventions. Of the remaining 6089 cases, 2,573 (42.3%) had an NIHSS score >10, the cutoff with a higher association for LVO. Only 703 patients (27.3% with NIHSS score >10) were ultimately diagnosed with LVO and referred for EST. Across all NIHSS scores, only 884 (6.6%) suspected acute stroke patients had LVO and EST referral. Conclusions Even if field‐based tools were as accurate as NIHSS scoring and predictions by stroke neurologists, only about 1 in 4 acute stroke patients diverted to EST‐capable centers would benefit by receiving EST. Depending on geography and stroke center performance on door‐to‐needle time, many systems may be better served by focusing on expediting evaluation, treatment with intravenous thrombolysis, and transfer to EST‐capable centers.

Background: Published data suggest that treating qualified acute strokes within the extended window (EW) or 6-24 hours of last seen normal with endovascular therapy (EST) is associated with better 90-day outcome. In a real-world multi-ethnic practice setting, we assessed our experience in triaging and treating patients in the EW. Methods: In 2016, our system of care launched a telestroke program for 19 primary and 2 comprehensive stroke centers to include immediate video evaluation by a stroke neurologist. In 2018, screening in the EW began. If the patient met clinical criteria (baseline independence and initial NIHSS ≥ 6), neuroimaging was performed to assess for a large vessel occlusion (LVO). Referral for EST was made for patients with an LVO and appropriate CT perfusion criteria. Our study included all health plan members presenting within the EW in 2019. Assessment included demographics, NIHSS, neuroimaging data, LVO, discharge outcomes, 90-day mRS and mortality with 95% confidence interval. Results: In 2019, there were 5349 suspected strokes (1255 EW) evaluated by teleneurologists; 2130 (39.8%) patients were appropriate for acute stroke imaging workup. Of 2130, final study cohort included 388 (18.2%) EW patients who met clinical criteria and underwent neuroimaging workup, and 117 of these patients (30.2%) had an LVO. There were 57 (14.7%) meeting CT perfusion criteria and referred for EST. Compared to 331 who were not referred for EST, the 57 patients were older and more likely to have atrial fibrillation, higher NIHSS, and to be discharged to a short-term facility than home. The 51 patients who went for EST within our system had 90-day good (mRS 0-2), bad (mRS 5-6), and mortality rates comparable to those from DAWN and DEFUSE-3 trials [Table]. Conclusions: In our system, only a small proportion of suspected strokes met criteria for EST during the EW. It was possible in a community setting to achieve 90-day outcomes that were comparable to those from clinical trials.

Background: Stroke patients have high rates of all-cause rehospitalization at 30 days (7-24%) and within one year (30-62%). Limited information is available on how to predict these outcomes. We assessed two existing predictive models and whether adding NIHSS or modified Rankin scale (mRS) score improved their predictive ability for 30-day non-elective rehospitalization and/or mortality post-stroke. Methods: Using a cohort of ischemic stroke patients in a large multi-ethnic integrated healthcare system from June 2010 to December 2017, we tested 2 existing predictive models for a composite outcome (30-day non-elective hospitalization or death). The models were based on administrative data (LACE) as well as a comprehensive model (Transition Support Level, TSL) that included multiple clinical data elements from the electronic health record, including admission acute physiology and discharge care directives. LACE score included information on length of stay, acuity, comorbidities, and emergency department visits. The models, NIHSS and mRS scores were tested independently, and in combination and combined with age and sex. We assessed model performance using the area under the receiver operator characteristic (c statistic), Nagelkerke pseudo-R 2 , and Brier score. Results: The study cohort included 4843 patients with 5,014 stroke hospitalizations. Average age was 71.9 ± 14 years with 50.6% female and 52.1% White. Median initial NIHSS was 4. Median length of stay was 4 days, and 55.6% were discharged home. There were 527 non-elective readmissions within 30 days. The logistic models revealed that the best performing models were TSL (c-statistic = 0.685) and TSL plus mRS score at discharge (c-statistic = 0.694) [Table]. Conclusions: We found that neither the initial NIHSS nor the mRS score at discharge enhanced the predictive ability of the LACE or TSL models. Future efforts at prediction of short-term stroke outcomes will need to incorporate new data elements.

Introduction Data on the comparative effectiveness of Diabetes Prevention Programs (DPPs) in the workplace are limited. Methods Between September 2015 and July 2016, employees of the City and County of San Francisco who were at risk for type 2 diabetes (N = 158) were randomly assigned to one of 2 DPP-derived programs recognized by the Centers for Disease Control and Prevention: an in-person YMCA-DPP (n = 78) or an online virtual lifestyle management DPP (VLM-DPP) offered through Canary Health (n = 80). The primary outcome was change in body weight assessed at 6 and 12 months. Follow-up ended in August 2017. Results Both the YMCA-DPP and VLM-DPP yielded a significant reduction in percentage body weight at 6 months. For the YMCA-DPP, mean percentage change at 6 months was -2.70% (95% confidence interval [CI], -3.91% to -1.48%) and at 12 months was -2.46% (95% CI, -4.24% to -0.68%). For the VLM-DPP, mean percentage change at 6 months was -2.41% (95% CI, -4.07% to -0.77%) and at 12 months was -1.59% (95% CI, -3.51% to 0.33%). The mean between-condition difference at 6 months was -0.25% (95% CI, -2.04% to 1.55%) and at 12 months was -0.84% (95% CI, -3.03% to 1.34%). No significant differences were observed between conditions. The YMCA-DPP had a slightly higher reduction in waist circumference than VLM-DDP at 6 months (mean between-condition difference -2.00 cm [95% CI, -4.24 to 0.25 cm]). Participant engagement, expressed as mean number of completed core program sessions, was significantly higher for the YMCA-DPP than the VLM-DPP. Participants of the YMCA-DPP completed an average of 10.2 sessions (95% CI, 9.0 to 11.4), and participants of the VLM-DPP completed an average of 5.9 sessions (95% CI, 4.7 to 7.1). The adjusted mean between-condition difference was 4.2 sessions (95% CI, 2.54 to 5.99). Conclusion Both the YMCA-DPP and VLM-DPP yielded weight loss at 6 months, which was maintained at 12 months in the YMCA-DPP. The workplace may be an effective setting to offer DPPs.

Background: Published data suggest that the faster acute stroke patients are treated with IV alteplase the better they do post discharge. It is not clear that reducing door-to-needle (DTN) time by 15 minutes (from 60 to 45 to 30) is associated with better functional outcome and/or less mortality. In a real-world practice setting, we assessed the effect of different DTN times on clinical outcomes. Methods: In 2016, a new standardized telestroke program for 21 stroke centers in an integrated healthcare system was launched. It included immediate evaluation by a stroke neurologist via video, expedited IV alteplase treatment, rapid CT angiographic study, and expedited transfer and treatment for patients with large vessel occlusion. From 2/15/18 to 2/25/19, we collected 90-day modified Rankin Score (mRS) for adult members who received IV alteplase. We also collected data on demographics, NIHSS, DTN times, thrombectomy, length of stay, discharge outcomes, 90-day mRS and mortality in those treated with IV alteplase stratified by the DTN time (60 vs. 45 vs. 30 minutes). Multivariate logistic regression was used to examine whether DTN category was predictive of good functional outcome (mRS=0-2) adjusted for age, gender, race, and NIHSS. Results: During the study period, the full cohort had 784 patients treated with IV alteplase. Average age was 71.5 ± 14.9 years with 51.8% female. Median NIHSS was 6. Median DTN time was 34 minutes. Those with faster DTN arrived more by EMS, had higher NIHSS, higher rate of thrombectomy, and shorter length of stay. A smaller cohort of 340 patients had a 90-day mRS. Multivariate models revealed a trend for faster DTN time being associated with less 90-day mortality (OR=0.81, p=0.24) and good functional outcome (OR=1.73, p=0.07) among EMS arrival (Table). Conclusions: In our study cohort, every 15-minute reduction in DTN had stronger association with better outcomes. Further efforts are underway to capture more complete mRS data for the full cohort.

Background: Risks and benefits of thrombectomy in elderly stroke patients remained unclear. We evaluated outcomes in the elderly who underwent endovascular therapy (EST) in a large integrated healthcare system. Methods: In 2016, our integrated healthcare system launched a new standardized acute telestroke care workflow for all 21 stroke centers. It included immediate evaluation by a stroke neurologist via video, expedited IV alteplase treatment, rapid CT angiographic investigation, and expedited transfer and EST for patients with large vessel occlusion (LVO). From January 2016 through December 2018, our study cohort included adult members who had EST within our care system. We compared patient characteristics, door-to-needle (DTN) times, door-to-groin (DTG) times, inpatient and 90-day mortality between those treated with EST aged Results: There were 291 acute stroke patients who underwent EST [Table]. The older subgroup had a higher percentage of female and higher rates of atrial fibrillation. They were more likely to arrive by EMS, to have a higher initial NIHSS and to have a faster DTN time. Average DTG times and inpatient mortality rates were not different between groups. The elderly had a higher rate of 90-day mortality. In multivariate model, being elderly was associated with higher 90-day mortality (OR=2.56, 95% CI 1.29-5.09, p=0.007). Conclusions: For those who underwent EST in a large community setting with a standardized approach to acute stroke treatment, being elderly was associated with a higher risk of 90-day mortality. Further data analyses are being carried out with additional co-morbidities, inpatient complications, and 90-day functional outcome to better understand outcomes in older patients undergoing EST.

Little is known about the prevalence of diabetes autoantibodies (DAA) among young adults newly diagnosed with diabetes (DM). Our objective was to identify patient characteristics associated with presence of DAA among 20-45-year-olds with new-onset DM from 2.3 million Kaiser Permanente California members. Patients underwent research testing for GADA, ZnT8A, IA2A and IAA. IAA results were not counted for patients with prior insulin use. Demographic and clinical data were from electronic health records. Models predicting any DAA positivity were trained on 70% of cases and validated on the remaining 30%. The best predictive logistic regression model was based on area under the receiver operating characteristic curve (AUC), parsimony and interpretability. Of 7,862 patients with incident DM (mean age 36.8±6.0 years, BMI 37.1 ±8.7), 1,669 (mean age 36.9 ±6.0 years, BMI 37.2 ±9.2) were tested for DAA ∼9.5 (±3.6) months post-diagnosis; 130 (7.8%) were positive (5.4% single DAA, 2.4% multiple DAA). Prevalence of GADA was 6.1%, IA2A 2.0%, IAA 1.9%, and ZnT8A 1.7%. The best model (Table) yielded AUCs of 0.74 and 0.68 in training and validation datasets, respectively. Association with DAA was positive for younger age, lower BMI, and glucagon prescription and negative for Asian race. These findings provide insights into patient characteristics associated with antibody positivity in young adults. Disclosure J.M. Lawrence: None. J. Slezak: None. X. Li: None. L. Yu: None. M. Rewers: None. H.S. Takhar: None. S.B. Sridhar: None. L.I. Vega-Daily: None. J.G. Alexander: None. J. Ritchie: None. S. Saydah: None. G. Imperatore: None. A. Ferrara: None. Funding Centers for Disease Control and Prevention (1U18DP006289); JDRF (2-SRA-2018-533-S-B)

Aims To estimate incidence of type 1 diabetes (T1D) and to develop a T1D prediction model among young adults. Methods Adults 20–45 years newly-diagnosed with diabetes in 2017 were identified within Kaiser Permanente’s healthcare systems in California and invited for diabetes autoantibody (DAA) testing. Multiple imputation was conducted to assign missing DAA status. The primary outcome for incidence rates (IR) and the prediction model was T1D defined by ≥1 positive DAA. Results Among 2,347,989 persons at risk, 7862 developed diabetes, 2063 had DAA measured, and 166 (8.0%) had ≥1 positive DAA. T1D IR (95% CI) per 100,000 person-years was 15.2 (10.2–20.1) for ages 20–29 and 38.2 (28.6–47.8) for ages 30–44 years. The age-standardized IRs were 32.5 (22.2–42.8) for men and 27.2 (21.0–34.5) for women. The age/sex-standardized IRs were 30.1 (23.5–36.8) overall; 41.4 (25.3–57.5) for Hispanics, 37.0 (11.6–62.4) for Blacks, 21.4 (14.3–28.6) for non-Hispanic Whites, and 19.4 (8.5–30.2) for Asians. Predictors of T1D among cases included female sex, younger age, lower BMI, insulin use and having T1D based on diagnostic codes. Conclusions T1D may account for up to 8% of incident diabetes cases among young adults. Follow-up is needed to establish the clinical course of patients with one DAA at diagnosis.

A nursing portfolio is a means of documenting skills such as communication, creativity, and critical thinking. More important, it reflects professional development, self-evaluation, and achievement of goals. Designing and implementing a portfolio enables traditional nursing students and RNs returning to school to describe their achievements during a specified period of time. For the adult student seeking scholastic or clinical credit for past work or life experiences, the portfolio provides a creative and structured way for this to be obtained without taking a standardized test.

Assessing the training needs of local public health workers is an important step toward providing appropriate training programs in emergency preparedness and core public health competencies. The North Carolina Public Health Workforce Training Needs Assessment survey was implemented through the collaboration of several organizations, including the North Carolina Center for Public Health Preparedness at the North Carolina Institute for Public Health, the outreach and service unit of the University of North Carolina School of Public Health, the Office of Public Health Preparedness and Response in the North Carolina Division of Public Health Epidemiology Section, and local health departments across the state.

Since its development in the 1960s, problem-based learning (PBL) has become increasingly prominent in nursing education. In 1998, Samford University received a grant from the PEW Charitable Trusts to promote, apply, and evaluate PBL in its undergraduate curriculum over three years. Nursing faculty approached this project with tenacity and enthusiasm. PBL has become integrated into the nursing curriculum in clinical and nonclinical courses. Descriptions of its implementation in specific courses are provided, and its usefulness in nursing education is discussed. Evaluations and test scores indicate that PBL has had a positive effect on the students and exceeded the educational outcomes anticipated by the faculty.