Use of Best Practice Alerts to Improve Adherence to Evidence-Based Screening in Pediatric Diabetes Care

Background: Youth with type 1 diabetes (T1D) are at increased risk for comorbid autoimmune conditions and long-term complications. To help with early identification of these complications, the American Diabetes Association (ADA) has published evidence-based screening guidelines. The aim of our quality improvement intervention was to improve and sustain adherence to the ADA recommended screening guidelines to \u3e90% for youth with T1D in the Texas Children’s Hospital (TCH) Diabetes Center by utilizing best practice alerts (BPA) within the electronic medical record (EMR). Methods: In accordance with the ADA Standards of Care screening guidelines for youth with T1D, we analyzed the database of TCH patients to obtain the following baseline percentages: 1) urine microalbumin-to-creatinine ratio, 2) thyroid function screen, 3) lipid panel, and 4) retinopathy screen. In the TCH EMR, we developed BPAs to alert providers and provide decision support on ADA-based screening recommendations at each clinic encounter. Comparisons were made to screening rates for each category pre- and post-intervention. Results: In the four years following the BPA build, the screening percentage for each category improved from a baseline of 90%, which has been maintained for three consecutive fiscal years. Conclusions: The use of EMR-based BPAs to alert providers of the need for evidenced-based screening is effective in increasing adherence to standard of care guidelines. With this quality improvement intervention, we achieved our goal of \u3e90% for each category. Similar tools for decision support may be effectively utilized for evidence-based screening in other disease states

Comparison of Blood Pressure and Blood Glucose Level Among Elderly with Non-communicable Disease

Due to increasing age, elderly are prone to non-communicable diseases (NCD), such as hypertension (HT) and diabetes mellitus (DM). Easy physical condition monitoring of people with HT and/or DM is by measuring their blood pressure (BP) and/or blood glucose level (BGL) periodically. This study aimed to compare and analyze the differences of BP and BGL among elderly with HT and/or DM in Bangkok and Surabaya. This cross-sectional study involved 100 and 96 elderly with HT and/or DM in communities of Bangkok and Surabaya respectively (n=196). There were three groups of samples which consisted of 60 DM, 68 HT, and 68 DM&HT cases. Instruments used were demography questionnaire, sphygmomanometer, and glucometer. Test of one-way ANOVA, Least Significant Difference (LSD), Kruskal-Wallis, and Mann-Whitney U were used for data analysis (α<.05). There was a significant difference of systolic and diastolic BP found between groups (p=.000 and p=.011 respectively), but no difference found between the groups of HT and DM&HT (p=.657 and p=.330 respectively). There was a significant difference of BGL found between groups (p=.002), but no difference found between the groups of HT and DM (p=.075) and between the groups of DM and DM&HT (p=.066). BP is significantly different between the group of HT and DM in term of systole and diastole, especially in elderly, but BGL is similar. The risk of being HT for elderly with DM is very high. Elderly with DM&HT have high BP and BGL similarly to those with single disease of HT or DM

Differential and Joint Effects of Metformin and Statins on Overall Survival of Elderly Patients with Pancreatic Adenocarcinoma: A Large Population-Based Study.

Background: Published evidence indicates that individual use of metformin and statin is associated with reduced cancer mortality. However, their differential and joint effects on pancreatic cancer survival are inconclusive.Methods: We identified a large population-based cohort of 12,572 patients ages 65 years or older with primary pancreatic ductal adenocarcinoma (PDAC) diagnosed between 2008 and 2011 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Exposure to metformin and statins was ascertained from Medicare Prescription Drug Event files. Cox proportional hazards models with time-varying covariates adjusted for propensity scores were used to assess the association while controlling for potential confounders.Results: Of 12,572 PDAC patients, 950 (7.56%) had used metformin alone, 4,506 (35.84%) had used statin alone, and 2,445 (19.45%) were dual users. Statin use was significantly associated with improved overall survival [HR, 0.94; 95% confidence interval (CI), 0.90-0.98], and survival was more pronounced in postdiagnosis statin users (HR, 0.69; 95% CI, 0.56-0.86). Metformin use was not significantly associated with overall survival (HR, 1.01; 95% CI, 0.94-1.09). No beneficial effect was observed for dual users (HR, 1.00; 95% CI, 0.95-1.05).Conclusions: Our findings suggest potential benefits of statins on improving survival among elderly PDAC patients; further prospective studies are warranted to corroborate the putative benefit of statin therapy in pancreatic cancer.Impact: Although more studies are needed to confirm our findings, our data add to the body of evidence on potential anticancer effects of statins. Cancer Epidemiol Biomarkers Prev; 26(8); 1225-32. ©2017 AACR

Effect of cardiometabolic risk factors on hypertension management: a cross-sectional study among 28 physician practices in the United States

<p>Abstract</p> <p>Objective</p> <p>This cross-sectional study sought to determine the prevalence of cardiometabolic risk factor clusters (CMRFCs) and their effect on BP control among hypertensive patients from 28 US physician practices.</p> <p>Methods</p> <p>Each participating practice identified a random sample of 150-300 adults aged ≥ 18 years diagnosed with hypertension. The primary outcome variable was BP control (BP < 140/90 mmHg for non-diabetic and <130/80 mmHg for diabetic patients). CMRFCs included hypertension in addition to obesity, dyslipidemia, and diabetes.</p> <p>Results</p> <p>Overall, 6,527 hypertensive patients were identified for study inclusion. More than half (54.3%) were female, and mean age was 64.7 years. Almost half (48.7%) were obese (BMI ≥ 30 kg/m²). About 1 in every 4 patients (25.3%) had diabetes, and 60.7% had dyslipidemia. Mean blood pressure was 132.5/77.9 mmHg, and 55.0% of all patients had controlled BP; 62.4% of non-diabetic patients, and 33.3% of diabetic hypertensive patients, had BP controlled to recommended levels. Most (81.7%) hypertensive patients had ≥ 1 cardiometabolic risk factor, and 12.2% had all 3 risk factors. As compared to hypertensive patients without additional risk factors, adjusted odds ratios for BP control were significantly lower for all combinations of CMRFCs (ORs 0.15-0.83, all p < 0.04), with the exception of patients who had only dyslipidemia in addition to hypertension (OR = 1.09, p = NS). Prescriber adherence to recommended hypertension treatment guidelines for patients with diabetes, heart failure, or prior myocardial infarction was high. Although patients with risk factors were prescribed more antihypertensive medications than those without, hypertensive patients with all 3 risk factors were prescribed a mean of 2.4 antihypertensive medications compared to 1.7 for those with no risk factors; odds of BP control in these patients, however, was 0.23 [95% CI 0.19-0.29] that of patients with no other CMRFCs.</p> <p>Conclusions</p> <p>Across 28 US practices, only 18% of hypertensive patients did not have any additional cardiometabolic risk factors. The high prevalence of CMRFCs presents a challenge to effective hypertension management.</p

Primary Stroke Prevention: 3-hydroxy-3-methyl-glutaryl-Coenzyme A (HMG-CoA) Reductase Inhibitor (statin) Use in the Diabetic Patient

Purpose: The primary objective for this retrospective chart review was to evaluate provider adherence to the 2011 AHA/ASA Primary Stroke Prevention guideline of prescribing a statin to all diabetic patients for primary prevention of stroke, regardless of dyslipidemia. A second aim of this study is to identify provider facilitators and barriers to prescribing a statin therapy for primary prevention. Methods: Using a retrospective study design, a random sample of 100 medical records of diabetic patients presenting to a university women’s health clinic within the previous year were reviewed for statin use and rationale. Results: Of the 100 diabetic patients sampled, only 69% were currently prescribed a statin therapy. Furthermore, only one patient had a diabetic rationale for statin use. Primary stroke prevention counseling and therapy aimed at prevention of primary stroke will be completed at a future date. Conclusion: In this clinic setting there is no documentation of adherence to the 2011 AHA/ASA Primary Stroke Prevention Guideline recommendation that statin therapy be used as a primary prevention in the diabetic population

Personalized management of dyslipidemias in patients with diabetes-it is time for a new approach (2022)

Dyslipidemia in patients with type 2 diabetes (DMT2) is one of the worst controlled worldwide, with only about 1/4 of patients being on the low-density lipoprotein cholesterol (LDL-C) target. There are many reasons of this, including physicians' inertia, including diabetologists and cardiologists, therapy nonadherence, but also underusage and underdosing of lipid lowering drugs due to unsuitable cardiovascular (CV) risk stratification. In the last several years there is a big debate on the risk stratification of DMT2 patients, with the strong indications that all patients with diabetes should be at least at high cardiovascular disease (CVD) risk. Moreover, we have finally lipid lowering drugs, that not only allow for the effective reduction of LDL-C and do not increase the risk of new onset diabetes (NOD), and/or glucose impairment; in the opposite, some of them might effectively improve glucose control. One of the most interesting is pitavastatin, which is now available in Europe, with the best metabolic profile within statins (no risk of NOD, improvement of fasting blood glucose, HOMA-IR, HbA1c), bempedoic acid (with the potential for the reduction of NOD risk), innovative therapies-PCSK9 inhibitors and inclisiran with no DMT2 risk increase, and new forthcoming therapies, including apabetalone and obicetrapib-for the latter one with the possibility of even decreasing the number of patients diagnosed with prediabetes and DMT2. Altogether, nowadays we have possibility to individualize lipid lowering therapy in DMT2 patients and increase the number of patients on LDL-C goal without any risk of new onset diabetes and/or diabetes control worsening, and in consequence to reduce the risk of CVD complications due to progression of atherosclerosis in this patients' group

Metabolic Syndrome Screening in Seriously Mentally Ill Patients: A Quality Improvement Project

A Project Submitted in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCE in Nursing ScienceSeriously mentally ill patients who are taking second-generation antipsychotics have a high risk of metabolic complications, including obesity, diabetes mellitus type II, hypertension, and hyperlipidemia. Guidelines to screen for metabolic syndrome were established by the American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, and North American Association for the Study of Obesity (Clark, 2004). Compliance with implementing the guidelines to screen and monitor for metabolic syndrome vary from regular monitoring to little or none. This quality improvement project provided an educational intervention on screening and monitoring for metabolic syndrome in patients who were seriously mentally ill. The educational interventions were attended by 21 psychiatric-mental health nurse practitioners. After the educational intervention was completed, there was significant improvement in provider knowledge as well as motivation to screen and monitor patients taking second-generation antipsychotic medications for metabolic syndrome. Education may motivate mental health providers to increase the use of metabolic screening guidelines for patients taking second-generation antipsychotic medications potentially improving long term outcomes for this patient population.Title Page / Abstract / Table of Contents / List of Appendices / Metabolic Syndrome in Seriously Mentally Ill Patients: A Quality Improvement Project / Background Significance / Literature Review / Purpose / Educational Intervention using an Evidence Based Practice Model / Methods / Dissemination / Significance to Nursing / Limitations / Summary and Conclusions / References / Appendice

Adherence to Guidelines of Secondary Prevention in patients with Ischemic Heart Disease in a Tertiary Cardiac Center

Background: Coronary heart disease (CHD) is the leading cause of death in United State (U.S.). Controlling of modifiable risk factors such as smoking, hypertension (HT), diabetes mellitus (D.M.), dyslipidemia, physical inactivity &amp; obesity will prevent other serious cardiovascular complications. Objective: This study was designed to determine the adherence of the patients who were known to have ischemic heart disease (I.H.D.) to the ACC/ AHA Guidelines of secondary prevention of I.H.D. Patients  and  methods : This is an outpatient  base  study ,was  conducted at the Iraqi Center of  Heart Disease  outpatient clinic  from    1st. of  October  2009 till 31st. of  March  2010.Where  two  hundred &amp; forty tow  (242) patients were selected. Variable data were taken from the patients as follows: age, gender.  Level of education, type of I.H.D., smoking habits, body weight &amp;height, hypertensive patients, the control of blood sugar by measuring of HbA1c level for the diabetic patients. Fasting lipid profile, renal function testes, Hb also were tested. Baseline cardiac investigations in  form of CXR, ECG, Echocardiography , TMT &amp; previous coronary angiography were reviewed  &amp; finally several questioners for the patients regarding their disease, risk factors, cardio protective drugs &amp;times of visits their physicians during a month. Results: One hundred &amp; sixty seven patients (69%) were smokers, (65%) of them quit smoking. (64%) were hypertensive, 57 % of them had uncontrolled HT. 16.5 % were diabetics, 90% of them had uncontrolled D.M. which is estimated by measurement of Hb1Ac &lt; 7%. (69%) were overweight, 24.4% of them were obese. Conclusion: Most of the patients included in the study were not reaching a goal according to AHA/ACC Guidelines of secondary prevention apart from quit smoking &amp; this may put them at high risk of development of further life threatening cardiovascular events like: recurrent ischemia, acute coronary syndrome, heart failure or even death. Keywords: Ischemic heart disease, ACC/AH Guideline, secondary prevention

Diabetes Guidelines Implementation Toolkit

Diabetes Guidelines Implementation Toolkit is a capstone project aimed to help the Grady North Fulton Health Center to implement the American Diabetes Association (ADA) “Standards in Medical Care in Diabetes, 2011” guidelines. This toolkit can also be used to implement the diabetes guidelines in any other primary or community healthcare facility to improve diabetes care. Diabetes can affect many parts of the body and can lead to serious complications such as blindness, kidney damage, and lower-limb amputations. Working together, people with diabetes, their support network, and their health care providers can reduce the occurrence of these and other diabetes complications by controlling the levels of blood glucose, blood pressure, blood lipids, and by receiving other preventive care practices in a timely manner. Once the decision to put into practice the evidence-based diabetes guidelines has been made, this implementation toolkit will serve as a guide to help go through the process of implementation. The toolkit will suggest practical ways to implement the use of the guidelines using a stepwise approach, resources and template materials such as information handouts, flow sheets, referral forms, sample patient letters, etc. will be provided in the toolkit to facilitate the implementation. The final goal of the implementations is to improve the delivery of effective preventive health care services and promote diabetes preventive behaviors in order to prevent diabetes, its complications and disabilities, and the burden associated with the disease

The clinical link between type D personality and diabetes

Introduction: Type D personality consists of a mixture of high levels of negative affectivity and social inhibition, resulting in a stable tendency to experience negative emotions, by inhibiting the expression of these emotions. We have reanalyzed the clinically relevant studies examining the role of this personality profile in diabetes, by providing a qualitative synthesis of the data. In this regard, the aim of this study is to provide a systematic review by evaluating the clinical link between Type D personality and diabetes. Method: When focusing on PRISMA guidelines, we have performed a comprehensive research of the literature on PubMed, Scopus, ScienceDirect, ISI Web of Science, PsycINFO, and Google Scholar by using search terms as "distressed personality" OR (i.e., Boolean operator) "Type D personality" combined with the Boolean "AND" operator with "diabetes." Results: A total of seven research studies were identified and included in the review. Type D was found to be more prevalent in diabetes patients than controls. As regards the specific association with diabetes variables, Type D personality is a significant predictor of both poor medication adherence and unhealthy behaviors, by predicting negative mental health consequences also (i.e., depressed mood, anhedonia, and anxiety). Conclusion: Our review emphasized for the first time that Type D personality affects clinical factors in patients with diabetes by provoking adverse outcomes. The core implication of the study comprises the clinical relevance to detect, from a clinimetric point of view, Type D personality in diabetes in order to prevent potentially negative clinical outcomes