24-h ambulatory recording of aortic pulse wave velocity and central systolic augmentation: a feasibility study

We assessed the feasibility of ambulatory pulse wave analysis by comparing this approach with an established tonometric technique. We investigated 35 volunteers (45.6 years; 51.0% women) exclusively at rest (R study) and 83 volunteers (49.9 years; 61.4% women) at rest and during daytime (1000-2000 h) ambulatory monitoring (R+A study). We recorded central systolic (cSP), diastolic (cDP) and pulse (cPP) pressures, augmentation index (cAI) and pulse wave velocity (PWV) by brachial oscillometry (Mobil-O-Graph 24h PWA Monitor) and radial tonometry (SphygmoCor). We applied the Bland and Altman's statistics. In the R study, tonometric and oscillometric estimates of cSP (105.6 vs. 106.9 mm Hg), cDP (74.6 vs. 74.7 mm Hg), cPP (31.0 vs. 32.1 mm Hg), cAI (21.1 vs. 20.6%) and PWV (7.3 vs. 7.0 m s(-1)) were similar (P >= 0.11). In the R+A study, tonometric vs. oscillometric assessment yielded similar values for cSP (115.4 vs. 113.9 mm Hg; P=0.19) and cAI (26.5 vs. 25.3%; P=0.54), but lower cDP (77.8 vs. 81.9 mm Hg; P= 0.17) with cDP (r=0.15) or cPP (r=0.13). Irrespective of measurement conditions, brachial oscillometry compared with an established tonometric method provided similar estimates for cSP and systolic augmentation, but slightly underestimated PWV. Pending further validation, ambulatory assessment of central hemodynamic variables is feasible. Hypertension Research (2012) 35, 980-987; doi:10.1038/hr.2012.78; published online 24 May 201

Redesigning Primary Care Processes to Improve the Offering of Mammography: The Use of Clinic Protocols by Nonphysicians

OBJECTIVE: To develop, within the framework of continuous quality improvement, new processes for offering mammography and determine whether protocols executed completely by nonphysicians would increase mammography utilization. DESIGN: A prospective follow-up study with patients from an intervention clinic and two control clinics. SETTING: Three general internal medicine clinics in a large, urban teaching hospital in Detroit, Michigan. PATIENTS/PARTICIPANTS: A total of 5,934 women, aged 40 through 75 years, making 16,546 visits to one of the clinics during the study period (September 1, 1992, through November 31, 1993). INTERVENTION: Medical assistants and licensed practical nurses in the intervention clinic were trained to identify women due for screening mammography, and to directly offer and order a mammogram if patients agreed. MEASUREMENTS AND MAIN RESULTS: Patients were considered up-to-date with screening if they had a mammogram within 1 year (if age 50–75) or 2 years (if age 40–49) prior to the visit or a mammogram within 60 days after the visit. The proportion of visits each month in which a woman was up-to-date with mammography was calculated using computerized billing records. Prior to the intervention, the proportion of visits in which women were up-to-date was 68% (95% confidence interval [CI] 63%, 73%) in the intervention clinic and 66% (95% CI 61%, 71%) in each of the control clinics. At the end of the evaluation, there was an absolute increase of 9% (95% CI 2%, 16%) in the intervention clinic, and a difference of 1% (95% CI −5%, 7%) in one of the control clinics and −2% (95% CI −3%, 5%) in the other. In the intervention clinic, the proportion of visits in which women were up-to-date with mammography increased over time and was consistent with a linear trend (p = .004). CONCLUSIONS: Redesigning clinic processes to make offering of mammography by medical assistants and licensed practical nurses a routine part of the clinic encounter can lead to mammography rates that are superior to those seen in physicians’ usual practice, even when screening levels are already fairly high. Physicians need not be considered the sole, or even the primary, member of the health care team who can effectively deliver some preventive health measures