Prevalence of antiplatelet therapy in patients with diabetes

OBJECTIVE: To determine the prevalence of, and patient characteristics associated with, antiplatelet therapy in a cohort of primary care patients with Type 1 or Type2 diabetes. METHODS: Subjects participating in a randomized trial of a decision support system were interviewed at home and medication usage verified by a research assistant. Eligibility for antiplatelet therapy was determined by American Diabetes Association criteria and clinical contraindications. The association between antiplatelet use and patient characteristics was examined using bivariate and multivariate logistic regression. RESULTS: The mean age of subjects was 64 years (range 31–93). The prevalence of antiplatelet use was 54% overall; 45% for subjects without known CVD vs. 78% for those with CVD; 46% for women vs. 63% for men; and 45% for younger subjects (age< 65) vs. 62% for senior citizens. After controlling for race/ethnicity, income, education, marital status, insurance status and prescription coverage, the following were associated with the use of antiplatelet therapy: presence of known CVD (OR 3.4 [2.2, 5.1]), male sex (OR 2.0 [1.4, 2.8]), and age > = 65 (OR 1.9 [1.3, 2.7]). The prevalence of antiplatelet therapy for younger women without CVD was 32.8% compared to a prevalence of 90.3% for older men with CVD. CONCLUSION: Despite clinical practice guidelines recommending antiplatelet therapy for patients with diabetes, there are still many eligible patients not receiving this beneficial therapy, particularly patients under 65, women, and patients without known CVD. Effective methods to increase antiplatelet use should be considered at the national, community, practice and provider level

Limitations of diabetes pharmacotherapy: results from the Vermont Diabetes Information System study

BACKGROUND: There are a wide variety of medications available for the treatment of hyperglycemia in diabetes, including some categories developed in recent years. The goals of this study were to describe the glycemic medication profiles in a cohort of adult patients enrolled in primary care, to compare the regimens with measures of glycemic control, and to describe potential contraindicated regimens. METHODS: One thousand and six subjects with diabetes cared for in community practices in the Northeast were interviewed at home at the time of enrollment in a trial of a diabetes decision support system. Laboratory data were obtained directly from the clinical laboratory. Current medications were obtained by direct observation of medication containers by a research assistant. RESULTS: The median age of subjects was 63 years; 54% were female. The mean A1C was 7.1%, with 60% of subjects in excellent glycemic control (A1C < 7%). Ninety percent of patients were taking 2 or fewer medications for glycemic control, with a range of 0 to 4 medications. Insulin was used by 18%. As the number of diabetes medications increased from 0 to 4, the A1C increased from 6.5% to 9.2% (p < 0.001). The association between glycemic control and number of glycemic medications was confirmed using logistic regression, controlling for potential confounders. Almost 20% of subjects on metformin or thiazolidenediones had potential contraindications to these medications. CONCLUSION: Patients with diabetes cared for in primary care are on a wide variety of medication combinations for glycemic control, though most are on two or fewer medications. A greater number of diabetes medications is associated with poorer glycemic control, reflecting the limitations of current pharmacotherapy. One quarter of patients are on glycemic medications with potential contraindications

Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes

BACKGROUND: Inconsistent findings reported in the literature contribute to the lack of complete understanding of the association of literacy with health outcomes. We evaluated the association between literacy, physiologic control and diabetes complications among adults with diabetes. METHODS: A cross-sectional study of 1,002 English speaking adults with diabetes, randomly selected from the Vermont Diabetes Information System, a cluster-randomized trial of a diabetes decision support system in a region-wide sample of primary care practices was conducted between July 2003 and March 2005. Literacy was assessed by the Short-Test of Functional Health Literacy in Adults. Outcome measures included glycated hemoglobin, low density lipoprotein, blood pressure and self-reported complications. RESULTS: After adjusting for sociodemographic characteristics, duration of diabetes, diabetes education, depression, alcohol use, and medication use we did not find a significant association between literacy and glycemic control (beta coefficent,+ 0.001; 95% confidence interval [CI], -0.01 to +0.01; P = .88), systolic blood pressure (beta coefficent, +0.08; 95% CI, -0.10 to +0.26; P = .39), diastolic blood pressure (beta coefficent, -0.03; 95% CI, -0.12 to +0.07, P = .59), or low density lipoprotein (beta coefficent, +0.04; 95% CI, -0.27 to +0.36, P = .77. We found no association between literacy and report of diabetes complications. CONCLUSION: These findings suggest that literacy, as measured by the S-TOFHLA, is not associated with glycated hemoglobin, blood pressure, lipid levels or self-reported diabetes complications in a cross-sectional study of older adults with diabetes under relatively good glycemic control. Additional studies to examine the optimal measurement of health literacy and its relationship to health outcomes over time are needed

Strategic sensemaking by social entrepreneurs:Creating strategies for social innovation

Purpose: This study explores how a small minority of social entrepreneurs break free from third sector constraints to conceive, create and grow non-profit organisations that generate social value at scale in new and innovative ways. Design/methodology/approach: Six narrative case histories of innovative social enterprises were developed based on documents and semi-structured interviews with founders and long serving executives. Data were coded “chrono-processually”, which involves locating thoughts, events and actions in distinct time periods (temporal bracketing) and identifying the processes at work in establishing new social ventures. Findings: This study presents two core findings. First, the paper demonstrates how successful social entrepreneurs draw on their lived experiences, private and professional, in driving the development and implementation of social innovations, which are realised through application of their capabilities as analysts, strategists and resources mobilisers. These capabilities are bolstered by personal legitimacy and by their abilities as storytellers and rhetoricians. Second, the study unravels the complex processes of social entrepreneurship by revealing how sensemaking, theorising, strategizing and sensegiving underpin the core processes of problem specification, the formulation of theories of change, development of new business models and the implementation of social innovations. Originality/value: The study demonstrates how social entrepreneurs use sensemaking and sensegiving strategies to understand and address complex social problems, revealing how successful social entrepreneurs devise and disseminate social innovations that substantially add value to society and bring about beneficial social change. A novel process-outcome model of social innovation is presented illustrating the interconnections between entrepreneurial cognition and strategic action.</p

The Single Item Literacy Screener: Evaluation of a brief instrument to identify limited reading ability

BACKGROUND: Reading skills are important for accessing health information, using health care services, managing one's health and achieving desirable health outcomes. Our objective was to assess the diagnostic accuracy of the Single Item Literacy Screener (SILS) to identify limited reading ability, one component of health literacy, as measured by the S-TOFHLA. METHODS: Cross-sectional interview with 999 adults with diabetes residing in Vermont and bordering states. Participants were randomly recruited from Primary Care practices in the Vermont Diabetes Information System June 2003 – December 2004. The main outcome was limited reading ability. The primary predictor was the SILS. RESULTS: Of the 999 persons screened, 169 (17%) had limited reading ability. The sensitivity of the SILS in detecting limited reading ability was 54% [95% CI: 47%, 61%] and the specificity was 83% [95% CI: 81%, 86%] with an area under the Receiver Operating Characteristics Curve (ROC) of 0.73 [95% CI: 0.69, 0.78]. Seven hundred seventy (77%) screened negative on the SILS and 692 of these subjects had adequate reading skills (negative predictive value = 0.90 [95% CI: 0.88, 0.92]). Of the 229 who scored positive on the SILS, 92 had limited reading ability (positive predictive value = 0.4 [95% CI: 0.34, 0.47]). CONCLUSION: The SILS is a simple instrument designed to identify patients with limited reading ability who need help reading health-related materials. The SILS performs moderately well at ruling out limited reading ability in adults and allows providers to target additional assessment of health literacy skills to those most in need. Further study of the use of the SILS in clinical settings and with more diverse populations is warranted

The role of innovation narratives in accomplishing organizational ambidexterity

Persistent tensions arising from the exploration-exploitation paradox continuously threaten the accomplishment of organizational ambidexterity. Structural, contextual and sequential solutions designed to alleviate these tensions dominate the ambidexterity literature. None of these adequately explains how top executives implement tension-alleviating managerial initiatives or how they respond in real time to tension-induced organizational perturbations. In this paper, through analysis of top management team (TMT) speeches at Procter &amp; Gamble over a 15-year period, we show how the construction and communication of four innovation narratives – contextualizing, mutualizing, dramatizing and focalizing – reduced tensions and enhanced organizational ambidexterity. We demonstrate the importance of TMT reflexivity in devising and communicating performative narratives, illustrate the polyphonic model of narrative strategizing, and present a cyclical model suggesting that the accomplishment of organizational ambidexterity is an ongoing dynamic process

Patient Perspectives on Medication Assisted Therapy in Vermont

Introduction. Medication-Assisted Therapy (MAT) for opioid addiction has dramatically increased in Vermont, supported by a novel statewide system that integrates specialty treatment centers ( Hubs ) with primary care office-based opioid therapy ( Spokes ). In 2010, Vermont had the highest per capita buprenorphine use in the US. Previous studies of patient perspectives of MAT have identified social barriers, rigid program rules, and concerns about withdrawal and relapse as common causes of treatment failure. Our goal was to elicit patient perspectives on barriers and enablers of successful MAT to further inform system refinement. Methods. An interview guide was developed based on previous literature as well as discussions with program leadership, staff and clinicians, and community stakeholders. Responses were organized using thematic content analysis with consensus across seven interviewers and two analysts. The interviews were conducted with 44 patients enrolled in MAT at two Hub sites in Burlington, VT in October 2016. Results. The median age of subjects was 34 years, 34% were employed at least part-time, and 72% were female. Half reported a mental health condition and 20% reported chronic pain. Barriers included transportation (25%), lack of stable housing, and stigma (41%). Enablers included feeling supported (82% felt well-supported; 52% felt supported by healthcare professionals). Subjects expressed high confidence in the treatment system and high self-efficacy for sobriety. Conclusions. Patients in MAT have complex medical, mental health, social, personal, and work lives. A comprehensive system that addresses this wide range of domains is critical to achieving optimal outcomes.https://scholarworks.uvm.edu/comphp_gallery/1245/thumbnail.jp

Assessing Patient Preferences for Communication Companions in Primary Care

Introduction: Adults with communication impairments encounter obstacles in accessing high quality healthcare. While having a companion accompany a patient during clinic visits is a potential solution, the literature suggests that the efficacy of this strategy remains unclear. We sought to determine patient preferences regarding the roles of a communication companion and other approaches to overcoming communication challenges. Methods: The Patient-Provider-Companion survey was provided to adult primary care patients during check-in at five urban and rural practices in northern Vermont. The survey offered a checklist of options regarding the roles a companion may play to improve communication during a visit, including active roles such as speaking for the patient, or more passive roles such as taking notes. Other questions assessed how best to communicate health information after a visit. All responses were collected anonymously and analyzed using descriptive statistics. Results: Of the 179 survey respondents, the mean age was 55 (range 19-94), with 65% women. Eleven percent of respondents brought a companion to the visit, and the most highly endorsed companion roles were: “helping understand what the doctor says or means” (63%), and “prompt or remind to ask questions” (68%). Additionally, 105 patients provided their preferences for healthcare communication: 50% wanted key takeaways at the end of the visit, and 46% wanted time to summarize back what they heard. Fewer than 10% requested specific aids such as use of a clear mask or an amplifier. Among the 46 respondents who endorsed a method of keeping family up to date, the most common preference was to “read notes and instructions via the patient portal” (77%). Conclusions: Patient accompaniment to a primary care visit is common. Among accompanied patients, we identified preference for the roles a companion may play, which included strategies to help the patient understand as well as help with being understood. Asynchronous communication through the patient portal to the medical record is highly endorsed and deserves further exploration as an option for patients with communication disabilities. Bringing a companion and using the patient portal are customizable, patient-centered strategies that can be appropriate for people with unique and overlapping communication disabilities

21st Century Cures Act: Patient Perceptions on Open Information Sharing in Vermont Primary Care Clinics

Introduction: The 21st Century Cures Act federally mandated the release of progress notes, laboratory test results, and radiology/pathology reports to the patient’s electronic health record (EHR) portal. This study investigates patient perspectives on shared notes and addresses provider concerns about patient uptake due to potential factors like worry, confusion, and distress at the University of Vermont Medical Center. Materials and Methods: An electronic cross-sectional survey was designed and distributed to 7,240 eligible patients, adults who logged into MyChart on Epic and had an outpatient/telemedical visit at either the Colchester Family Medicine and South Burlington Primary Care locations in Vermont within one year prior to the study. Results: The survey response rate was 4.6%. Of the respondents, 90% agreed that the use of shared notes is a good idea, 76% found accessing notes easy, and 2% felt more worried about their health because of shared notes. 89%, 85%, and 82% of respondents found visit notes important for understanding their health, remembering their care plan, and feeling in control of their care, respectively. Conclusions: Based on this survey, provider concerns about patient stress may be overstated, as patients appear to benefit from shared notes through increased engagement with their health, communication with providers, and adherence to care plans

The role of innovation narratives in accomplishing organizational ambidexterity

Persistent tensions arising from the exploration-exploitation paradox continuously threaten the accomplishment of organizational ambidexterity. Structural, contextual and sequential solutions designed to alleviate these tensions dominate the ambidexterity literature. None of these adequately explains how top executives implement tension-alleviating managerial initiatives or how they respond in real time to tension-induced organizational perturbations. In this paper, through analysis of top management team (TMT) speeches at Procter &amp; Gamble over a 15-year period, we show how the construction and communication of four innovation narratives – contextualizing, mutualizing, dramatizing and focalizing – reduced tensions and enhanced organizational ambidexterity. We demonstrate the importance of TMT reflexivity in devising and communicating performative narratives, illustrate the polyphonic model of narrative strategizing, and present a cyclical model suggesting that the accomplishment of organizational ambidexterity is an ongoing dynamic process