scholarly journals Accounting for Blood Pressure Seasonality Alters Evaluation of Practice-Level Blood Pressure Control Intervention

2019 ◽  
Author(s):  
Thomas Gepts ◽  
Ann M Nguyen ◽  
Charles Cleland ◽  
Winfred Wu ◽  
Hang Pham-Singer ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Fixed Effects ◽  
Clinical Care ◽  
Large Body ◽  
Negative Association ◽  
Seasonal Effects ◽  
Intervention Effect ◽  
Contrast Model ◽  
Practice Level

Abstract Background Despite the large body of literature evaluating interventions to improve hypertension management, few studies have addressed seasonal variation in blood pressure (BP) control. This underreported phenomenon has implications for interpreting study findings and informing clinical care. We share a methodology that accounts for BP seasonality, presented through a case study – HealthyHearts NYC, an intervention aimed at increasing adherence to the Million Hearts BP control evidence-based guidelines in primary care practices. Methods We used a randomized stepped-wedge design (n = 257 practices). Each intervention included 13 visits from practice facilitators trained in improving practice-level BP control over 12 months. Two models were used to assess the intervention effect–one that did not account for seasonality (Model 1) and one that did (Model 2). Model 2 was a re-specification of Model 1 to include our proposed two fixed-effects terms to address BP seasonality. Results Model 1 showed a significant negative association between the intervention and BP control (IRR=0.98, 95% CI=0.96-0.99, p=<.05). In contrast, Model 2, which did address seasonality, showed no intervention effect on BP control (IRR = 0.99, 95% CI=0.97-1.01, p=.19). Conclusions These findings reveal that analyses that do not account for BP seasonality may not present an accurate picture of intervention effects. In our case study, accounting for BP seasonality turned a negative association into a null association. We recommend that when evaluating BP control, studies compare outcome measures across similar seasons and that the measurement period last long enough to account for seasonal effects. Trial Registration Number NCT02646488

scholarly journals Contrasting Medical and Legal Standards of Evidence: A Precision Medicine Case Study

2016 ◽  
Vol 44 (1) ◽  
pp. 194-204 ◽  
Author(s):  
Gary E. Marchant ◽  
Kathryn Scheckel ◽  
Doug Campos-Outcalt
Keyword(s):  
Precision Medicine ◽  
New Technologies ◽  
Clinical Care ◽  
Large Body ◽  
Standard Of Care ◽  
Genetic Profile ◽  
Legal Standards ◽  
Standards Of Evidence ◽  
The Individual

As the health care system transitions to a precision medicine approach that tailors clinical care to the genetic profile of the individual patient, there is a potential tension between the clinical uptake of new technologies by providers and the legal system's expectation of the standard of care in applying such technologies. We examine this tension by comparing the type of evidence that physicians and courts are likely to rely on in determining a duty to recommend pharmacogenetic testing of patients prescribed the oral anti-coagulant drug warfarin. There is a large body of inconsistent evidence and factors for and against such testing, but physicians and courts are likely to weigh this evidence differently. The potential implications for medical malpractice risk are evaluated and discussed.

HIPEREMESIS GRAVIDARUM PADA IBU HAMIL DI KLINIK BIDAN SUPRIYATI SRIBIT BERBAH SLEMAN

2019 ◽  
Vol 14 (1) ◽  
pp. 51
Author(s):  
Pramukti Dian Setianingrum ◽  
Farah Irmania Tsani
Keyword(s):  
Blood Pressure ◽  
Pregnant Women ◽  
Hyperemesis Gravidarum ◽  
Unwanted Pregnancy ◽  
The Body ◽  
Nausea And Vomiting ◽  
Daily Activities ◽  
World Health ◽  
The World

Backgroud: The World Health Organization (WHO) explained that the number of Hyperemesis Gravidarum cases reached 12.5% of the total number of pregnancies in the world and the results of the Demographic Survey conducted in 2007, stated that 26% of women with live births experienced complications. The results of the observations conducted at the Midwife Supriyati Clinic found that pregnant women with hyperemesis gravidarum, with a comparison of 10 pregnant women who examined their contents there were about 4 pregnant women who complained of excessive nausea and vomiting. Objective: to determine the hyperemesis Gravidarum of pregnant mother in clinic. Methods: This study used Qualitative research methods by using a case study approach (Case Study.) Result: The description of excessive nausea of vomiting in women with Hipermemsis Gravidarum is continuous nausea and vomiting more than 10 times in one day, no appetite or vomiting when fed, the body feels weak, blood pressure decreases until the body weight decreases and interferes with daily activities days The factors that influence the occurrence of Hyperemesis Gravidarum are Hormonal, Diet, Unwanted Pregnancy, and psychology, primigravida does not affect the occurrence of Hyperemesis Gravidarum. Conclusion: Mothers who experience Hyperemesis Gravidarum feel nausea vomiting continuously more than 10 times in one day, no appetite or vomiting when fed, the body feels weak, blood pressure decreases until the weight decreases and interferes with daily activities, it is because there are several factors, namely, hormonal actors, diet, unwanted pregnancy, and psychology.

scholarly journals Blood Pressure Trajectories Across the Life Course

2021 ◽  
Vol 34 (3) ◽  
pp. 234-241
Author(s):  
Norrina B Allen ◽  
Sadiya S Khan
Keyword(s):  
Blood Pressure ◽  
Measurement Errors ◽  
Clinical Care ◽  
Population Level ◽  
Cumulative Exposure ◽  
Older Adulthood ◽  
Individual Level ◽  
The Life Course ◽  
Level Group ◽  
Improve Health

Abstract High blood pressure (BP) is a strong modifiable risk factor for cardiovascular disease (CVD). Longitudinal BP patterns themselves may reflect the burden of risk and vascular damage due to prolonged cumulative exposure to high BP levels. Current studies have begun to characterize BP patterns as a trajectory over an individual’s lifetime. These BP trajectories take into account the absolute BP levels as well as the slope of BP changes throughout the lifetime thus incorporating longitudinal BP patterns into a single metric. Methodologic issues that need to be considered when examining BP trajectories include individual-level vs. population-level group-based modeling, use of distinct but complementary BP metrics (systolic, diastolic, mean arterial, mid, and pulse pressure), and potential for measurement errors related to varied settings, devices, and number of readings utilized. There appear to be very specific developmental periods during which divergent BP trajectories may emerge, specifically adolescence, the pregnancy period, and older adulthood. Lifetime BP trajectories are impacted by both individual-level and community-level factors and have been associated with incident hypertension, multimorbidity (CVD, renal disease, cognitive impairment), and overall life expectancy. Key unanswered questions remain around the additive predictive value of BP trajectories, intergenerational contributions to BP patterns (in utero BP exposure), and potential genetic drivers of BP patterns. The next phase in understanding BP trajectories needs to focus on how best to incorporate this knowledge into clinical care to reduce the burden of hypertensive-related outcomes and improve health equity.

scholarly journals Use of past care markers in risk-adjustment: accounting for systematic differences across providers

2021 ◽  
Author(s):  
Laura Anselmi ◽  
Yiu-Shing Lau ◽  
Matt Sutton ◽  
Anna Everton ◽  
Rob Shaw ◽  
...  
Keyword(s):  
Risk Adjustment ◽  
Fixed Effects ◽  
Goodness Of Fit ◽  
Reporting Quality ◽  
Cost Of Care ◽  
Local Health ◽  
Administrative Records ◽  
Practice Level ◽  
Improve Model ◽  
The Cost

AbstractRisk-adjustment models are used to predict the cost of care for patients based on their observable characteristics, and to derive efficient and equitable budgets based on weighted capitation. Markers based on past care contacts can improve model fit, but their coefficients may be affected by provider variations in diagnostic, treatment and reporting quality. This is problematic when distinguishing need and supply influences on costs is required.We examine the extent of this bias in the national formula for mental health care using administrative records for 43.7 million adults registered with 7746 GP practices in England in 2015. We also illustrate a method to control for provider effects.A linear regression containing a rich set of individual, GP practice and area characteristics, and fixed effects for local health organisations, had goodness-of-fit equal to R2 = 0.007 at person level and R2 = 0.720 at GP practice level. The addition of past care markers changed substantially the coefficients on the other variables and increased the goodness-of-fit to R2 = 0.275 at person level and R2 = 0.815 at GP practice level. The further inclusion of provider effects affected the coefficients on GP practice and area variables and on local health organisation fixed effects, increasing goodness-of-fit at GP practice level to R2 = 0.848.With adequate supply controls, it is possible to estimate coefficients on past care markers that are stable and unbiased. Nonetheless, inconsistent reporting may affect need predictions and penalise populations served by underreporting providers.

Satisfaction of tuberculosis patients with health services in Ghana

2017 ◽  
Vol 30 (6) ◽  
pp. 545-553 ◽  
Author(s):  
Frank Bonsu ◽  
Felix Afutu ◽  
Nii Nortey Hanson-Nortey ◽  
Mary-Anne Ahiabu ◽  
Joshua Amo-Adjei
Keyword(s):  
Client Satisfaction ◽  
Service Providers ◽  
Healthcare Providers ◽  
Large Body ◽  
Service Users ◽  
Content Type ◽  
Sputum Production ◽  
Interview Guide

Purpose Within human services, client satisfaction is highly prioritised and considered a mark of responsiveness in service delivery. A large body of research has examined the concept of satisfaction from the perspective of service users. However, not much is known about how service providers construct client satisfaction. The purpose of this paper is to throw light on healthcare professionals’ perspectives on patient satisfaction, using tuberculosis (TB) clinics as a case study. Design/methodology/approach In-depth interviews were conducted with 35 TB clinic supervisors purposively sampled from six out of the ten regions of Ghana. An unstructured interview guide was employed. The recorded IDIs were transcribed, edited and entered into QSR NVivo 10.0 and analysed inductively. Findings Respondents defined service satisfaction as involving education/counselling (on drugs, nature of condition, sputum production, caregivers and contacts of patients), patient follow-up, assignment of reliable treatment supporters as well as being attentive and receptive to patients, service availability (e.g. punctuality at work, availability of commodities), positive assurances about disease prognosis and respect for patients. Practical implications Complementing opinions of health service users with those of providers can offer key performance improvement areas for health managers. Originality/value To the best of the authors’ knowledge, this is a first study that has examined healthcare providers’ views on what makes their clients satisfied with the services they provide.

Abstract P494: Long-term Outcomes of a Cluster-randomized Trial Testing the Effects Blood Pressure Telemonitoring and Pharmacist Management

Hypertension ◽  
2017 ◽  
Vol 70 (suppl_1) ◽  
Author(s):  
Karen L Margolis ◽  
Stephen E Asche ◽  
Anna R Bergdall ◽  
Steven P Dehmer ◽  
Beverly B Green ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Randomized Trial ◽  
Clinical Care ◽  
Cluster Randomized Trial ◽  
Home Blood Pressure ◽  
Uncontrolled Hypertension ◽  
Routine Clinical Care ◽  
Differential Reduction ◽  
Cluster Randomized

Background/Aims: Hypertension is a common condition and leading cause of cardiovascular disease. We previously reported results of a cluster-randomized trial evaluating a home blood pressure (BP) telemonitoring and pharmacist management intervention, with significant reductions in BP favoring the intervention arm over 18 months. This analysis examined the durability of the intervention effect on BP through 54 months of follow-up and compared BP measurements performed in the research clinic and in routine clinical care. Methods: The Hyperlink trial randomized 16 primary care clinics having 450 study-enrolled patients with uncontrolled hypertension to either Telemonitoring Intervention (TI) or usual care (UC) study arms. BP was measured as the mean of 3 measurements obtained at each research clinic visit. General linear mixed models utilizing a direct likelihood-based ignorable approach for missing data were used to examine change from baseline to 54 months in systolic and diastolic BP (SBP and DBP). Results: Research clinic BP measurements were obtained from 326 (72%) study patients at the 54 month follow-up visit. Routine clinical care BP measurements were obtained from 444 (99%) of study patients from 7025 visits during the follow-up period. For TI patients, based on research clinic measurements baseline SBP was 148.2 mm Hg and 54 month follow-up was 131.2 mm Hg (-17.0 mm Hg, p<.001). For UC patients, baseline SBP was 147.7 mm Hg and 54 month follow-up was 131.7 mm Hg ( -16.0 mm Hg, p<.001). The differential reduction by study arm in SBP from baseline to 54 months was -1.0 mm Hg (95% CI: -5.4 to 3.4, p=0.63). For TI patients, baseline DBP was 84.4 mm Hg and 54 month follow-up was 77.8 (-6.6 mm Hg, p<.001). For UC patients, baseline DBP was 85.1 mm Hg and 54 month follow-up was 79.1 mm Hg (-6.0 mm Hg, p<.001). The differential reduction by study arm in DBP from baseline to 54 months was -0.6 mm Hg (95% CI: -3.5 to 2.4, p=0.67). SBP and DBP results from routine clinical measurements closely approximated the pattern of results from research clinic measurements. Conclusion: Significant BP reductions in the TI arm relative to UC were no longer seen at 54 month follow-up. To maintain intervention benefits over a longer period of time additional intervention is needed.

Evaluating prediction of continuous clinical values: a glucose case study (Preprint)

2021 ◽  
Author(s):  
George Hripcsak ◽  
David J Albers
Keyword(s):  
Predictive Models ◽  
Clinical Utility ◽  
Clinical Care ◽  
Glucose Measurement ◽  
Care Processes ◽  
Low Glucose ◽  
Potential Clinical Utility ◽  
Rms Error ◽  
Error Grid

BACKGROUND Background: It would be useful to be able to assess the utility of predictive models of continuous values before clinical trials are carried out. OBJECTIVE Objective: To compare metrics to assess the potential clinical utility of models that produce continuous value forecasts. METHODS Methods: We ran a set of data assimilation forecast algorithms on time series of glucose measurements from intensive care unit patients. We evaluated the forecasts using four sets of metrics: glucose root mean square error, a set of metrics on a transformed glucose value, the estimated effect on clinical care based on an insulin guideline, and a glucose measurement error grid (Parkes grid). We assessed correlation among the metrics and created a set of factor models. RESULTS Results: The metrics generally correlated with each other, but those that estimated the effect on clinical care correlated with the others the least and were generally associated with their own independent factors. The other metrics appeared to separate into those that emphasized errors in low glucose versus errors in high glucose. The Parkes grid was well correlated with the transformed glucose but not the estimation of clinical care. CONCLUSIONS Discussion: Our results indicate that we need to be careful before we assume that commonly used metrics like RMS error in raw glucose or even metrics like the Parkes grid that are designed to measure importance of differences will correlate well with actual effect on clinical care processes. A combination of metrics appeared to explain the most variance between cases. As prediction algorithms move into practice, it will be important to measure actual effects.

scholarly journals Stimulus-response time to invasive blood pressure alarms: implications for the safety of critical-care patients

2014 ◽  
Vol 35 (2) ◽  
pp. 135-141 ◽  
Author(s):  
Adele Kuckartz Pergher ◽  
Roberto Carlos Lyra da Silva
Keyword(s):  
Blood Pressure ◽  
Response Time ◽  
Response Times ◽  
Hemodynamic Instability ◽  
Military Hospital ◽  
Invasive Blood Pressure ◽  
Stimulus Response ◽  
The City ◽  
Physical Layout

Observational, descriptive, exploratory, case study with the objective of measuring the stimulus-response time of the team to alarms monitoring invasive blood pressure (IBP) and analyzing the implications of this time for the safety of the patient. From January to March 2013, 60 hours of structured observation were conducted with registration of the alarms activated by IBP monitors in an adult ICU at a military hospital in the city of Rio de Janeiro. 76 IBP alarms were recorded (1.26 alarms/hour), 21 of which (28%) were attended to and 55 (72%) considered as fatigued. The average response time to the alarms was 2 min. 45 sec. The deficit in human resource and physical layout were factors determining the delay in response to the alarms. The increase in response times to these alarms may compromise the safety of patients with hemodynamic instability, especially in situations such as shock and the use of vasoactive drugs.

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