Meeting News
Title: Comparative Effectiveness Of Two Telephone-delivered Behavioral Interventions To Improve Hypertension Control. Primary Outcomes Of A Randomized Controlled Trial
Event: AHA 2010
Topic(s): General Cardiology, PreventionVascular
Presenter: Sundar Natarajan
Writer(s): Xiushui Ren
Date Posted: 11/16/2010
Summary
Patient-tailored counseling to modify behavior results in improved blood pressure control.
Background
Despite known benefits of aggressive blood pressure (BP) control, the rate of adequate blood pressure control achieved in clinical practice is suboptimal.
The current study used telephone-delivered behavioral interventions targeting patients with uncontrolled BP in primary care settings.
Study Design
This is a randomized controlled trial comparing the effect of stage-matched intervention (SMI), health education intervention (HEI), and usual care (UC) to improve BP control in adults with uncontrolled BP despite treatment with antihypertensive drugs for ≥ 6 months. SMI and HEI patients received monthly phone counseling targeting diet, exercise and BP medication adherence for 6 months. In the SMI group, a social worker assessed each participant's behavior and delivered the appropriate tailored SMI based on their stage of change, decisional balance, and the skills model questions. Patients in the HEI group received nontailored education via calls by a social worker, during which participants received standard education about hypertension management based on national guidelines. The UC group participated in all clinical visits but did not receive monthly phone calls.
After a six-month active intervention phase, there was 6-month monitoring phase to assess sustainability. Patients were blinded to the intervention arms (SMI or HEI) and social workers were blinded to patient's BP. Research staff measuring outcomes were blinded to study assignment. The study was analyzed using longitudinal data analysis methods using an intention to treat strategy.
The primary endpoint was measured BP.
Results and Conclusions
A total of 533 participants from Department of Veterans Affairs with sustained uncontrolled BP from 2 large hospital-based outpatient clinics.
The baseline BP control rates were 42.6%, 40.6%, and 44.6% in SMI, HEI, and UC, respectively (p=0.74).
At 6 months, BP control rates were 62.3% (SMI), 52.4% (HEI), and 47.2% (UC); p values for pairwise comparisons were 0.02 for SMI vs. UC, 0.28 for HEI vs. UC, and 0.07 for SMI vs. HEI.
Thus, compared to usual care, patient-tailored counseling (stage-matched intervention) improved BP control whereas nontailored counseling (health education intervention) did not. Stage-matched intervention, therefore, should be considered a potentially effective approach to assisting patients reach BP control goals..
Finally, although clinicians were required to document their responses (such as change in therapy) to telemonitoring data, they did not record these responses systematically. However, telemonitoring sites in this study were highly motivated and the lack of systematic documentation probably did not significant alter the results. Thus, if monitoring of patients was coupled with more systematic and detailed interventions, it might still show some benefit.
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Meeting News
Title: State-Wide Care is Improved in the Reperfusion of Acute MI in Carolina Emergency Department Emergency Response (RACE-ER) Systems Improvement Program
Event: AHA 2010
Topic(s): General Cardiology
Presenter: Christopher B Granger
Writer(s): Xiushui Ren
Date Posted: 11/16/2010
Summary
A program focused on improving systems of care improves time to reperfusion in patients with STEMI.
Background
According to ACC/AHA recommendations, care for ST-segment elevation myocardial infarction (STEMI) should include the development of systems of care with a focus on reducing first medical contact to reperfusion time. Reperfusion of Acute MI in Carolina Emergency Department Emergency Response (RACE-ER) is a program to integrate care in all hospitals and EMS systems in North Carolina to increase speed and rate of reperfusion. RACE-ER is part of the AHA’s Mission:Lifeline program..
Study Design
The investigators measured delays of coronary reperfusion using ACTION Registry/Get With The Guidelines in STEMI patients from July 2008 through December 2009, including before and a year-long implementation in the 21 percutaneous coronary interventions (PCI) hospitals and 98 non-PCI hospitals, and over 500 associated EMS systems in North Carolina. The implementation focused on early diagnosis, early reperfusion activation, and optimizing performance at each point of care: EMS, emergency department, catheterization laboratory, and transfer.
Results and Conclusions
A total of 6841 patients were included in the study, of whom 57% presented directly to PCI centers and 43% were transferred from non-PCI centers. The mean age of patients was 59 years, and 30% were women.
Over the course of the study, the proportion of patients in the entire group treated with primary PCI increased from 77% to 82%, p=0.0003 for trend. Among transfer patients eligible for PCI, the rate of primary PCI increased from 52% to 66%, p<0.0001 for trend. Compared to pre-implementation, post-implementation median reperfusion times significantly improved according to first door-to-device (presenting to PCI hospital 67 vs. 60 minutes, respectively, p=0.0001; transferred to PCI hospital among transfer-designated centers 119 vs. 108 minutes, respectively, p=0.01) and first medical contact to device (presenting to PCI hospital via EMS 103 vs. 91 minutes, respectively, p<0.0001).
While significantly improved, only 32% of post-implementation patients had transfer to device time < 90 minutes and 64% < 120 minutes. Eligible but not treated with reperfusion dropped from 5.5% to 4.0%. In contrast to the original RACE data from 2006 when in-hospital mortality was 7.5%, mortality in RACE-ER was 5.8% pre- and 5.6% post- intervention.< 120 minutes. Eligible but not treated with reperfusion dropped from 5.5% to 4.0%. In contrast to the original RACE data from 2006 when in-hospital mortality was 7.5%, mortality in RACE-ER was 5.8% pre- and 5.6% post- intervention.