November/December 2008 Annals of Family Medicine tip sheet

November 10, 2008

Death Toll from Uncontrolled Blood Pressure in Ethnic Populations The Prevalence of Racial and Ethnic Disparities

Two studies in the current issue examine ethnic and racial disparities in hypertension care and control, and accompanying commentaries from three distinguished editorialists amplify and elucidate this important topic.

In the first study, Fiscella and Holt find that racial disparities in blood pressure control contribute to nearly 8,000 preventable deaths from heart disease and stroke among blacks every year. In what is thought to be the first study to quantify the toll of racial disparities in blood pressure control, researchers analyzed nationally representative data on 2,770 black and white adults, as well as meta-analyses of observational studies and treatment trials for systolic blood pressure. They found that the average systolic blood pressure among blacks with hypertension was approximately 7 mm Hg higher than that for whites with hypertension. Moreover, they found that a reduction in the average systolic blood pressure among hypertensive blacks to that of hypertensive whites would reduce the annual number of black deaths from heart disease by 5,590 and from stroke by 2,190. They suggest that primary care clinicians should be particularly diligent when managing hypertension in black patients and should focus their efforts on addressing patients' adherence barriers.

In the second article, Millet and colleagues find disparities in medication prescribing and blood pressure control between ethnic groups in England despite major investment in quality improvement initiatives and a health care system that offers universal access. Researchers analyzed data on 8,876 patients from family practices in southwest London after the implementation of a major pay-for-performance program that placed considerable emphasis on improving the quality of care for individuals with cardiovascular disease. They found black patients with hypertension had significantly higher average blood pressure values and were significantly less likely to achieve an established treatment target for blood pressure control than white or South Asian patients. Moreover, they found disparities were particularly marked among those patients with multiple cardiovascular conditions, who arguably may be the sickest patients. They conclude that large-scale quality improvement programs may require additional components to improve the quality of care of high-risk individuals, including those from minority ethnic groups.

Accompanying editorials from Former U.S. Surgeon General David Satcher, M.D., Ph.D., and Crystal Wile Cené, M.D., M.P.H., and Lisa A. Cooper, M.D., M.P.H., call on clinicians, researchers, health care administrators, health care planners and policy makers to work together to gain a better understanding of the barriers faced by ethnic minorities and develop comprehensive strategies to overcome them.

Racial Disparity in Hypertension Control: The Death Toll
By Kevin Fiscella, M.D., M.P.H., and Kathleen Holt, Ph.D.
University of Rochester School of Medicine and Dentistry, New York

Ethnic Disparities in Blood Pressure Management in Patients with Hypertension After the Introduction of Pay for Performance
By Christopher Millett, M.Sc., F.F.P.H., et al
Imperial College Faculty of Medicine, London

Examining Racial and Ethnic Disparities in Health and Hypertension Control
By David Satcher, M.D., Ph.D.
Morehouse School of Medicine, Atlanta, Georgia

Death Toll From Uncontrolled Blood Pressure in Ethnic Populations: Universal Access and Quality Improvement May Not Be Enough
Crystal Wile Cené, M.D., M.P.H., and Lisa A. Cooper, M.D., M.P.H.
University of North Carolina at Chapel Hill
Johns Hopkins School of Medicine, Baltimore, Maryland




Big Baby? Expectant Mothers Should Monitor BMI Increase During Pregnancy

Expectant mothers whose body mass index (BMI) increases 25 percent or more during pregnancy are more likely to give birth to big babies. Analyzing data from 186 deliveries at Eisenhower Army Medical Center, researchers found that 86.2 percent of those babies whose birth weight was above the 90th percentile (4000 grams or 8 pounds 13 ounces) had mothers whose BMI increased 25 percent or more during pregnancy, compared with 6.6 percent of the mothers with normal-weight infants. After adjusting for other maternal characteristics, they found the odds of giving birth to a high-birth-weight baby were more than 200 times higher among mothers whose BMI increased at least 25 percent. The researchers conclude that given the considerable complications associated with delivering high-birth-weight babies, having an indicator that helps diagnose the condition may allow clinicians to make better choices regarding timing and mode of delivery, as well as prepare for emergencies. They call for future studies in larger more heterogeneous populations.

Percentage Change in Antenatal Body Mass Index as a Predictor of Neonatal Macrosomia
By Chad A. Asplund, M.D., et al
Eisenhower Army Medical Center, Fort Gordon, Georgia




Family Medicine's Grant Funding and Representation at NIH Miniscule

Despite the National Institutes of Health's (NIH) stated focus on translating the fruits of medical research into community practice, and family medicine's well-developed clinical infrastructure that uniquely enables it to help bridge the chasm between medical knowledge and actual clinical care, family medicine receives a miniscule proportion of NIH grant funding and has correspondingly minimal representation on NIH advisory committees. Analyzing NIH grants from 2002 through 2006, researchers found that while grants to departments of family medicine increased from 89 ($25.6 million) in 2002, to 154 ($44.6 million) in 2006, these values represented only 0.2 percent (0.15 percent for dollars) and 0.33 percent (0.22 percent for dollars), respectively, of total NIH awards. Moreover, analyzing the current advisory committee memberships, they found family medicine representatives were on only 6.4 percent of all NIH advisory committees (0.38 percent of all members). The authors conclude that the lack of family medicine involvement in the planning and execution of federally funded research has adverse implications for the direction of biomedical research in the United States, its relevance to actual patient care, and its ultimate impact on public health. It also has implications for the status and vitality of the family medicine specialty. They call on the specialty to foster a better relationship with the NIH through greater research training, collaborations and self-advocacy. Greater interaction, they conclude, offers the potential for substantial mutual benefit.

Off the Roadmap? Family Medicine's Grant Funding and Committee Representation at NIH
By Sean C. Lucan, M.D., M.P.H., et al
Robert Wood Johnson Clinical Scholars Program, University of Pennsylvania, Philadelphia




New Screening Tool to Help Identify Patients with Prediabetes

Analyzing data on 4,045 adults aged 20 to 64 years without diagnosed diabetes, researchers developed a clinical tool to assess the likelihood of fasting glucose impairment (a condition in which blood sugar levels are higher than normal) with the aim of identifying people who might have prediabetes or undiagnosed diabetes. The tool, named TAG-IT, uses six factors (age, sex, body mass index, family history of diabetes, heart rate and hypertension), all of which are either self-reported or easily measured, and can be pulled from most electronic health records. The authors assert that TAG-IT represents an improvement over BMI alone or a list of risk factors because of its utility in younger adult populations and its ability to provide physicians with a way to assess the risks of combinations of factors.

Tool to Assess Likelihood of Fasting Glucose Impairment (TAG-IT)
By Richelle J. Koopman, M.D., M.S., et al
University of Missouri, Columbia




OTHER STUDIES IN THIS ISSUE

What Latina Patients Don't Tell Their Doctors


In-depth interviews with 28 Latina women living in Brooklyn revealed six factors that enhance or inhibit Latinas' disclosure of information to their physician. Researchers found that a warm, trusting, compassionate relationship in which the patient feels respected and truly heard is critical for disclosure of important health information. Time constraints, the presence of translators, sex and age differences, and physicians' lack of awareness of what constitutes sensitive issues for Latinas can all affect this relationship and thus disclosure. Notably, birthplace (foreign or U.S. born) also played a role in how the women perceived barriers to disclosure. To improve Latinas' disclosure of important health information to their physicians, the authors call for staff training in techniques for building rapport in an attempt to foster better communication, increase empathy and compassion and lead to the establishment of trusting relationships.

What Latina Patients Don't Tell Their Doctors: A Qualitative Study
By Kell Julliard, M.A., et al
Lutheran Medical Center, Brooklyn, New York




Primary Care Visits for Breast Symptoms and the Frequency of Cancer Diagnosis

A study of 84,285 women seeking care in Dutch family physician offices between 1985 and 2003 revealed that breast symptoms were reported in about 3 percent of all visits. Of the women complaining of breast symptoms, 3 percent of those women were subsequently diagnosed with breast cancer. Notably, those patients reporting a breast mass had a markedly elevated likelihood of breast cancer (15.04 likelihood ratio), suggesting that clinicians should aggressively work up such complaints regardless of patient age.

Characterizing Breast Symptoms in Family Practice
By Margaret M. Eberl, M.D., M.P.H, et al
Roswell Park Cancer Institute, Buffalo, New York




Automated Diabetes Intervention Cost Effective

Analyzing data from a clinical trial of 226 diabetic primary care patients, this study finds that an automated telephone self-management support intervention is a cost effective way to improve patients' diabetes outcomes. The annual cost of the intervention per quality adjusted life year gained was $65,167 when including all program costs, and $32,333 when including only ongoing costs - similar to that of many other accepted interventions targeted at diabetes prevention and treatment. The authors assert that because a considerable proportion of the costs associated with the intervention are fixed, cost-utility and cost-effectiveness estimates likely would be substantially improved if implemented on a larger scale.

Cost-Effectiveness of Automated Self-Management Support With Nurse Care Management Among Patients With Diabetes
By Margaret A. Handley, Ph.D., M.P.H., et al
University of California, San Francisco




New Tool for Identifying Teens at Risk for Depression

Analyzing nationally representative data on 4,791 U.S. adolescents, researchers developed a model to predict the onset of depressive symptoms and depression in adolescents. The 20-item index, named the Chicago Adolescent Depression Risk Assessment, allows primary care clinicians to easily screen and identify adolescents at high risk for depression.

Predicting Future Risk of Depressive Episode in Adolescents: The Chicago Adolescent Depression Risk Assessment (CADRA)
By Benjamin W. Van Voorhees, M.D., et al
The University of Chicago, Illinois




The Prognosis for Patients Seeking Care for Fatigue

This study follows the course of 642 patients with fatigue identified in a network of 147 Dutch primary care practices. Among the participants, researchers identified four different subgroups that had distinctly different patterns of outcomes over time. They found that a reduction in the severity of fatigue over time was associated with improvements in functioning, sleep and psychological symptoms. More than half of patients (58 percent), however, had a course of recurrent or chronic fatigue with minimal changes over the course of the one-year study. The researchers caution physicians to be aware that a substantial proportion of patients seeking care for fatigue also have impaired functioning, psychological problems and poor sleep quality.

Prognosis of Fatigue and Functioning in Primary Care: A 1-Year Follow-Up Study
By Iris Nijrolder, M.Sc., et al
EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands
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American Academy of Family Physicians

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