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


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

American Academy of Family Physicians

Related Diabetes Articles from Brightsurf:

New diabetes medication reduced heart event risk in those with diabetes and kidney disease
Sotagliflozin - a type of medication known as an SGLT2 inhibitor primarily prescribed for Type 2 diabetes - reduces the risk of adverse cardiovascular events for patients with diabetes and kidney disease.

Diabetes drug boosts survival in patients with type 2 diabetes and COVID-19 pneumonia
Sitagliptin, a drug to lower blood sugar in type 2 diabetes, also improves survival in diabetic patients hospitalized with COVID-19, suggests a multicenter observational study in Italy.

Making sense of diabetes
Throughout her 38-year nursing career, Laurel Despins has progressed from a bedside nurse to a clinical nurse specialist and has worked in medical, surgical and cardiac intensive care units.

Helping teens with type 1 diabetes improve diabetes control with MyDiaText
Adolescence is a difficult period of development, made more complex for those with Type 1 diabetes mellitus (T1DM).

Diabetes-in-a-dish model uncovers new insights into the cause of type 2 diabetes
Researchers have developed a novel 'disease-in-a-dish' model to study the basic molecular factors that lead to the development of type 2 diabetes, uncovering the potential existence of major signaling defects both inside and outside of the classical insulin signaling cascade, and providing new perspectives on the mechanisms behind insulin resistance in type 2 diabetes and possibly opportunities for the development of novel therapeutics for the disease.

Tele-diabetes to manage new-onset diabetes during COVID-19 pandemic
Two new case studies highlight the use of tele-diabetes to manage new-onset type 1 diabetes in an adult and an infant during the COVID-19 pandemic.

Genetic profile may predict type 2 diabetes risk among women with gestational diabetes
Women who go on to develop type 2 diabetes after having gestational, or pregnancy-related, diabetes are more likely to have particular genetic profiles, suggests an analysis by researchers at the National Institutes of Health and other institutions.

Maternal gestational diabetes linked to diabetes in children
Children and youth of mothers who had gestational diabetes during pregnancy are at increased risk of diabetes themselves, according to new research published in CMAJ (Canadian Medical Association Journal).

Two diabetes medications don't slow progression of type 2 diabetes in youth
In youth with impaired glucose tolerance or recent-onset type 2 diabetes, neither initial treatment with long-acting insulin followed by the drug metformin, nor metformin alone preserved the body's ability to make insulin, according to results published online June 25 in Diabetes Care.

People with diabetes visit the dentist less frequently despite link between diabetes, oral health
Adults with diabetes are less likely to visit the dentist than people with prediabetes or without diabetes, finds a new study led by researchers at NYU Rory Meyers College of Nursing and East Carolina University's Brody School of Medicine.

Read More: Diabetes News and Diabetes Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to