BACKGROUNDUncontrolled treatment-resistant hypertension (TRH), i.e., blood pressure (BP, mm Hg) ≥140/≥90mm Hg in and out of office on ≥3 different BP medications at optimal doses, is common and has a poor prognosis. Aldosterone antagonist (AA) and renin-guided therapy (RGT) are effective strategies for improving BP control in TRH but have not been compared.METHODSA comparative effectiveness TRH pilot study of AA vs. RGT was conducted in 4 primary care clinics with 2 each randomized to AA or RGT. The primary outcome was change in clinic BP defined by means of 5 automated office BP values. Eighty-nine patients with apparent TRH were screened and 44 met criteria for true TRH.RESULTSBaseline characteristics of 20 patients in the AA (70% Black, 45% female, mean age: 57.4 years) and 24 patients in RGT (79% Black, 50% female, 57.8 years) arms were similar with baseline BP 162±5/90±3 vs. 153±3/84±3, respectively, P = 0.11/0.20. BP declined to 144±5/86±4 in AA vs. 132±4/75±3 in RGT, P = 0.07/0.01; BP was controlled to JNC7 (Seventh Joint National Committee Report) goal in 25% vs. 62.5%, respectively, P < 0.01. Although BP changes from baseline, the primary outcome, were not different (-17.6±5.1/-4.0±3.0 AA vs. -20.4±3.8/-9.7±2.0 RGT, P = 0.65/0.10.), more BP medications were added with AA than RGT (+0.9±0.1 vs. +0.4±0.1 per patient, P < 0.01).CONCLUSIONSIn this TRH pilot study, AA and RGT lowered BP similarly, although fewer additional medications were required with RGT. A larger comparative effectiveness study could establish the utility of these treatment strategies for lowering BP of uncontrolled TRH patients in primary care.

BACKGROUND:Approximately 20% of children with sickle cell disease (SCD) have microalbuminuria (MA). Very little is known about the progression of MA in children and young adults with SCD. METHODS:In this study, we analyzed 5-year EMR data of 373 children [with ≥2 microalbumin-to-creatinine (MA/Cr) ratio measurements] followed at the Medical University of South Carolina to determine the rate, direction, magnitude, and predictors of MA/Cr change over time. RESULTS:Age range was 1-22 years; mean 10.2 ± 5.2 years, 49.5% were males. Median follow-up duration was 3.12 ± 1.16 years. At baseline, 328 children had normal (<20 mg/L) MA level. Forty-five (12.1%) of children had MA (≥20 mg/L), of which 91% were ≥8 years and 21 (47%) continued to have MA at the end of the study period. On the other hand, during the study period, 24 new patients developed MA and 24 normalized their MA to levels <20 mg/L. In multivariate logistic regression model, age and bilirubin levels were predictive of MA/Cr increase in patients who received at least one blood transfusion during the study period. Baseline MA level was not predictive of the change in MA/Cr. CONCLUSION:In children and young adults, microalbuminuria is considered a marker of early renal injury. Over time, MA/Cr levels may increase or decrease. Further studies are needed to confirm our findings, assess the reliability of MA as marker of long-term renal injury, and identify high risk patients with SCD likely to have worsening of MA over time.

Lack of recruitment of qualified research participants continues to be a significant bottleneck in clinical trials, often resulting in costly time extensions, underpowered results, and in some cases early termination. Some of the reasons for suboptimal recruitment include laborious consent processes and access to participants at remote locations. While new electronic consents technologies (eConsent) help overcome challenges related to readability and consent management, they do not adequately address challenges related to remote access. To address this, we have developed an innovative solution called “teleconsent”, which embeds the informed consent process into a telemedicine session. Teleconsent allows a researcher to remotely video conference with a prospective research participant, display and interactively guide participants in real-time through a consent form. When finished, the researcher and participant can electronically sign the consent form and print or download the signed document for archiving. This process can eliminate challenges related to travel and management of personnel at remote sites. Teleconsent has been successfully implemented in several clinical trials. Teleconsent can improve research recruitment by reducing the barriers related to informed consent, while preserving human interaction.

Purpose: Children with complex chronic conditions (CCC) have high health care needs and utilization. The purpose of this study was to identify place-related risk and protective factors associated with hospital utilization among children with CCC. Methods: A mixed methods study was conducted to generate a risk profile of place-related factors associated with hospital utilization. The quantitative phase of the study consisted of retrospective review of 216 urban hospital medical records of infants and young children with CCC. The qualitative phase of the study included interviews with parents/caregivers and focus groups with health care providers (HCPs) of children with CCC. Results from multiple regression modeling and directed content analysis were merged using a side-by-side table organized by ecological level.Findings: Place-related risk and protective factors on multiple ecological levels were identified. Key place-related factors associated with hospital utilization were more complex conditions, positive relationships with HCPs, more parent/family resources, and having fewer place-related resources. Conclusions: The results of this study suggest patterns of health care utilization among infants and young children with CCC are influenced by place-related factors. Parent relationships with HCPs and comfort with care, hospital resources, and parent resources determine location of care. Results of this study also imply place-related disparities in access to care, especially among children in smaller metropolitan areas and rural-dwelling children.DOI: http://dx.doi.org/ 10.14574/ojrnhc.v15i2.364Keywords: Rural population, Rural health services, Infant, Child, Preschool, Chronic disease

Efficiencies are needed to speed the dissertation process and graduation of prospective new faculty. We used a workflow process, the PERT chart, to organize and manage the many time-delimited tasks necessary for a complex dissertation. This article presents a case example that describes our experience and timely completion of the dissertation. PERT charts are useful tools to improve efficiency in nursing education.

While hospitals have widely adopted quality improvement (QI) initiatives, primary care practices continue to face unique challenges to QI implementation. The purpose of this article is to outline a strategy for promoting QI in primary care practices by introducing specially trained nurses. Two case examples are described, one with a QI nurse external to the practice and one with a nurse internal to the practice. Lessons learned and barriers and facilitators to QI in primary care are presented. Barriers and facilitators are identified in the following categories: practice infrastructure, practice leadership, and practice organizational culture. Implications for primary care practitioners and avenues for future work are discussed.

PURPOSE:The purpose of this study was to explore the factors associated with hospital utilization among infants and young children with complex chronic conditions (CCC).DESIGN AND METHODS:A descriptive, retrospective study was conducted with 216 medical records of children with CCC.RESULTS:Greater complexity, younger age, living with siblings, use of public insurance or self-pay, use of more than one type of insurance, and presence of conditions affecting certain body systems were associated with increased hospital and emergency department (ED) utilization.PRACTICE IMPLICATIONS:Nurses must have a heightened awareness of these at-risk characteristics to prevent avoidable hospital admissions and ED visits.

Children with complex chronic conditions (CCC) have greater health care needs and use rates than children in general. Elevated health care use includes more frequent hospital admissions, longer hospital stays, and greater health care expenses. Prior studies have examined population characteristics associated with increased hospital admissions, emergency department (ED) use, and general healthcare use, yet few studies have investigated these events from the parents' or health care providers' point of view. The purpose of this study was to explore parents/caregivers' and health care providers' perceptions of the factors placing infants and young children with CCC at risk for or protecting them against hospital admissions and ED visits. Parents or primary caregivers participated in interviews, and health care providers in pediatric acute care, pediatric primary care, and emergency care participated in focus groups. Interview and focus group data were analyzed using directed content analysis and an ecological risk and protective factors model. The analysis revealed that parents/caregivers and health care providers described risk factors and protective factors on multiple ecological levels surrounding the child with CCC. This article presents these findings, which add to current knowledge of factors influencing hospital admissions and ED visits and may be used to inform interventions addressing high health care utilization in this population. This article concludes with the implications of the findings for future research and nursing practice.

As Biobanking projects become more prevalent as an enabling resource for large –scale genetic research, it is important to assess public opinions from the community whose samples populate Biobanks. Although major studies were conducted to engage community members in advance of establishing Biobanks, few have included the attitudes/perceptions and educational needs of residents in the planning process. This qualitative pilot project was designed to engage the community in the planning process of establishing a Biobank and Clinical Data Warehouse. A thematic analysis of transcripts from seven focus groups and ten individual interviews revealed four major themes: Altruism, Acceptance, Anxiety & Fear, and Education. The voices from our community indicated a willingness to accept and participate using medical waste (biomaterials), given appropriate education is provided to patient and communities and they can exercise autonomy by signing a consent. This is a pivotal time in health care, especially in lieu of the evolving genomic era. Nurses have a tremendous responsibility and opportunity to become leaders in the era of Biobanking, and bridging the gap between discoveries from Biobanking and improving the quality of clinical care from bench to bedside.

Comparative effectiveness research (CER) is vital to translate new efficacious diagnostic and therapeutic approaches into effectiveness in usual clinical practice settings. Studying the practice environment in which effectiveness protocols are implemented is necessary to identify the complex challenges that can limit translation of evidence. These issues were addressed in our National Heart, Lung, and Blood Institute-funded R34, "Controlling Blood Pressure in Treatment-Resistant Hypertension (TRH): A Pilot Study." Qualitative methods were used in this cluster (clinic)-randomized, four-arm pilot study of TRH in eight diverse, community-based practices including: (i) focus group discussions with practice staff and physicians; (ii) conference calls with physicians; and (iii) discussions with research coordinators. Sources were summarized and analyzed by content analysis. Results include data segregated into categories representing facilitators of and barriers to research. Key facilitators included: (i) early success in controlling challenging TRH patients (ii) improved management of TRH, and (iii) reimbursement for study time and expenses. Barriers included: (i) time-consuming regulatory requirements; (ii) limited training and research experience of some study coordinators; and (iii) reluctance of some physicians to refer to Hypertension Specialists. Qualitative assessment is valuable for identifying facilitators and barriers to CER. This information is important in designing and implementing CER to accelerate translation of clinical efficacy into effectiveness.

Pre-hypertension, defined as blood pressure 120–139/80–89 mmHg, affects ~70 million people in the US. Blood pressures in the upper half of the pre-hypertensive range are linked with roughly threefold greater risk of incident hypertension than normal blood pressure <120/<80 mmHg, with an incidence rate of 8–20 % annually. Blood pressures in the upper half of the pre-hypertensive range also roughly double risk for cardiovascular events, even in the absence of progression to hypertension. Despite excess risk, guidelines recommend lifestyle interventions only for people with pre-hypertension in the absence of diabetes mellitus or clinical cardiovascular or chronic kidney disease. While efficacious, lifestyle changes have limited population effectiveness as Americans are heavier and their nutritional patterns less DASH-like than before DASH was published. Prevalent hypertension is higher in African Americans than Caucasians, but prevalent pre-hypertension is similar. African Americans experience a more rapid transition from pre-hypertension to hypertension than Caucasians with pre-hypertension. Interventions that normalize racial differences in incident hypertension could, over time, improve racial equity in prevalent hypertension and related clinical complications. Individuals with pre-hypertension can be safely treated with antihypertensive medications to significantly reduce incident hypertension. Given the evidence, practical clinical trials in African Americans with pre-hypertension to reduce and eliminate racial disparities in incident hypertension have merit. The results of these trials could provide the foundation for clinical guidelines to reduce racial disparities in prevalent hypertension and associated clinical cardiovascular and renal diseases.

Faith-based interventions hold promise for promoting health in ethnic minority populations. To date, however, few of these interventions have used a community-based participatory research (CBPR) approach, have targeted both physical activity and healthy eating, and have focused on structural changes in the church.To report the results of a group randomized CBPR intervention targeting physical activity and healthy eating in African-American churches.Group RCT. Data were collected from 2007 to 2011. Statistical analyses were conducted in 2012.Seventy-four African Methodist Episcopal (AME) churches in South Carolina and 1257 members within them participated in the study.Churches were randomized to an immediate (intervention) or delayed (control) 15-month intervention that targeted organizational and environmental changes consistent with the structural ecologic model. A CBPR approach guided intervention development. Intervention churches attended a full-day committee training and a full-day cook training. They also received a stipend and 15 months of mailings and technical assistance calls to support intervention implementation.Primary outcomes were self-reported moderate- to vigorous-intensity physical activity (MVPA), self-reported fruit and vegetable consumption, and measured blood pressure. Secondary outcomes were self-reported fat- and fiber-related behaviors. Measurements were taken at baseline and 15 months. Intent-to-treat repeated measures ANOVA tested group X time interactions, controlling for church clustering, wave, and size, and participant age, gender, and education. Post hoc ANCOVAs were conducted with measurement completers.There was a significant effect favoring the intervention group in self-reported leisure-time MVPA (d=0.18, p=0.02), but no effect for other outcomes. ANCOVA analyses showed an intervention effect for self-reported leisure-time MVPA (d=0.17, p=0.03) and self-reported fruit and vegetable consumption (d=0.17, p=0.03). Trainings were evaluated very positively (training evaluation item means of 4.2-4.8 on a 5-point scale).This faith-based structural intervention using a CBPR framework showed small but significant increases in self-reported leisure-time MVPA. This program has potential for broad-based dissemination and reach.This study is registered at www.clinicaltrials.gov NCT00379925.

Background: Faith-based interventions hold promise for promoting health in ethnic minority populations. To date, however, few of these interventions have used a community-based participatory research (CBPR) approach, have targeted both physical activity and healthy eating, and have focused on structural changes in the church.Purpose: To report the results of a group randomized CBPR intervention targeting physical activity and healthy eating in African-American churches.Design: Group RCT. Data were collected from 2007 to 2011. Statistical analyses were conducted in 2012.Setting/participants: Seventy-four African Methodist Episcopal (AME) churches in South Carolina and 1257 members within them participated in the study.Intervention: Churches were randomized to an immediate (intervention) or delayed (control) 15-month intervention that targeted organizational and environmental changes consistent with the structural ecologic model. A CBPR approach guided intervention development. Intervention churches attended a full-day committee training and a full-day cook training. They also received a stipend and 15 months of mailings and technical assistance calls to support intervention implementation.Main outcome measures: Primary outcomes were self-reported moderate-to vigorous-intensity physical activity (MVPA), self-reported fruit and vegetable consumption, and measured blood pressure. Secondary outcomes were self-reported fat-and fiber-related behaviors. Measurements were taken at baseline and 15 months. Intent-to-treat repeated measures ANOVA tested group X time interactions, controlling for church clustering, wave, and size, and participant age, gender, and education. Post hoc ANCOVAs were conducted with measurement completers.Results: There was a significant effect favoring the intervention group in self-reported leisure-time MVPA(d = 0.18, p = 0.02), but no effect for other outcomes. ANCOVA analyses showed an intervention effect for self-reported leisure-time MVPA (d = 0.17, p = 0.03) and self-reported fruit and vegetable consumption (d = 0.17, p = 0.03). Trainings were evaluated very positively (training evaluation item means of 4.2-4.8 on a 5-point scale).Conclusions: This faith-based structural intervention using a CBPR framework showed small but significant increases in self-reported leisure-time MVPA. This program has potential for broad-based dissemination and reach.

The Hypertension Initiative began in 1999 to help transition South Carolina from a leader in cardiovascular disease (CVD) to a model of heart and vascular health. Goals were to reduce heart disease and stroke by 50% by promoting healthy lifestyles and access to effective care and medications. Continuing medical education was used to train providers, encourage physicians to become American Society of Hypertension (ASH)-certified hypertension specialists and recruit practices into the community-based practice network (CBPN). Practice data audit with provider specific feedback is a key quality improvement tool. With ASH support, the CBPN has grown to 197 practices with approximately 1.6 million patients (approximately 700,000 hypertensives). Clinical data are obtained from electronic health records and quarterly provider feedback reports are generated. Hypertension, hypercholesterolemia, and diabetes control rose and South Carolina's ranking improved from 51st to 35th in CVD mortality from 1995 to 2006. The Hypertension Initiative expanded to the Outpatient Quality Improvement Network (O'QUIN) to encompass comparative effectiveness research and other chronic diseases. Lessons learned include: trust enables success, addressing practice priorities powers participation, infrastructure support must be multilateral, and strategic planning identifies opportunities and pitfalls. A collaborative practice network is attainable that produces positive, sustainable, and growing impacts on cardiovascular and other chronic diseases.

PURPOSE OF REVIEW:This review assesses whether controlling hypertension in 50% of all patients is the best we can do.RECENT FINDINGS:NHANES 2007-2008 data show that blood pressure was controlled to less than 140/less than 90 mmHg in 50% of all hypertensive patients, an increase from 27% in 1988-1994. The 50% control rate reflects the product of 72.5% of all patients treated and 69% of all treated patients controlled. However, there are opportunities for improvement, as 27.5% of all hypertensives, or 55% of uncontrolled patients, were untreated in 2007-2008. These individuals are disproportionately younger, men, and Hispanic. Moreover, 31% of all treated hypertensives, or 45% of uncontrolled patients, have blood pressure of at least 140/at least 90 mmHg. They are disproportionately older, women, and black.SUMMARY:Initiatives to raise hypertension treatment from 72.5% in 2007-2008 to 87.5% in the future are conceivable by targeting unaware and untreated patient groups and engaging them in ongoing healthcare. This could improve hypertension control by an absolute 10% of all patients. Reducing therapeutic inertia and increasing therapeutic efficiency could raise the proportion of patients on treatment who are controlled from 69 to 80% and could increase hypertension control by 8%. Combining these approaches could raise hypertension control to 70% of all hypertensive adults in the USA.

Prehypertension is a major risk factor for hypertension. Blacks have more prevalent and severe hypertension than whites, but it is unknown whether progression from prehypertension is accelerated in blacks. We examined this question in a prospective cohort study of 18 865 nonhypertensive persons (5733 black [30.4%] and 13 132 white [69.6%]) aged 18 to 85 years. Electronic health record data were obtained from 197 community-based outpatient clinics in the Southeast United States. Days elapsing from study entry to hypertension diagnosis, mainly blood pressure ≥140 mm Hg systolic and/or ≥90 mm Hg diastolic on 2 consecutive visits established conversion time within a maximum observation period of 2550 days. Cox regression modeling was used to examine conversion to hypertension as a function of race, while controlling for age, sex, baseline systolic and diastolic blood pressures, body mass index, diabetes mellitus, and chronic kidney disease. The covariable adjusted median conversion time when 50% became hypertensive was 365 days earlier for blacks than whites (626 versus 991 days; P<0.001). Among covariables, baseline systolic blood pressure 130 to 139 mm Hg (hazard ratio: 1.77 [95% CI: 1.69 to 1.86]) and 120 to 129 mm Hg (hazard ratio: 1.52 [95% CI: 1.44 to 1.60]), as well as age ≥75 years (hazard ratio: 1.40 [95% CI: 1.29 to 1.51]) and 55 to 74 years (hazard ratio: 1.29 [95% CI: 1.23 to 1.35]) were the strongest predictors of hypertension. Additional predictors included age 35 to 54 years, diastolic blood pressure 80 to 89 mm Hg, overweight and obesity, and diabetes mellitus (all P<0.001). Conversion from prehypertension to hypertension is accelerated in blacks, which suggests that effective interventions in prehypertension could reduce racial disparities in prevalent hypertension.

OBJECTIVESAlthough the co-occurrence of multiple risk factors increases the risk of cardiovascular disease (CVD) morbidity/mortality, few studies have examined the prevalence of risk factor clustering among African Americans in community-based faith settings. This study examined the prevalence and clustering of CVD risk factors in a sample of church members from South Carolina.DESIGNCross-sectional analysis of baseline data from a faith-based intervention, Faith, Activity, and Nutrition (FAN).SETTINGAfrican Methodist Episcopal churches in four geographically-defined districts in South Carolina.PARTICIPANTS1119 church members.MAIN OUTCOME MEASURESSelf-reported presence or absence of healthcare provider diagnosed diabetes, high cholesterol, and hypertension. Objectively measured blood pressure, height, and weight (body mass index) were also taken. The prevalence of single, multiple, and clustering of risk factors was computed.RESULTS62% of participants were obese, 64% had hypertension, 23% had diabetes, and 39% had high cholesterol; 15% had no risk factors, 24% had 1 risk factor, 30% had 2 risk factors, 22% had 3 risk factors, and 10% had 4 risk factors. The most common clusters of risk factors were: obese and hypertensive (18%), obese, hypertensive and hypercholesterolemic (13%), and obese, hypertensive, hypercholesterolemic, and diabetic (10%).CONCLUSIONSThe prevalence of risk factors and risk factor clustering in church members in South Carolina is exceedingly high. Culturally-relevant behavioral interventions targeting risk factor reduction in this population should be a public health goal.

The notion that eating chocolate would prevent or treat hypertension is appealing to many who produce and enjoy chocolate. Several studies have documented beneficial effects of dark chocolate on insulin action and endothelial function. However, the published studies on chocolate and blood pressure include a relatively small number of subjects, and results are conflicting. In addition, because of secrecy surrounding the production of chocolate and the unique sociocultural context of this popular food, research on efficacy and effectiveness is complex. This commentary summarizes 13 peer-reviewed studies on dark chocolate and blood pressure and raises questions relevant to its future as an evidence-based lifestyle intervention.