Prevention Of Chronic Conditions Research Articles

Ongoing Coverage for Ongoing Care: Access, Utilization, and Out-of-Pocket Spending Among Uninsured Working-Aged Adults with Chronic Health Care Needs

We sought to determine how part-year and full-year gaps in health insurance coverage affected working-aged persons with chronic health care needs. We conducted multivariate analyses of the 2002-2004 Medical Expenditure Panel Survey to compare access, utilization, and out-of-pocket spending burden among key groups of persons with chronic conditions and disabilities. The results are generalizable to the US community-dwelling population aged 18 to 64 years. Among 92 million adults with chronic conditions, 21% experienced at least 1 month uninsured during the average year (2002-2004). Among the 25 million persons reporting both chronic conditions and disabilities, 23% were uninsured during the average year. These gaps in coverage were associated with significantly higher levels of access problems, lower rates of ambulatory visits and prescription drug use, and higher levels of out-of-pocket spending. Implementation of health care reform must focus not only on the prevention of chronic conditions and the expansion of insurance coverage but also on the long-term stability of the coverage to be offered.

Post-menopausal cardiovascular health: A review

Counteracting the risk of cardiovascular complications in women immediately prior to and during the climacteric is of importance. Hormone replacement therapy (HRT) has been supported as an effective means of replacing the lost endogenous estrogen with a synthetic variant, thus precluding the onset of cardiovascular complications related to the vasculature. HRT has also been cited as being linked to increased occurrence of certain cancers, most particularly breast cancer. In the context of this contradictory information, lifestyle choices are an alternative. Diet and programmes of physical activity are commonly cited as effective tools in reducing the risk of cardiovascular health decline, and prevention of chronic conditions. Despite the literature in existence there remain unanswered questions. Aerobic exercise appears to positively affect the health status of post-menopausal women as far as weight control and bone density are concerned, but the literature is less clear on whether this form of activity is beneficial in reducing cholesterol levels and blood pressure and preventing cardiovascular incidents. Resistance training is even less well defined, and there is very little available literature on the effect of a resistance training regime on health indices such as blood lipid profiles in women who have entered the climacteric. This lack of conclusive clarity affects the recommendations offered by clinicians and renders the lay-person confused and uninterested. This paper will aim to present the current arguments in the literature, while noting areas for future research toward the understanding of health, post-menopause.

Description of an integrated framework for building linkages among primary care clinics and community organizations for the prevention of type 2 diabetes: emerging themes from the CC-Link study

Strong clinic-community linkages are pivotal for the success of preventive services that combine clinical and community resources. Unfortunately, there has been limited guidance for how clinical and community groups can partner to improve self-care and prevention for chronic conditions. This manuscript describes the development and implementation of an integrated framework to guide clinic-community linkages for the prevention of type 2 diabetes in an ongoing randomized effectiveness trial known as Clinical-Community Linkages to Prevent Diabetes (CC-Link) study. This study involves 10 primary care practices in a metropolitan area of the Midwest US. The study provided each practice location with technical assistance to select, implement, evaluate and refine different strategies to identify and address pre-diabetes using a clinic-community linkage. Sites were also randomized to receive either direct or indirect involvement by a community liaison/expert from the YMCA of Greater Indianapolis. Early implementation of the CC-Link Framework has underscored the importance of strong leadership and partnership synergy, and it uncovered several examples of how linkages can be designed to make the most of partner strengths. This success is promising, and an evaluation of the effectiveness of these efforts to improve lifestyle behaviours of adults with prediabetes is now underway.

Care for chronic conditions for indigenous Australians: Key informants’ perspectives on policy

The WHO's 2002 global report, Innovative Care for Chronic Conditions proposes a comprehensive framework for health systems to meet the challenges posed by chronic conditions. This paper uses the policy environment component of the WHO framework as a lens through which to examine key informants' perspectives on the management and prevention of chronic conditions in rural and remote Aboriginal communities in Australia. Twenty one semi-structured telephone interviews were conducted with a purposive sample of stakeholders, including senior commonwealth, state/territory and regional public servants and health service staff. All of the interviews were audio recorded, from which written summaries were produced. These summaries were then content analysed to build a composite picture of this area. The results indicate substantial success in developing national and sub-national strategies and refining funding and reporting arrangements. But much work remains to be done in strengthening partnerships, developing and retaining the workforce, and further shifting the focus from acute to chronic conditions. This paper provides a snapshot of the main policy issues, as identified by key informants, facing chronic disease management in rural and remote Indigenous communities in Australia. It has the potential to contribute to new national policy directions in Indigenous health.

More About Prospective Health Care

To the Editor: Dr. Campos-Outcalt’s response1 to our August article2 totally missed some key points. First, he stated that prospective health care is “defined as genomics-based medicine.” This could not be further from the truth or what we meant to convey. Although prospective medicine integrates genetic risk factors when appropriate and validated, it is defined as personalized, predictive, preventive, and participatory medicine that utilizes many tools and capabilities to foster strategic health planning. We clearly pointed out that the “know-how and capabilities to be proactive already existed” before the capabilities resulting from research in genomics emerged. Fields such as genomics, proteomics, metabolomics, systems biology, bioinformatics, and diagnostic imaging will enhance the move towards prospective medicine, but they do not define it. The key to prospective care is strategic health planning. Second, Dr. Campos-Outcalt stated that we attributed today’s health care system ailments to the absence of a “personalized” system rather than to the lack of universal coverage and overemphasis on specialty care. This is not the case; we clearly stated that today’s health care crisis is partially attributable to focusing on the treatment of disease events as well as being reactive and sporadic, leading to ineffective prevention of chronic conditions. Furthermore, we cited other significant contributing factors, including the current state of health care insurance and reimbursement systems. The prospective health care approach is one means to address the problems plaguing our system. Our article indicates our belief that, in addition to prospective health care, changes in access to health care insurance, the reimbursement system, and public health measures will all be needed to create a rational health care system. Finally, the claim that we “appear to believe that medical intervention has the major role to play in preventing illness,” as opposed to community-based approaches, is erroneous. Although in our article, we focused on individualized health care, we clearly stated that “public health and personalized approaches should be synergistic and will compel the close engagement of public health and medicine.” In conclusion, we respectfully request that Dr. Campos-Outcalt reread what we wrote. Ralph Snyderman, MD Chancellor emeritus, Duke University, and James B. Duke Professor of Medicine, Duke University Medical Center, Durham, North Carolina; ([email protected]). Ziggy Yoediono, MD, MBA Senior research fellow, Duke Center for Research on Prospective Health Care, Duke University Medical Center, Durham, North Carolina.

What skills do primary health care professionals need to provide effective self-management support?Seeking consumer perspectives

This research aimed to identify the skills required by primary health care (PHC) professionals to provide effective chronic condition prevention and self-management support, according to the perceptions of a sample of Australian consumers and carers. Qualitative data were collected and integrated from a focus group, key informant interviews and National Stakeholder meetings and a National Workshop, supported by an extensive literature review. With the exception of health professionals specifically trained or currently working in this area, consumers and carers perceive there is a lack of understanding, competence and practice of chronic condition prevention and self-management support among PHC professionals. The PHC workforce appears not to have the full set of skills needed to meet the growing burden of chronic conditions on the health system. Recommendations include education and training that focuses on improved communication skills, knowledge of community support resources, identification of consumers’ strengths and current capacities, collaborative care with other health professionals, consumers and carers and psychosocial skills to understand the impact of chronic conditions from the person’s perspective.

Hormone Replacement Therapy and Atherosclerosis in Postmenopausal Women

Despite the clear-cut epidemiological evidence of protective effects of endogenous estrogens in premenopausal women,1,2 the results of randomized clinical trials using conjugated equine estrogens and medroxyprogesterone acetate instead of natural hormones have led to a paradigm shift in the usefulness of hormone treatment in postmenopausal women.3,4 One of the main criticisms in addition to the types of drugs chosen for treatment was the age of the patients. Indeed, in both WHI trial and HERS study, treatment of patients was initiated in women many years beyond menopause.5 In fact, the number of years since menopause was an independent indicator for nonfatal myocardial infarction or coronary related death.5 In this context, it appears of interest that heart disease may contribute to menopausal age and that menopausal age actually may be an indicator of cardiovascular risk.6,7 See page 1782 It was noted as early as 1952 that the natural endogenous estrogen 17β-estradiol inhibits experimental atherosclerosis,8 and oral estrogens were even unsuccessfully evaluated to treat coronary artery disease in male patients.9–11 However, at the time little was known about the mechanisms by which sex steroid hormones affect vascular homeostasis and thrombogenesis. During the past 2 decades, considerable advances were made in the understanding of how natural estrogens act on the vasculature. 17β-estradiol causes rapid and endothelium-independent dilation of coronary arteries of men and women,12 and chronic treatment with 17β-estradiol inhibits experimental atherosclerosis in males and females.13,14 On the other hand, treatment with conjugated equine estrogens, which contain more than 30 different steroid compounds including testosterone and substances of still undefined vascular activity (Table), have shown less favorable effects,2–4 as has been reported for the synthetic progestin medroxyprogesterone acetate.15 With the identification of molecular targets of 17β-estradiol and other estrogens it now appears that …

Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal Women: Recommendation Statement: United States Preventive Services Task Force

Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal Women: Recommendation Statement: United States Preventive Services Task Force

Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal Women: Recommendations from the U.S. Preventive Services Task Force

This statement summarizes the U.S. Preventive Services Task Force recommendations on hormone therapy for the prevention of chronic conditions in postmenopausal women and the supporting scientific evidence, and updates the Task Force's 2002 recommendations on hormone replacement therapy. The updated statement is based on the results of the Women's Health Initiative randomized, controlled trial, as well as the information in the 2002 summary of the evidence on this topic, which is available on the USPSTF Web site (http://www.preventiveservices.ahrq.gov).

Postmenopausal estrogen for treatment of hot flashes: clinical applications.

Use of postmenopausal estrogen has changed since the release of the first results from the Women's Health Initiative in 2002. Professional organizations, the US Food and Drug Administration, and the US Preventive Services Task Force have issued new recommendations against use of estrogen and progestin or progesterone for prevention of chronic conditions. This article applies the current state of evidence for postmenopausal estrogen use to management decisions in 2 clinical scenarios initiating therapy in a perimenopausal woman with hot flashes and discontinuing estrogen use in a long-term user.

Traitement hormonal substitutif et risque cardiovasculaire : non indication ou contre-indication ?

In the field of the cardiovascular risk and treatment of menopause, only one instruction can be currently given to the prescribers: caution. Since the publication of heart and estrogen/progestin replacement study, the dogma of the cardioprotection induced by hormonal replacement therapy began to crumble. This paradigm had set up with observational studies, which for the majority had neglected in their retrospective analysis the socio-economic factor. Since shock caused by HERS, nine randomized studies are accumulated. All are negative, except for EPAT. At present, all confirms the prophetic recommendation of J.E. Rossow, in 1996: “Putting the brakes on the bandwagon”. The last guidelines formally prohibit HRT in coronary women or with the aim of primary prevention of chronic conditions in healthy postmenauposal women.

Menopausal hormone therapy: summary of a scientific workshop.

Menopausal hormone therapy: summary of a scientific workshop.

HRT, women and heart disease: facts about prevention

In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended counseling all perimenopausal and postmenopausal women about the potential benefits and harms of HRT. They determined that there was insufficient evidence to recommend for or against HRT for all women, but thought that individual decisions should be based on patient risk factors, an understanding of the probable benefits (for example, the prevention of myocardial infraction or fracture) and harms (for example, endometrial cancer with unopposed estrogen or breast cancer), and personal preferences. New recommendations were posted on October 23, 2002, and now the USPSTF recommends against the routine use of estrogen and progestin for the prevention of chronic conditions in postmenopausal women. The USPSTF found fair to good evidence that the combination of estrogen and progestin has both benefits and harms.

Postmenopausal Hormone Replacement Therapy for the Primary Prevention of Chronic Conditions: Recommendations And Rationale: United States Preventive Services Task Force

Postmenopausal Hormone Replacement Therapy for the Primary Prevention of Chronic Conditions: Recommendations And Rationale: United States Preventive Services Task Force

The High Cost of Lost Opportunities for Prevention-Reply

<h3>In Reply.</h3> —As indicated by Dr Havas, significant savings can be gained through primary prevention of chronic disease. While it seemed implicit to us, the message of prevention always bears reinforcing. In addition, it is important to recognize another large source of potential savings—both in dollars and human suffering—from the prevention of secondary conditions. Secondary conditions are diseases, impairments, functional limitations, or additional disabilities that are caused by (ie, occur as a result of) another condition.¹Crucially important to preventing these sequelae is a health care system that ensures continuity of care, access to assistive technology and resources, and health education—fundamental elements that enable individuals to manage their own health care effectively and prevent further illness and disability. It was our hope that, by measuring the total prevalence and costs of chronic conditions as a whole, the need for both primary prevention of chronic conditions and the secondary prevention of disability

Survival Curves, Prevalence Rates, and Dark Matters Therein

Survival curves are a visual aid to help us think about interrelationships between chronic morbidity, disability, and mortality. Prevalence rates indicate a population's morbidity and disability status at given times. The curves and rates are both residues of very dynamic processes: Chronic conditions may be alleviated as well as progress; functions may be restored as well as lost. The dynamics can be represented by transition rates between states; transition rates can vary across population groups (heterogeneity). Contemporary data and life table techniques are advancing to measure morbidity-disability-mortality dynamics and summarize them in statistical manner. Topics that remain elusive or overlooked are comorbidity, nonfatal chronic conditions, frailty, generalized symptoms, and difficulty in many activity domains; these are dark matters. Future scenarios of health depend on premises about where prevention of chronic conditions will occur. I present three basic scenarios (one includes the compression of morbidity) and note their implications for transitions between states and for morbidity and disability prevalence rates. Compression of morbidity is an intriguing notion, but to know if it occurs or not over the next century requires a deep foundation of epidemiologic data and analysis, and that is where scientific efforts must be devoted.

Chronic conditions and physician use patterns in ten urban poverty areas

Little is known about the health status of the population in poverty areas where the concentration of the poor is high. The purpose of the study was to compare prevalence of chronic conditions among the poor in ten poverty areas with the national average for poor and then relate the level of chronicity to physician utilization. Some findings were: 1) the poor in poverty areas have a much higher level of chronic conditions, especially major chronic conditions, than would be suspected from national data on the poor; 2) persons with chronic conditions in poverty areas see physicians at a high rate regardless of income; and 3) for the vast majority of persons residing in poverty areas — the nonchronics — physician utilization is low. Conclusions are: 1) the escape from poverty by the poor in poverty areas is not optimistic without intensive effort at prevention of chronic conditions; and 2) perhaps some relationship may exist between low utilization of ambulatory care by the majority of the poverty population—the nonchronics—and the high chronic rate.

Chronic conditions and physician use patterns in ten urban poverty areas.

Little is known about the health status of the population in poverty areas where the concentration of the poor is high. The purpose of the study was to compare prevalence of chronic conditions among the poor in ten poverty areas with the national average for poor and then relate the level of chronicity to physician utilization. Some findings were: 1) the poor in poverty areas have a much higher level of chronic conditions, especially major chronic conditions, than would be suspected from national data on the poor; 2) persons with chronic conditions in poverty areas see physicians at a high rate regardless of income; and 3) for the vast majority of persons residing in poverty areas — the nonchronics — physician utilization is low. Conclusions are: 1) the escape from poverty by the poor in poverty areas is not optimistic without intensive effort at prevention of chronic conditions; and 2) perhaps some relationship may exist between low utilization of ambulatory care by the majority of the poverty population—the nonchronics—and the high chronic rate.